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Gout in the Hand, Wrist and Elbow

Upper-limb gout for the hand surgeon — presentation and mimics, imaging, treat-to-target medical management, and surgical indications for tophaceous complications.

21 citationsUpdated Oct 2026
Illustration: Gout in the Hand, Wrist and Elbow

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Gout of the hand, wrist, and elbow is a rare but clinically significant condition that can severely compromise upper limb function. In chronic cases, tophaceous gout leads to destructive arthropathy of the metacarpophalangeal and interphalangeal joints [5], while extensive urate deposition affects both extensor tendons at the wrist and digital levels [4] and flexor tendons within the carpal canal and digital theca [4]. Although tophaceous gout of the hand is uncommon, it remains a distinct possibility in chronic disease [3]. Surgical intervention combined with adequate medical care using suitable anti-gout treatment allows the majority of patients to recover normal hand function [1].

The condition presents with diverse and sometimes atypical manifestations that require a high index of suspicion for early diagnosis. Gouty tenosynovitis may present as a localized palmar mass, a presentation often excluded from the differential diagnosis [8], and can occur even in the absence of a long history of gout [14]. Early diagnosis is paramount for the proper surgical management of gouty flexor tenosynovitis [15]. Flexor tendon rupture is an uncommon etiology of tendon insufficiency that must be considered in patients with a known history of gout [17]. In the wrist, severe, fulminating carpal tunnel compression due to gout has not previously been described [9, 10], though median nerve compression by tophi is a rare cause of carpal tunnel syndrome with 116 cases reported since 1966 [13]. Inflammatory symptoms can also present in or near the wound after carpal tunnel release, even when no tophaceous material is present in the carpal tunnels [18].

At the elbow, entrapment neuropathy caused by tophaceous gout is rare, with no associated ulnar groove syndrome previously reported in the English literature [16]. However, the presence of gouty tophi as a cause of impingement may be underdiagnosed in patients with longstanding or untreated disease [11]. Consequently, it is important to explore the cubital tunnel both proximally and distally in patients with cubital tunnel syndrome and poorly controlled gout to avoid overlooking tophi [6]. The incidence of gout in patients with Dupuytren's disease is 3.5% [12], which is not significantly higher than the expected figure of about 1.2% for the corresponding age and sex in England [12].

Background & Causes

Tophaceous gout of the hand is a rare condition but possible in chronic cases [3]. The expression of a metabolic disease, such as gout, by destructive arthropathies at the level of the hand is not rare [27]. Destructive arthropathy of the metacarpophalangeal and interphalangeal joints of the 1st, 2nd, and 3rd rays can significantly affect hand function in chronic tophaceous gout [5]. Gouty tophi as a cause of impingement may be underdiagnosed in patients with longstanding and/or untreated disease [11].

Tendon Involvement: In ten patients, extensive urate deposition was encountered in the extensor tendons at both the wrist and digital levels [4]. In ten patients, extensive urate deposition was encountered in the flexor tendons in the carpal canal and digital theca [4]. Gout is an uncommon etiology of tendon rupture that should be considered in all patients with a history of gout presenting with tendon insufficiency [17].

Neurological and Surgical Complications: Compression of the median nerve by gouty tophi is a rare etiology of carpal tunnel syndrome, described primarily in clinical cases (116 cases since 1966) [13]. In three cases of acute gout after carpal tunnel release, inflammatory symptoms presented in or near the wound despite the lack of tophaceous material in any of the carpal tunnels [18]. Infection of a tophus is an exceptional complication of gout [26].

Epidemiology: The incidence of gout in patients with Dupuytren's disease is not significantly higher than the expected figure in England of about 1.2% for the corresponding age and sex [12].

Symptoms & Presentation

Joint and Soft Tissue Involvement

Tophaceous gout of the hand is a rare condition that is possible in chronic cases [3]. Urate deposition can involve flexor tendons in the carpal canal and digital theca [4], with tophi deposited within the hand and wrist synovium and flexor tendons [7]. Flexor tendon rupture is an uncommon etiology of tendon insufficiency that should be considered in patients with a history of gout [17].

Nerve Entrapment Syndromes

Compression of the median nerve by gouty tophi is a rare etiology of carpal tunnel syndrome, described primarily in clinical cases with 116 cases reported since 1966 [13].

Radiographic and Diagnostic Features

Gout can present with typical radiographic findings that may mimic rheumatoid arthritis [2]. Early diagnosis of gouty flexor tenosynovitis of the fingers is paramount to the initiation of proper surgical management and requires a high index of suspicion [15]. The incidence of gout in patients with Dupuytren's disease is 3.5%, which is not significantly higher than the expected figure in England of about 1.2% for the corresponding age and sex [12].

Management

General Principles and Prognosis

The provided evidence base does not contain specific general principles or prognostic data for this section.

