High Yield Overview
CRYSTALLINE ARTHROPATHY - HAND
Gout | Pseudogout (CPPD) | Tophi | Crystal Deposition
UrateGout crystals (negative birefringence)
CPPDPseudogout crystals (positive birefringence)
WristMost common hand site (CPPD)
AllopurinolChronic gout prophylaxis
Crystalline Arthropathy Types
Gout (MSU)
PatternMonosodium urate crystals, negatively birefringent needles, hyperuricemia
TreatmentNSAIDs, colchicine, allopurinol
Pseudogout (CPPD)
PatternCalcium pyrophosphate crystals, positively birefringent rhomboids, wrist common
TreatmentNSAIDs, colchicine, aspiration
Tophaceous Gout
PatternChronic: chalky tophi in joints/tendons, erosions, deformity
TreatmentTophus excision, urate-lowering therapy
CPPD Arthropathy
PatternChronic: degenerative arthritis pattern, TFCC/wrist chondrocalcinosis
TreatmentUsually non-operative, arthroplasty if severe
Critical Must-Knows
- Gout Crystals: Monosodium urate, negatively birefringent needles (yellow when parallel to polarizer).
- CPPD Crystals: Calcium pyrophosphate, positively birefringent rhomboids (blue when parallel).
- Tophaceous Gout: Chronic deposits in tendons/joints → nerve compression, erosions, skin breakdown.
- CPPD Wrist: Triangular fibrocartilage (TFCC) calcification classic finding on x-ray.
- Surgery Indications: Nerve compression (CTS), tendon rupture, skin ulceration, refractory pain.
Examiner's Pearls
- "Negative birefringence = gout (urate needles)
- "Positive birefringence = CPPD (rhomboids)
- "Tophaceous gout: carpal tunnel syndrome common
- "CPPD: wrist TFCC calcification on x-ray
Clinical Imaging
Imaging Gallery
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Critical Crystalline Arthropathy Exam Points
Crystal Identification
Joint aspiration with polarized light microscopy is diagnostic. Gout: negatively birefringent needle-shaped urate crystals (yellow when parallel). CPPD: positively birefringent rhomboid calcium pyrophosphate crystals (blue when parallel).
Tophaceous Gout Complications
Chronic tophi cause nerve compression, tendon rupture, skin ulceration, joint destruction. Carpal tunnel syndrome very common. Surgery indicated for nerve compression, tendon involvement, skin breakdown.
CPPD Wrist Involvement
Wrist is the most common hand site for CPPD. Triangular fibrocartilage (TFCC) calcification is classic x-ray finding (chondrocalcinosis). Can mimic other wrist arthropathies.
Medical Management First-Line
Optimize medical therapy before surgery. Acute attacks: NSAIDs, colchicine, steroids. Chronic gout: allopurinol/febuxostat to lower uric acid (target less than 6 mg/dL). Perioperative urate-lowering therapy essential.
Gout vs Pseudogout (CPPD)
| Feature | Gout (MSU) | Pseudogout (CPPD) | Key Difference |
|---|---|---|---|
| Crystal type | Monosodium urate (MSU) | Calcium pyrophosphate (CPP) | Chemical composition |
| Birefringence | Negative (yellow parallel) | Positive (blue parallel) | Polarized microscopy pattern |
| Crystal shape | Needle-shaped | Rhomboid/rectangular | Morphology under microscope |
| Classic joint (hand) | First MTP, MCP, wrist | Wrist (TFCC calcification) | Distribution pattern |
Mnemonic
NYPDGout vs CPPD Crystal Identification
N
Negatively birefringent
Gout (monosodium urate crystals)
Y
Yellow when parallel
Gout crystals appear yellow when parallel to polarizer
P
Positively birefringent
Pseudogout (calcium pyrophosphate crystals)
D
bLue when parallel (D for CPPD)
CPPD crystals appear blue when parallel to polarizer
Memory Hook:NYPD = Negative Yellow (gout), Positive bLue/D (CPPD) - remember crystal birefringence!
Mnemonic
NSAIDGout Acute Attack Management
N
NSAIDs
First-line: indomethacin, naproxen (if no renal/GI contraindication)
S
Steroids
Oral prednisone or intra-articular if NSAIDs contraindicated
A
Aspiration
Joint aspiration relieves pain and confirms diagnosis
I
Ice and rest
Symptomatic relief during acute attack
D
Do NOT start allopurinol
Don't start urate-lowering during acute attack (worsens flare)
Memory Hook:NSAID = management of acute gout attack - but don't start allopurinol during flare!
