Learning Radiology xray montage

Gout - Hand

General Considerations

  • Deposition of sodium urate monohydrate crystals in synovial membranes, articular cartilage, ligaments, bursae leading to destruction of cartilage
  • Age of onset is usually greater than 40 years; males much more often than females
  • Radiologic features usually not seen until 6-12 years after initial attack
  • Radiologic features present in 50% of affected patients


  • Idiopathic Gout
    • M:F = 20:1
    • Overproduction of uric acid
    • Abnormality of renal urate excretion
  • Secondary Gout
    • Rarely cause for radiographically apparent disease
    • Myeloproliferative disorders, e.g. polycythemia vera, leukemia, lymphoma, multiple myeloma
    • Blood dyscrasias
    • Myxedema, hyperparathyroidism
    • Chronic renal failure
    • Glycogen storage disease
    • Myocardial infarction
    • Lead poisoning


  • Asymptomatic hyperuricemia
  • Acute monarticular gout
  • Polyarticular gout
  • Chronic tophaceous gout = multiple large urate deposits


  • Joints: hands + feet (1st MTP joint most commonly affected = podagra), elbow, wrist
    • Carpometacarpal compartment especially common), knee, shoulder, hip, sacroiliac joint (15%, unilateral)
  • Ear pinna > bones, tendon, bursa

Soft tissue findings

  • Calcific deposits in gouty tophi in 50% (only calcium urate crystals are opaque)
  • Eccentric juxta-articular lobulated soft-tissue masses (hand, foot, ankle, elbow, knee)
  • Bilateral olecranon bursitis
  • Aural calcification

Joint findings

  • Preservation of joint space initially
  • Absence of periarticular demineralization
  • Erosion of joint margins with sclerosis
  • Cartilage destruction late in course of disease
  • Periarticular swelling (in acute monarticular gout)
  • Chondrocalcinosis (menisci, articular cartilage of knee) resulting in secondary osteoarthritis

Bone findings

  • "Punched-out" lytic bone lesion ± sclerosis of margin
  • "Mouse / rat bite" from erosion of long-standing soft-tissue tophus
  • "Overhanging margin" (40%)
  • Ischemic necrosis of femoral / humeral heads
  • Bone infarction

Coexisting disorders

  • Psoriasis
  • Glycogen storage disease Type I
  • Hypo- and hyperparathyroidism
  • Down’s syndrome
  • Lesch-Nyhan syndrome (choreoathetosis, spasticity, mental retardation, self-mutilation of lips + fingertips)


  • Colchicine, allopurinol (effective treatment usually does not change x-ray findings)



Gout. There are large tophaceous deposits (white arrows) surrounding several of the joints of the right hand. There are juxta-articular, punched-out lytic erosions (white and yellow circles) and a lack of osteoporosis characteristic of gout. The erosions are shown in close-up view (blue arrows).
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