Article
Gouty arthritis of hand: tendon and joint involment
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Published: | February 6, 2020 |
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Objectives/Interrogation: Gout is uncommon in the upper extremity. Gouty involment of hand is typically associated with an advanced stage of the disease in patients with uncontrolled hyperuricemia. The usual lesions are tophi, which are subcutaneous or bursal deposits of monosodium urate. The treatment is primarily medical. Surgery should be considered if the medical treatment is not tolerated by the patient or if the gouty deposits produce nerve compression, tenosynovitis or tendon rupture.
Methods: We present the case of a 49-year old patient with a previous hyperuricemic event that presents palmar nodules on 4th and 5th fingers of the dominant hand which limits the flexion with no prior traumatic event. The physical examination showed palmar nodules and a limited flexion of 4th and 5th fingers. An MRI was performed showing important synovial proliferation and distension concerning the common synovial sheath of the 4th and 5th flexor tendons, as well as partial rupture of flexor digitorum profundis and probable rupture of the flexor digitorum superficialis of 5th finger. It also showed an interphalangeal arthritis of 5th finger. A blood analysis confirmed hyperuricemia. The patient was referred to Rheumatology. A surgical treatment is then performed: A volar Brunner approach over the 4th and 5th fingers showed a partial rupture and proliferative tenosynovitis of the flexor digitorum profundis and a tenosynovitis of the superficialis of the 4th finger and a tenosynovitis of both tendons of 5th finger with an important degenerative arthropathy of the distal interphalangeal joint. Consequently, the surgery consisted in a reconstruction of the flexor tendon using an autograft of the palmaris longus for the flexor digitorum profundis and superficialis of the 4th finger and a distal interphalangeal arthrodesis of the 5th finger. The tenosynovial tissue was excised and sent for histological examination. The patient was immobilized with a forearm splint in flexion. After two weeks the surgery wounds were in good state with no signs of infection, and the splint was removed to allow early protected mobilization. The analysis of the tissue showed various gouty thopi and presence of synovitis.
Results and Conclusions: Patients with flexor tendon ruptures and degenerative arthropathy present an high disease activity. Prevention of tendon ruptures by early tenosynovectomy is advised, due to poor prognosis. Aside from surgery, the multidisciplinary management of gouty arthritis is necessary.