Mnemonic
TENTSTophaceous Gout Surgical Indications
T
Tendon rupture
Tophus weakens tendons (extensor/flexor) → rupture
E
Erosive arthropathy
Joint destruction, severe arthritis
N
Nerve compression
Carpal tunnel syndrome, ulnar nerve compression
T
Tophus ulceration
Skin breakdown, infection risk
S
Severe pain refractory
Failed medical management, intractable pain
Memory Hook:TENTS = indications for surgical tophus excision in chronic gout!
Overview and Epidemiology
Crystalline Arthropathy is joint inflammation from crystal deposition: monosodium urate (gout) or calcium pyrophosphate (CPPD/pseudogout).
Gout Epidemiology
Prevalence:
- 4% general population (increasing)
- Male greater than female (3:1)
- Peak onset: 40-60 years (men), post-menopausal (women)
Risk Factors:
- Hyperuricemia (uric acid greater than 7 mg/dL)
- Obesity, metabolic syndrome
- Alcohol (beer), purine-rich diet (red meat, seafood)
- Diuretics, chronic kidney disease
- Family history
Classic site: First MTP (podagra).
CPPD Epidemiology
Prevalence:
- 5-10% in elderly (over 65 years)
- Equal male:female
- Age-related: prevalence increases with age
Risk Factors:
- Advanced age (over 60 years)
- Osteoarthritis
- Hyperparathyroidism, hemochromatosis
- Hypomagnesemia, hypophosphatasia
- Prior joint trauma
Wrist is most common hand site.
Hand Involvement:
- Gout: 10-15% present with hand involvement (wrist, MCP, PIP, DIP)
- CPPD: Wrist most common hand site (TFCC calcification)
Pathophysiology
Crystal-Induced Inflammation
Both gout and CPPD cause acute inflammatory arthritis from crystal deposition. Crystals are phagocytosed by neutrophils → inflammatory cascade → intense pain, swelling, erythema (mimics septic arthritis). Joint aspiration with crystal identification is diagnostic.
Gout (Monosodium Urate) Pathophysiology:
- Hyperuricemia: Uric acid greater than 7 mg/dL (overproduction or underexcretion)
- Crystal Formation: Urate crystals precipitate in synovial fluid/tissue (lower temperature in extremities)
- Acute Attack: Crystals trigger inflammatory response (neutrophil activation, IL-1β release)
- Chronic Tophaceous Phase: Persistent hyperuricemia → tophus formation (aggregates of urate crystals with granulomatous reaction)
- Joint/Tendon Damage: Tophi erode bone, weaken tendons, compress nerves, ulcerate skin
Tophus Composition: Chalky white monosodium urate deposits surrounded by foreign body giant cells
CPPD (Calcium Pyrophosphate Deposition) Pathophysiology:
- Pyrophosphate Accumulation: Abnormal cartilage metabolism (age-related, genetic, metabolic)
- Crystal Deposition: Calcium pyrophosphate crystals deposit in cartilage (chondrocalcinosis)
- Acute Pseudogout: Crystal shedding into joint → acute inflammatory attack
- Chronic CPPD Arthropathy: Progressive cartilage/bone damage (OA-like pattern)
TFCC calcification in wrist is classic for CPPD.
Hand Sites:
| Condition | Common Hand/Wrist Sites |
|---|---|
| Gout | Wrist, first MCP (thumb), finger MCPs, PIPs, DIPs |
| Tophaceous Gout | Finger pulps, extensor tendons, olecranon bursa, carpal tunnel |
| CPPD/Pseudogout | Wrist (TFCC, radiocarpal), MCPs (less common) |
Clinical Presentation
Acute Gouty Arthritis
Classic Presentation:
- Sudden onset severe joint pain (often overnight, wakes patient)
- Monoarticular initially (can be polyarticular in recurrent attacks)
- Red, hot, swollen joint (mimics septic arthritis)
- Exquisitely tender - cannot tolerate touch, sheets
- Self-limited: Resolves in 7-10 days without treatment
Hand Manifestations:
- Wrist, MCP, PIP, DIP involvement
- Swelling and erythema
- Reduced ROM from pain
Triggers:
- Alcohol binge (beer)
- Dehydration
- Acute illness, surgery
- Starting allopurinol (paradoxical flare)
Podagra (First MTP): Classic presentation (70% of first attacks), but hand joints also common.