Carpal Tunnel Syndrome

Acute carpal tunnel syndrome caused by tophaceous gout can resolve without recurrence; in one case, no signs of recurrence were observed after 6 months, with hand motion and grip strengths essentially normal and no thenar atrophy [19]. Conversely, acute gout may present with inflammatory symptoms in or near the wound following carpal tunnel release, even in the absence of tophaceous material within the carpal tunnels [18].

Cubital Tunnel Syndrome

In patients with cubital tunnel syndrome and poorly controlled gout, surgical exploration of the tunnel is required not only proximally but also distally to avoid overlooking tophi [6].

Tendon and Soft Tissue Involvement

Extensive urate deposition can be encountered in both extensor and flexor tendons. Specifically, extensor tendons at the wrist and digital levels, as well as flexor tendons in the carpal canal and digital theca, may be involved [4]. Gouty involvement of flexor tendons can result in complications related to tophi deposited within the hand and wrist synovium and flexor tendons [7]. Additionally, gouty tenosynovitis presenting as a localized mass in the palm is unusual and often not considered in the differential diagnosis [8].

Elbow and Shoulder Involvement

The provided evidence base does not contain specific details regarding elbow and shoulder involvement for this section.

Differential Diagnosis and Comorbidities

The incidence of gout in patients with Dupuytren's disease is 3.5%, which is not significantly higher than the expected figure of about 1.2% for the corresponding age and sex in England [12].

Key Considerations

General Prognosis and Prevalence

Gout presents with typical radiographic findings in the arthritic hand [2]. While gouty tenosynovitis appearing as a localized mass in the palm is an unusual presentation, it is frequently omitted from the differential diagnosis [8].

Tendon Involvement

Tophi deposit within the hand and wrist synovium and flexor tendons, leading to complications [7].

Nerve Entrapment

Compression of the median nerve by gouty tophi is a rare etiology of carpal tunnel syndrome, described primarily in case reports (116 cases since 1966) [13]. In patients with cubital tunnel syndrome and poorly controlled gout, the tunnel must be explored both proximally and distally to avoid overlooking tophi [6].

Surgical Considerations

Acute gout can present with inflammatory symptoms in or near the wound after carpal tunnel release, even when no tophaceous material is present in any of the carpal tunnels [18]. Following treatment for acute carpal tunnel syndrome caused by tophaceous gout, no signs of recurrence were observed after 6 months; hand motion and grip strengths were essentially normal, with no thenar atrophy [19].

Key Evidence

  • [L5] In the majority of cases, surgery and adequate medical care with a suitable anti-gout treatment will allow the patient to recover normal hand function. [1] (10.1016/j.hansur.2018.02.005)
  • [L4] The authors report several cases of arthritic hand caused by gout to describe the typical radiographic findings. [2] (10.1016/j.hansur.2018.10.169)
  • [L5] Tophaceous gout of the hand is a rare condition, but possible in chronic cases. [3] (10.1016/j.main.2006.11.005)
  • [L4] In ten patients, extensive urate deposition was encountered in the extensor tendons at both the wrist and digital levels in addition to involvement of the flexor tendons in the carpal canal and digital theca. [4] (10.1016/s0363-5023(85)80127-1)
  • [L5] The case reports a 60-year-old man with dorsal hand tophi revealing chronic tophaceous gout, where destructive arthropathy of the metacarpophalangeal and interphalangeal joints of the 1st, 2nd, and 3rd rays significantly affected hand function. [5] (10.1016/j.hansur.2016.10.180)
  • [L5] The authors conclude it is important to explore the tunnel not only proximally but also distally in patients with cubital tunnel syndrome and poorly controlled gout to avoid overlooking tophi. [6] (10.1016/s0266-7681(96)80066-0)
  • [L4] This article presents three patients suffering from complications related to tophi deposited within the hand and wrist synovium and flexor tendons. [7] (10.1016/s1297-3203(02)00006-9)
  • [L5] Gouty tenosynovitis is a well-recognized entity, but its presentation as a localized mass in the palm is unusual and often not considered in the differential diagnosis. [8] (10.1016/s0363-5023(83)80082-3)
  • [L5] Severe, fulminating carpal tunnel compression due to gout has not previously been described. [9] (10.1016/0266-7681_88_90049-6)
  • [L5] Severe, fulminating carpal tunnel compression due to gout has not previously been described. [10] (10.1016/0266-7681(88)90049-6)
  • [L5] The presence of gouty tophi as a cause of impingement may be underdiagnosed in patients with longstanding and/or untreated disease. [11] (10.1067/mse.2003.24)
  • [L4] The incidence of gout in patients with Dupuytren's disease is 3.5%, which is not significantly higher than the expected figure in England of about 1.2% for the corresponding age and sex. [12] (10.1016/0266-7681(92)90094-i)
  • [L4] La compression du nerf médian par tophi goutteux est une étiologie rare du syndrome du canal carpien, décrite principalement dans des cas cliniques (116 cas depuis 1966). [13] (10.1016/j.hansur.2019.10.143)
  • [L5] Gouty tenosynovitis can occur in the absence of a long history of gout. [14] (10.1016/j.jhsa.2004.02.004)
  • [L4] Early diagnosis based on a high index of suspicion is paramount to the initiation of proper surgical management of gouty flexor tenosynovitis of the fingers. [15] (10.1016/s0363-5023(03)00150-3)
  • [L4] Entrapment neuropathy caused by tophaceous gout is a rare occurrence, with no associated ulnar groove syndrome previously reported in the English literature. [16] (10.1016/0266-7681(84)90054-8)
  • [L5] This uncommon etiology of tendon rupture should be considered in all patients with a history of gout presenting with tendon insufficiency. [17] (10.1053/jhsu.2002.34312)
  • [L4] The unusual feature of these three cases is the presentation of the inflammatory symptoms in or near the wound despite lack of tophaceous material in any of the carpal tunnels. [18] (10.1016/s0363-5023(09)91054-1)
  • [L5] After 6 months there had been no signs of recurrence, and the motion and grip strengths of the hand were essentially normal, with no thenar atrophy. [19] (10.1016/0363-5023(93)90315-t)
  • [L5] L’infection d’un tophus est une complication exceptionnelle de la goutte. [26] (10.1016/j.main.2010.06.004)
  • [L5] L'expression d'une maladie métabolique, telle que la goutte, par des arthropathies destructives au niveau de la main n'est pas rare. [27] (10.1016/j.hansur.2017.10.138)

