The authors report an unusual case of flexor
tenosynovitis, severe
carpal tunnel syndrome, and triggering at the carpal tunnel as the first manifestation of
gout. A 69-year-old man presented with digital flexion
contracture and severe
carpal tunnel syndrome of his right hand and was treated surgically. A flexor tenosynovectomy and a median nerve neurolysis were performed through an extended carpal tunnel approach. The sublimis and the profundus tendons were involved. Partial
ruptures and multiple whitish lesions suggestive of tophacceous infiltration of the flexor tendons were seen. Macroscopically, the removed synovial tissue was involved by multiple whitish nodules that were milimetric in size and was suggestive of
monosodium urate crystals deposits. By light microscopy examination, numerous nonnecrotizing
granulomas of different sizes were observed that were compounded by large aggregations of acellular nonpolarized material, surrounded by epithelioid histiocytes, mononuclear cells, and
foreign body multinucleated giant cells. Postoperatively, the patient recovered with resolution of the median nerve symptoms and a near-to-full range of motion of the affected digits.To the authors' knowledge, this patient is the first case report with flexor tendons tophacceous infiltration as the first clinical sign of
gout. Gouty flexor
tenosynovitis can occur in the absence of a long history of
gout. A high index of suspicion is paramount to the initiation of proper management. Operative treatment of gouty flexor
tenosynovitis is mandatory to debulk tophaceous deposits, improve tendon gliding, and decompress nerves. Routine
uric acid determination could be helpful in the preoperative evaluation of patients with flexor
tenosynovitis.