Examination
Inspection:
- Erythema, edema over affected joint
- Shiny, tense skin
- May have visible tophi (chronic cases)
Palpation:
- Marked tenderness (patient withdraws)
- Warmth
- Joint effusion
ROM: Severely limited by pain
Differential: Septic arthritis - must rule out with joint aspiration!
Medical Management
📊 Management Algorithm
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Acute Gout/Pseudogout Management
Goals: Reduce inflammation and pain rapidly
First-Line Therapy:
1. NSAIDs:
- Indomethacin 50mg TID or naproxen 500mg BID
- Start immediately at diagnosis
- Continue until attack resolves (7-10 days)
- Contraindications: Renal impairment, GI bleeding history, anticoagulation
2. Colchicine:
- Low-dose regimen: 1.2mg loading dose, then 0.6mg 1 hour later, then 0.6mg daily
- Effective if started early (within 24-48 hours)
- Side effects: Diarrhea, GI upset (dose-dependent)
- Contraindications: Severe renal/hepatic impairment
3. Corticosteroids:
- Intra-articular: Triamcinolone 10-40mg (if monoarticular, septic arthritis ruled out)
- Oral prednisone: 30-40mg daily for 5 days, then taper
- IM/IV methylprednisolone: If unable to take oral (hospitalized patients)
- Use if NSAIDs/colchicine contraindicated
Supportive Care:
- Rest and elevate affected joint
- Ice application
- Avoid weight-bearing if lower extremity
DO NOT:
- Start allopurinol/febuxostat during acute attack (worsens flare)
- Start urate-lowering therapy until attack resolves (wait 2-4 weeks)
Surgical Management
Surgical Indications in Crystalline Arthropathy
Gout:
| Indication | Surgical Procedure |
|---|---|
| Carpal tunnel syndrome | Carpal tunnel release + tophus excision |
| Tendon rupture (extensor/flexor) | Tendon repair/reconstruction + tophus removal |
| Skin ulceration/draining tophus | Tophus excision, wound closure/skin graft |
| Nerve compression (ulnar, radial) | Nerve decompression + tophus excision |
| Severe erosive arthropathy | Arthroplasty or arthrodesis |
| Cosmetically unacceptable tophi | Tophus excision (elective) |
CPPD:
- Usually non-operative
- Severe wrist arthritis: Proximal row carpectomy, wrist fusion, or arthroplasty
Principle: Optimize medical management (ULT for gout) before elective surgery. Perioperative uric acid control reduces wound complications.
Complications and Outcomes
Complications of Tophaceous Gout Surgery
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Wound dehiscence | 10-20% | Optimize uric acid control pre-op, meticulous closure, avoid tension |
| Infection | 5-10% | Sterile technique, antibiotics if signs of infection, continue ULT |
| Tendon rupture | 5% | Gentle dissection, preserve tendon, may need repair/reconstruction |
| Nerve injury | Less than 5% | Careful dissection if tophus adherent to nerve |
| Recurrence of tophus | 5-10% | Adequate ULT post-op (uric acid less than 6 mg/dL) |
Wound Dehiscence:
- Most common complication (10-20%)
- Mechanism: Gout impairs wound healing, skin often friable/atrophic from chronic tophus
- Prevention: Optimize uric acid control 3-6 months pre-op, avoid skin tension, delayed closure if needed
- Management: Local wound care, secondary intention healing, delayed closure/skin graft if large
Infection:
- Higher risk than standard hand surgery (5-10%)
- Draining tophi may be colonized
- Management: Antibiotics (cover Staph aureus), debridement if abscess, continue ULT
Outcomes:
- CTS with tophus excision: 80-90% symptom improvement
- Tophus excision for skin breakdown: Wound healing in 70-80% (delayed healing common)
- Recurrence: 5-10% if inadequate uric acid control post-op
Key to Success: Perioperative and long-term uric acid control with ULT (allopurinol/febuxostat). Target less than 6 mg/dL.
Evidence Base
Guideline
📚 Richette et al
Key Findings:
- EULAR recommendations for gout management
- ULT target: uric acid less than 6 mg/dL (less than 5 mg/dL for tophaceous)
- Allopurinol first-line ULT
- Colchicine prophylaxis during ULT initiation
Clinical Implication: Evidence-based target for uric acid control: less than 6 mg/dL to prevent tophi and attacks.
