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

Causes:

• 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

Stages

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

Location:

• 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)

Treatment

• 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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