Wrist gout - it might take time to diagnose it

The railway junction between your hand and your forearm.

Most non medical people will be surprised to read the wrist has eight bones, called the carpals, in two rows, all of which have joints and cartilage between them. It’s all these bones that make the wrist so flexible. One of these rows connects the two bones of the forearm – the radius and ulna – to the bones of the hand – the metacarpals.

The wrist bones are held together by ligaments, and are surrounded by capsules in which the precious synovial fluid for prescribing gout accurately is located. Plus the wrist holds tendons, muscles, nerves, blood vessels and two bursae, the small sacs into which gout crystals can also deposit and which can suffer inflammation for reasons other than the gout crystals.

However, despite all these joints, wrist gout is not as common as in most other gouty areas.

Since gout normally begins down in the toes or ankles, a wrist gout flare is probably a sign of chronic gout, the stage of gout where you had your first attack a number of years ago and have suffered more flares in other joints.

At this gout stage, it might be that attacks "fly" from one joint to another, and up to an ear, in a single painful session.

A tophus is the chalky-like white matter that grows from gout’s accumulated MSU crystals which get deposited out of the serum (blood) every time you have a gout attack. It usually forms a shape like a knobbly lump under the skin, but in smaller amounts it can be deposited on cartilage, tendons, (and their sheaths),
ligaments, in and on bones, in the ears, and even on the floor of the wrist's carpal tunnel (see below). All these deposit places apply to the wrist too. Tophi don’t usually form in gout patients until they have suffered gout, without successful treatment, for about 10 years, although two years has been known.

A first attack in the wrist is rare, and this fact helps to rule out gout from all the other afflictions that affect the wrist – carpal tunnel syndrome, rheumatoid arthritis, osteoarthritis, tendinitis, pseudo gout, ganglion cysts, bursitis, repetitive stress injury and others.

Ganglion cysts are swellings but they are not painful, merely uncomfortable, and they certainly do not cause the severe pain of gout. Unlike gout’s crystals, pseudo gout’s crystals, a different kind, can usually be seen by X ray.

More about the difference between gout and pseudo gout here.  

Gout can cause these wrist problems

Tendinitis is inflammation of the wrist’s tendons.  A variant, tensosynovitis, is inflammation of the tendons plus their protecting sheath, if they have one. If either is caused by gout, tendons will be encrusted or inflamed by tophi. Bursitis is inflammation of the bursa sacs where gout is suspected if they are very inflamed. Gout is not the only, or main cause of bursitis, but it is if the inflammation is caused by gout crystals or tophi.

What's a wrist gout attack like?

If it’s gout of the wrist, you’ve probably had a gout flare somewhere else before. Gout can attack both sides of the wrist. Its crystals can infest into or onto the fluid sacs, cartilage, tendon and the bursae. Over time, without successful treatment, tophi will grow on and into the bones. You could end up with a tophi lump on your wrist. The wrist will be inflamed, sore, very painful and the skin, reddish.  No prizes for guessing that you’ll have lost the ability to move the hand. Or you’ll have very limited movement. Normal service from the wrist will resume after the attack is over.

A gout wrist could be difficult to diagnose

It may take time before you learn that this is a gout attack, and not one of the many other afflictions that can affect the wrist. The best test for a diagnosis of gout is whether the needle-shaped MSU gout crystals can be seen under the lens of a polarising (polarizing) microscope. The test requires removing synovial fluid out of the affected joint.

However, in some joints it’s difficult for the doctor to get enough synovial fluid out, to examine for the presence of gout crystals. Unfortunately, the wrist is one such series of joints because of all those small bones. If another joint is also inflamed, that one can be searched in the same way for MSU crystals. The best wrist joint for getting fluid is said to be the forearm radius joint adjacent to some of the wrist’s carpal bones - the radiocarpal joint.

Your rheumatologist, or other doctor, might be able to do it, s/he might not. A rheumatologist who has the necessary polarising (polarizing) microscope on the premises, which s/he often uses, is best.

If this diagnosis of gout isn’t possible, a judgement has to be made of how many of all the other distinguishing marks of gout your medical history and your wrist have. These are the major hallmarks of gout - compare them with your wrist’s condition and your medical history:

•    Most important – have you had a wrist gout attack, or gout attack elsewhere, before?