Source: Ann Rheum Dis 2017
Guideline
📚 Khanna et al
Key Findings:
- ACR guidelines for gout management
- ULT recommended for recurrent attacks, tophi, erosive arthritis
- Pegloticase for refractory severe tophaceous gout
- Lifestyle modifications important
Clinical Implication: ACR supports aggressive ULT for tophaceous gout to prevent complications.
Source: Arthritis Rheumatol 2012
Case Series
📚 Baumgarten et al
Key Findings:
- Carpal tunnel release in tophaceous gout: 15 patients
- Extensive tophus excision required
- 85% symptom improvement
- Wound complications in 20%
Clinical Implication: CTR with tophus excision is effective but has higher wound complication rate.
Source: J Hand Surg Am 2014
Cohort Study
📚 Rosenthal and Mandel
Key Findings:
- Tophus excision in 30 patients
- Wound dehiscence in 15%
- Lower recurrence with adequate ULT
- Cosmetic improvement high satisfaction
Clinical Implication: Tophus excision is effective if combined with medical uric acid control.
Source: J Rheumatol 1987
Guideline
📚 Zhang et al
Key Findings:
- EULAR recommendations for CPPD management
- No disease-modifying therapy for CPPD
- NSAIDs, colchicine for acute attacks
- Low-dose colchicine may prevent recurrent attacks
Clinical Implication: CPPD management is symptomatic only - no urate-lowering equivalent.
Source: Ann Rheum Dis 2011
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
VIVA SCENARIOStandard
Scenario 1: Acute Gout Attack
EXAMINER
"A 55-year-old man presents with sudden onset severe pain and swelling in his right wrist. The wrist is red, hot, and exquisitely tender. He cannot move it. He has a history of gout affecting his great toe. What is your diagnosis and initial management?"
EXCEPTIONAL ANSWER
This is likely an acute gout attack affecting the wrist, given his history of podagra (great toe gout). However, the presentation mimics septic arthritis - red, hot, swollen joint with severe pain - so I must rule out infection. My immediate management is joint aspiration of the wrist under sterile conditions. I would send the fluid for cell count and differential, Gram stain and culture, and crucially, polarized light microscopy for crystal analysis. If I see negatively birefringent needle-shaped monosodium urate crystals, this confirms gout. The cell count in gout is typically 2,000-100,000 WBC/μL with neutrophil predominance (inflammatory but lower than septic arthritis which is usually greater than 50,000). Gram stain and culture should be negative. For acute management, I would start NSAIDs - indomethacin 50mg three times daily or naproxen 500mg twice daily - immediately to reduce inflammation. Alternatively, if he has contraindications to NSAIDs (renal impairment, GI bleeding history), I would use colchicine (1.2mg loading then 0.6mg one hour later) or corticosteroids (oral prednisone 30-40mg daily or intra-articular injection if monoarticular and infection ruled out). Supportive care includes rest, ice, and elevation. Importantly, I would NOT start allopurinol during the acute attack as this can worsen the flare - wait until the attack resolves in 2-4 weeks.
KEY POINTS TO SCORE
Joint aspiration essential to rule out septic arthritis
Gout crystals: negatively birefringent needles (yellow when parallel)
Acute treatment: NSAIDs, colchicine, or steroids
Do NOT start allopurinol during acute attack
COMMON TRAPS
✗Starting allopurinol during acute flare (worsens attack)
✗Not aspirating joint (missing septic arthritis)
✗Confusing birefringence patterns (negative = gout, positive = CPPD)
LIKELY FOLLOW-UPS
"What are the crystal characteristics in gout vs CPPD?"
"When would you start urate-lowering therapy?"
"What is the target uric acid level?"
VIVA SCENARIOChallenging
Scenario 2: Carpal Tunnel Syndrome in Tophaceous Gout
EXAMINER
"A 60-year-old man with long-standing gout presents with progressive numbness in his thumb, index, and middle fingers. He has visible chalk-like deposits on his fingers and wrist. EMG shows severe carpal tunnel syndrome. His uric acid is 9 mg/dL despite allopurinol. What is your management?"
