Gouty tenosynovitis with compartment syndrome in the hand: A case report

Abstract

Background: Gout is a common type of inflammatory arthritis caused by the deposition of monosodium urate crystals in the joints and surrounding tissues. It typically appears with abrupt and intense pain, redness, and swelling in the affected joint. It frequently targets the lower extremities, such as the big toe. However, rarely, gout can manifest in atypical locations, including the hands, leading to an uncommon presentation known as gouty tenosynovitis. However, it can result in significant morbidity owing to the potential for severe complications, such as myonecrosis and compartment syndrome.

Case summary: An 82-year-old male patient with a history of hypertension, cerebral infarction, Parkinson's disease, and recurrent gout attacks sought medical attention because of progressive pain and swelling in the right hand. Imaging findings revealed forearm swelling, raising concerns of possible tenosynovitis, bursitis, septic arthritis, and compartment syndrome. A fasciotomy was performed to decompress the patient's hands and forearms. The procedure revealed diffuse tenosynovitis, tophi with a pus-like discharge surrounding the carpal tunnel, and involvement of the flexor and extensor tendon sheaths. However, microbiological investigations, including Gram staining, acid-fast bacilli, tuberculosis, and non-tuberculous mycobacteria, yielded negative results. The patient was ultimately diagnosed with a severe gouty attack with compartment syndrome and myonecrosis. Septic arthritis and infectious flexor tenosynovitis were ruled out. Serial debridement and inflammation control were initiated, followed by staged closure with a skin graft.

Conclusion: Septic-like complications can occur in the absence of infection in severe gout attacks with pus-like discharges due to compartment syndrome and myonecrosis. Cultures can be used to differentiate between gouty attacks, septic arthritis, and infectious tenosynovitis. Involvement of the flexor and extensor muscles, as in this case, is rare. This study contributes to the literature by reporting a rare case of successful fasciotomy and serial debridement in an elderly patient with multiple comorbidities.

Keywords: Case report; Compartment syndrome; Extensor compartment; Gout; Tenosynovitis.