•    Has the affected wrist been injured before? Sprains, broken wrists – gout often goes for places that have been injured.

•    Although the pain and inflammation may continue for weeks, did the size of the inflammation peak after 12-24 hours?
•    Is the wrist red, swollen, sore and very painful?

•    Was the attack accompanied by a fever? In gout (and pseudo gout) it may be.

•    Is your uric acid level (UA) above normal? This is NOT conclusive of gout, merely indicative, because most people with an above normal UA level never have a gout attack, and people with normal UA may get one. The UA level should be taken after the gout attack because if it is taken during a gout attack it will probably be lower than usual.

•    Are you are heavy drinker?

•    Are your kidneys functioning normally? Mal-performing kidneys raise uric acid levels.

•    Has a family member, past and present, had gout?

•    Do you have the classic conditions of the metabolic syndrome - obesity, high blood sugar, hyperlipidemia (hyperlipidaemia) - elevated blood fats such as triglycerides and cholesterol - and insulin resistance?

•    What other meds are you taking? For example are you taking one of the thiazide diuretic class of drugs for high blood pressure? They raise uric acid levels, and can therefore trigger gout.

•     Did the attack begin during the night? Gout attacks frequently do.

A tophus or tophi (plural) in the wrist, can lead to carpal tunnel syndrome, although it’s rare

Carpal tunnel syndrome (CTS) is the squeezing of the median nerve which runs through the wrist and into the hand. It is normally caused by swelling fibres (fibers) – ligaments and tendons – on the palm (inside) side of the wrist, which squeeze the nerve. So you can easily imagine that deposited tophi on adjacent tendons or ligaments can squeeze this nerve and cause CTS. CTS causes tingles, numbness and finger pain. It can be treated with NSAID’s, or if they don’t work, by an anti-inflammatory corticosteroid such as cortisone, injected into the affected area. Failing that, by surgery to remove the pressure on the nerve. In gout’s case, by surgery to remove the tophus or tophi. Or you solve it because you get uric acid down to levels at which tophi shrink, eventually away.

What can you do about wrist gout pain?

Epsom salts Some report relief from Epsom salts and it's worth finding out if they give you some relief, and when during a wrist gout attack. There's more information about using Epsom salts on our ankle gout page.

Cabbage leaves Wrapping your wrist(s) in chilled cabbage leaves may seem like a whacky, oddball method but there is a rational behind it. Read more on our gout foot pain page

Ice  Icing the wrist may also bring relief, but it might also encourage more crystal deposition since crystal deposition is very likely to be promoted by the cold. So if ice gives you some relief, stop it as soon as you think you’ve got the most relief you’re going to get. A survey a few years ago showed that more gout sufferers thought they could get relief from ice, than those who thought they could get it from heat.

Medicines There are no specific conventional gout medicine treatments for gout of the wrist. For pain you will be given an NSAID, such as indomethacin, and perhaps colchicine to halt an attack. If they fail to work – corticosteroids.

As with gout in all body areas, the long term aim of all types of treatment is to lower the serum (blood) uric acid level to below the level at which gout crystals dissolve and tophi shrinks, wherever they are located. This level is thought to be below 6.0 mg/dL (men) and around 5.5 mg/dL (women), but precisely it is a personal matter between you and your gout. You may need to go lower.

With medications, lowering uric acid to these levels and dissolving crystals can occur within six months to two years for most people, especially if you are healthy in other respects. But you will be on guard against gout for the rest of your life. With natural remedies you may be able to lower uric acid sufficiently too, and stave off impending gout attacks with them. You can find details of the drugs and the natural gout remedies on the rest of this website.

This page about wrist gout was last reviewed, or updated, on 29 August 2010.

Related topics.You might also enjoy

Big toe gout is a big gout issue 

Read why finger gout may be one of the worst kinds of gout you can get. 

Elbow gout is different to gout in other body areas. Read why and how here. 

Read about features of gout foot pain, including a home remedy that might help.

Knee gout is about more than knobbly knees.

Read what it's like when gout attacks the ears. 

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