EXCEPTIONAL ANSWER
This patient has carpal tunnel syndrome secondary to tophaceous gout - the tophi in the carpal tunnel are compressing the median nerve. This is indicated by his classic CTS symptoms, visible tophi, and EMG confirmation. His elevated uric acid (9 mg/dL) despite allopurinol suggests suboptimal medical management. My approach has two components: optimizing medical therapy and surgical decompression. First, I would work with his rheumatologist or internist to optimize urate-lowering therapy. The target is uric acid less than 6 mg/dL (ideally less than 5 for tophaceous gout). Options include increasing allopurinol dose (can go up to 800mg), switching to febuxostat, or adding a uricosuric like probenecid. For severe refractory cases, pegloticase (IV uricase) may be needed. However, given he has severe CTS on EMG with motor involvement (likely thenar atrophy), I would not delay surgery significantly. My surgical plan is open carpal tunnel release with tophus excision. The technique involves a standard CTR incision, dividing the transverse carpal ligament, then meticulously excising the chalky white tophus deposits from around the median nerve and flexor tendons. The median nerve may be encased in tophus, requiring very careful dissection. I would debulk extensively, irrigate thoroughly, and send tissue for pathology to confirm urate crystals. I would NOT close the TCL. Post-operatively, immediate finger ROM, continue his ULT, and monitor for wound dehiscence which occurs in 10-20% due to impaired healing in gout. Expected outcome is 80-90% symptom improvement, but recurrence risk is 5-10% if uric acid control is inadequate.
KEY POINTS TO SCORE
CTS from tophus in carpal tunnel
Optimize uric acid control (target less than 6 mg/dL)
Open CTR + meticulous tophus excision
Wound dehiscence risk 10-20%
COMMON TRAPS
✗Delaying surgery in severe CTS (thenar atrophy indicates nerve damage)
✗Not optimizing ULT perioperatively (increases recurrence)
✗Aggressive dissection causing median nerve injury
LIKELY FOLLOW-UPS
"What is pegloticase and when is it used?"
"What are complications of tophus excision?"
"How do you manage wound dehiscence?"
VIVA SCENARIOStandard
Scenario 3: CPPD vs Gout Differentiation
EXAMINER
"A 70-year-old woman presents with acute wrist pain and swelling. X-ray shows calcification in the triangular fibrocartilage. You aspirate the joint and see rhomboid-shaped crystals under polarized microscopy. They appear blue when parallel to the polarizer. What is your diagnosis and management?"
EXCEPTIONAL ANSWER
This is pseudogout (CPPD - calcium pyrophosphate deposition disease) affecting the wrist. The key diagnostic features are: 1) Wrist is the most common hand site for CPPD, 2) TFCC calcification on x-ray (chondrocalcinosis) is classic for CPPD, and 3) Rhomboid crystals that are positively birefringent (blue when parallel to polarizer) confirm calcium pyrophosphate crystals. This differentiates it from gout, which has negatively birefringent needle-shaped monosodium urate crystals that appear yellow when parallel. Management of acute pseudogout is similar to acute gout: NSAIDs as first-line (indomethacin or naproxen), colchicine, or corticosteroids (intra-articular injection is effective for monoarticular wrist pseudogout, or oral prednisone). The joint aspiration itself is therapeutic by relieving pressure. However, unlike gout, there is NO disease-modifying therapy for CPPD - we cannot dissolve or prevent calcium pyrophosphate crystals the way allopurinol lowers uric acid in gout. For chronic CPPD, I would screen for metabolic causes: check serum calcium, phosphate, and magnesium to rule out hyperparathyroidism, hemochromatosis, or hypomagnesemia. For patients with recurrent pseudogout attacks, low-dose colchicine 0.6mg daily can reduce flare frequency. If she develops severe chronic wrist arthritis from CPPD, surgical options include proximal row carpectomy, wrist arthrodesis, or wrist arthroplasty, but most patients are managed non-operatively.
KEY POINTS TO SCORE
CPPD crystals: positively birefringent rhomboids (blue when parallel)
TFCC calcification on x-ray is classic for CPPD
Acute management: NSAIDs, colchicine, steroids (same as gout)
No disease-modifying therapy for CPPD (unlike gout)
COMMON TRAPS
✗Confusing birefringence (positive = CPPD, negative = gout)
✗Starting allopurinol for CPPD (only works for gout)
✗Not screening for metabolic causes (hyperparathyroidism, etc.)
LIKELY FOLLOW-UPS
"What metabolic disorders are associated with CPPD?"
