Gout & Pseudogout
Crystal Arthropathy
Jacksonville, FL
Sudden, severe joint pain — often at night, often in the wrist or finger — with swelling, redness, and warmth that looks almost like an infection. Dr. R. David Graham at JOI diagnoses and manages crystal arthropathy in the hand and upper extremity, coordinates with primary care and rheumatology for long-term management, and addresses the surgical complications of chronic tophaceous gout.
- Gout: monosodium urate crystals — hyperuricemia is the driver
- Pseudogout: calcium pyrophosphate crystals — wrist is a common site
- Aspiration for diagnosis: crystal analysis + culture to exclude septic joint
- Acute management: NSAIDs, colchicine, or short-course corticosteroids
- Long-term urate management coordinated with primary care / rheumatology
- Surgical: tophaceous deposits compressing nerves or rupturing tendons — excision
Gout and pseudogout can mimic septic arthritis. Aspiration with crystal analysis and culture is the key diagnostic step — it confirms the diagnosis and excludes infection simultaneously.
Understanding Crystal Arthropathy
Sudden Joint Pain That Looks
Like an Infection — But Isn't
Gout and pseudogout are crystal arthropathies — inflammatory arthritis caused by deposition of crystals in joints and soft tissues. Gout results from monosodium urate crystals accumulating when serum uric acid levels exceed the saturation threshold. Pseudogout results from calcium pyrophosphate (CPPD) crystal deposition, often associated with aging or underlying metabolic conditions. Both produce acute inflammatory attacks that can closely mimic a septic joint — sudden onset, severe pain, swelling, redness, and warmth.
In the upper extremity, gout commonly affects the wrist and MCP joints. Pseudogout has a predilection for the wrist — CPPD crystals frequently deposit in the triangular fibrocartilage and intercarpal ligaments, producing acute wrist pain and swelling that can be dramatic. The knee and ankle are the most common sites overall, but upper extremity involvement is well recognized.
The critical diagnostic step is aspiration. Joint aspiration and synovial fluid analysis — crystal examination under polarized microscopy plus culture — simultaneously confirms the crystal arthropathy diagnosis and excludes a septic joint. Septic arthritis requires urgent surgical irrigation and debridement; crystal arthropathy is managed medically. Getting this distinction right on the same day matters.
Dr. Graham manages the acute evaluation, aspiration, and acute treatment, coordinating with primary care or rheumatology for the long-term urate-lowering therapy (allopurinol, febuxostat) that prevents gout recurrence. The surgical complications of chronic tophaceous gout — deposits that accumulate over years and compress nerves or rupture tendons — are addressed operatively when they arise.
- ✓ Gout: monosodium urate crystals, negative birefringence under polarized light, needle-shaped
- ✓ Pseudogout (CPPD): calcium pyrophosphate, weakly positive birefringence, rhomboid-shaped
- ✓ Both: aspirate and examine under polarized microscopy — culture simultaneously
- ✓ Gout triggers: dietary purines, alcohol, dehydration, medications (diuretics)
- ✓ Pseudogout triggers: aging, trauma, illness, surgery (including unrelated procedures)
- ✓ Both: NSAIDs or colchicine acutely; urate-lowering therapy for gout prevention
Treatment
Acute Management and Surgical Complications
Acute Attack Management
NSAIDs (indomethacin, naproxen) are first-line when tolerated. Colchicine is effective early in an attack. Short-course oral corticosteroids or intra-articular cortisone injection for patients who cannot take NSAIDs or colchicine. Aspiration of a tense joint provides diagnostic information and immediate mechanical pain relief.
Long-term urate-lowering therapy (allopurinol, febuxostat) for gout is coordinated with the patient's primary care physician or rheumatologist — the goal is sustained serum uric acid below 6.0 mg/dL.
Surgical Complications of Tophaceous Gout
Chronic gout that is not adequately controlled produces tophaceous deposits — chalky white urate aggregates in the soft tissues of the hand, wrist, and elbow. These deposits can:
- Compress the median or ulnar nerve (carpal or Guyon's tunnel)
- Erode through the extensor or flexor tendons, producing rupture
- Drain spontaneously through the skin (tophi) — sterile, but require wound management
- Restrict joint motion from intra-articular deposits
When tophaceous deposits produce nerve compression or tendon rupture, Dr. Graham performs surgical excision of the deposits and repair of the damaged structures.
FAQs
Frequently Asked Questions
Related Conditions
Next Steps
Sudden severe joint pain —
needs same-day evaluation.
Acute gout and pseudogout attacks are painful and need to be distinguished from septic arthritis, which is a surgical emergency. Walk-ins seen same day via JOI Now, Monday–Friday.
Jacksonville Beach, FL 32250
Walk-ins welcome via JOI Now for acute joint pain.