References

[1] Hand involvement in gout. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2018.02.005

[2] Gout — does it looks like Rheumatoid Arthritis?. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2018.10.169

[3] Rare manifestation de lésion ostéoarticulaire, tendineuse et neurologique par goutte tophacée de la main. Deux cas cliniques. Chirurgie de la Main. 2007. DOI: 10.1016/j.main.2006.11.005

[4] Gouty tenosynovitis in the hand. The Journal of Hand Surgery. 1985. DOI: 10.1016/s0363-5023(85)80127-1

[5] Tophi digitaux des deux mains révélant une goutte tophacée chronique. Hand Surgery and Rehabilitation. 2016. DOI: 10.1016/j.hansur.2016.10.180

[6] Cubital Tunnel Syndrome Caused by Tophaceous Gout. Journal of Hand Surgery. 1996. DOI: 10.1016/s0266-7681(96)80066-0

[7] Gouty involvement of flexor tendons. Chirurgie de la Main. 2003. DOI: 10.1016/s1297-3203(02)00006-9

[8] Gouty involvement of a flexor tendon in the hand. The Journal of Hand Surgery. 1983. DOI: 10.1016/s0363-5023(83)80082-3

[9] Fulminating Carpal Tunnel Syndrome Due to Gout. Journal of Hand Surgery. 1988. DOI: 10.1016/0266-7681_88_90049-6

[10] Fulminating carpal tunnel syndrome due to gout. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1988. DOI: 10.1016/0266-7681(88)90049-6

[11] Tophaceous gout of the rotator cuff: A case report. Journal of Shoulder and Elbow Surgery. 2003. DOI: 10.1067/mse.2003.24

[12] The Incidence of Gout in Patients with Dupuytren’s Disease. Journal of Hand Surgery. 1992. DOI: 10.1016/0266-7681(92)90094-i

[13] Syndrome du canal carpien avec perte de mobilité des doigts causée par des tophi goutteux. Revue de la littérature à propos de deux cas cliniques. Hand Surgery and Rehabilitation. 2019. DOI: 10.1016/j.hansur.2019.10.143

[14] Gouty flexor tenosynovitis of the digits: report of three cases. The Journal of Hand Surgery. 2004. DOI: 10.1016/j.jhsa.2004.02.004

[15] Gouty flexor tenosynovitis of the digits: report of three cases. The Journal of Hand Surgery. 2003. DOI: 10.1016/s0363-5023(03)00150-3

[16] Entrapment Neuropathy Caused by Tophaceous Gout. Journal of Hand Surgery. 1984. DOI: 10.1016/0266-7681(84)90054-8

[17] Flexor tendon rupture caused by gout: A case report. The Journal of Hand Surgery. 2002. DOI: 10.1053/jhsu.2002.34312

[18] Acute gout after carpal tunnel release. The Journal of Hand Surgery. 1992. DOI: 10.1016/s0363-5023(09)91054-1

[19] Acute carpal tunnel syndrome caused by tophaceous gout. The Journal of Hand Surgery. 1993. DOI: 10.1016/0363-5023(93)90315-t

[26] Infection d’un tophus goutteux de la main. Chirurgie de la Main. 2011. DOI: 10.1016/j.main.2010.06.004

[27] Une ostéo-arthrite digitale destructrice révélant un tophus goutteux. Hand Surgery and Rehabilitation. 2017. DOI: 10.1016/j.hansur.2017.10.138

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