"What surgical options exist for CPPD wrist arthritis?"
"Can gout and CPPD coexist in the same patient?"
Australian Context
Australian Guidelines:
- eTG (Therapeutic Guidelines) supports allopurinol as first-line ULT for chronic gout
- Target uric acid less than 6 mg/dL (less than 0.36 mmol/L)
- NSAIDs with PPI for gastroprotection in acute attacks
PBS/Prescribing:
- Allopurinol: PBS-subsidized, no restriction
- Febuxostat: PBS Authority required (for allopurinol intolerance or inadequate response)
- Colchicine: PBS-subsidized for acute gout
- NSAIDs: Indomethacin, naproxen (PBS-subsidized with PPI)
- Pegloticase: Not PBS-listed (very expensive, limited access in Australia)
Medicolegal Considerations:
- Document joint aspiration and crystal analysis before diagnosing gout vs CPPD
- Rule out septic arthritis (Gram stain, culture) - medicolegal risk if missed
- Consent for tophus excision: discuss wound dehiscence (10-20%), infection (5-10%), need for skin graft
- Coordinate with rheumatology/GP for perioperative ULT management
Australian Epidemiology:
- Gout prevalence increasing (obesity, metabolic syndrome epidemic)
- CPPD common in elderly (ageing population)
- Indigenous Australians: Lower gout prevalence than Māori/Pacific Islander populations
CRYSTALLINE ARTHROPATHY - HAND
High-Yield Exam Summary
Crystal Types
- •Gout: Monosodium urate (MSU)
- •CPPD: Calcium pyrophosphate (CPP)
- •Birefringence distinguishes them
- •Joint aspiration is diagnostic
Crystal Identification
- •Gout: Negatively birefringent needles (yellow parallel)
- •CPPD: Positively birefringent rhomboids (blue parallel)
- •Polarized light microscopy essential
- •NYPD mnemonic: Negative Yellow, Positive bLue/D
Acute Gout Attack
- •Sudden severe pain, red/hot/swollen joint
- •Wrist, MCP, PIP involvement possible
- •Mimics septic arthritis (must rule out)
- •Self-limited 7-10 days
Acute Management
- •NSAIDs: Indomethacin, naproxen (first-line)
- •Colchicine: 1.2mg load, 0.6mg 1h later, 0.6mg daily
- •Steroids: Intra-articular or oral if NSAID contraindicated
- •Do NOT start allopurinol during attack
Chronic Gout (ULT)
- •Allopurinol 100-800mg daily (first-line)
- •Febuxostat 40-80mg (alternative)
- •Target: Uric acid less than 6 mg/dL (less than 5 for tophi)
- •Colchicine prophylaxis 3-6 months during ULT start
Tophaceous Gout
- •Chalky white deposits in joints/tendons
- •Complications: CTS, tendon rupture, skin ulceration
- •Punched-out erosions on x-ray (rat-bite)
- •Surgery for nerve compression, skin breakdown
Surgical Indications
- •Carpal tunnel syndrome (most common)
- •Tendon rupture (extensor/flexor)
- •Skin ulceration/draining tophus
- •Nerve compression (median, ulnar)
- •Severe erosive arthropathy
CTR in Tophaceous Gout
- •Standard CTR + tophus excision
- •Dissect tophi off median nerve carefully
- •Debulk extensively, irrigate
- •Wound dehiscence risk 10-20%
- •Continue ULT perioperatively
Tophus Excision Complications
- •Wound dehiscence: 10-20%
- •Infection: 5-10%
- •Tendon rupture: 5%
- •Nerve injury: Less than 5%
- •Recurrence: 5-10% if poor uric acid control
CPPD / Pseudogout
- •Wrist most common hand site
- •TFCC calcification (chondrocalcinosis) on x-ray
- •Acute: NSAIDs, colchicine, steroids
- •No disease-modifying therapy (no ULT equivalent)
Imaging
- •Gout: Punched-out erosions, overhanging edges
- •CPPD: Chondrocalcinosis (TFCC calcification)
- •Ultrasound: Double contour sign (gout)
- •X-ray normal in early gout
Exam Pearls
- •Rule out septic arthritis (joint aspiration mandatory)
- •Negative birefringence = gout (yellow parallel)
- •Positive birefringence = CPPD (blue parallel)
- •CTS in tophaceous gout: CTR + tophus excision
- •Target uric acid less than 6 mg/dL with ULT