Hand & Wrist

Gout and Pseudogout of the Hand and Wrist

Gout and pseudogout can look alike but are treated differently, and the wrist is a common site for both. Dr. Peter FitzGibbons evaluates hand and wrist crystal arthritis for patients in Bethesda, Germantown, and throughout Montgomery County.

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What is gout and pseudogout of the hand and wrist?

Gout and pseudogout are crystal-induced arthritis affecting the hand and wrist. Gout is caused by monosodium urate crystals from high uric acid, while pseudogout comes from calcium pyrophosphate crystals, most often in the wrist. Both cause sudden, painful, swollen joints. Diagnosis relies on joint fluid analysis, and most cases respond well to medication rather than surgery.

Gout and pseudogout are both forms of crystal-induced inflammatory arthritis, meaning the joint pain and swelling come from crystals that form inside the joint rather than from wear-and-tear arthritis or infection. Despite the similar names and similar-looking attacks, they are caused by two entirely different substances.

Gout is caused by deposits of monosodium urate (MSU) crystals, which form when the level of uric acid in the blood exceeds its solubility limit, roughly 6.8 mg/dL, over a sustained period (StatPearls, Gout). Genetics is the primary driver of a person's baseline uric acid level, and obesity, insulin resistance, high cholesterol, heart disease, hypothyroidism, and kidney disease all contribute; gout flares have also been reported after injury, surgery, infection, and even after intravenous contrast dye for imaging studies (ASSH HandCare, Gout in Hands). Gout classically affects the big toe, but the elbow, wrist, and finger joints are also common sites (ASSH HandCare).

Pseudogout, more precisely called acute calcium pyrophosphate (CPP) crystal arthritis, is one presentation of a broader condition called calcium pyrophosphate deposition disease (CPPD). Instead of urate, the culprit is calcium pyrophosphate dihydrate crystals deposited in cartilage, the joint lining, and surrounding tissue (Azam, Minalyan & Naik, StatPearls, CPPD). When this deposition is visible on x-ray within cartilage, it's called chondrocalcinosis. In the wrist specifically, this deposition classically involves the triangular fibrocartilage complex, a cushioning structure on the pinky side of the wrist, and a specific pattern involving the joint between the scaphoid, trapezium, and trapezoid bones. CPPD can also produce a pattern of progressive wrist collapse (called SLAC wrist) as the ligament between two of the wrist's carpal bones deteriorates over time (Saffar, "Chondrocalcinosis of the wrist," J Hand Surg Br). CPPD is strongly linked to aging, affecting 30 to 50 percent of people over 85, and is also associated with iron overload (hemochromatosis), overactive parathyroid glands, and low magnesium levels (StatPearls, CPPD). While the knee is the single most common joint affected by an acute pseudogout attack overall, the wrist is a leading site specifically for hand and upper-extremity attacks (StatPearls, CPPD).

Symptoms — do you recognize these?

Acute attacks of gout and pseudogout often look alike, which is one reason lab testing matters.

Sudden, severe pain in a joint, often the wrist, along with redness, warmth, and swelling
Symptoms severe enough to mimic a joint infection
With gout specifically, painless chalky deposits called tophi that build up under the skin over time if the condition goes untreated, which can erode through tendons or skin
With chronic CPPD, a more persistent, symmetrical joint swelling and stiffness in the hands and wrists that can resemble rheumatoid arthritis
Attacks that come and go, with symptom-free periods in between

If a joint is acutely hot, swollen, and severely painful, especially with fever, this can look identical to a joint infection and needs prompt evaluation. Call our office or seek urgent care so the fluid inside the joint can be tested, since treating an infection and treating a crystal flare require very different approaches.

How we diagnose it

Diagnosis combines history, physical exam, x-rays, and laboratory testing, but the single most useful test for either condition is joint fluid aspiration, removing a small sample of fluid from the joint with a needle and examining it under a polarized light microscope. This is considered the gold-standard test for pseudogout in particular (StatPearls, CPPD).

The crystals themselves look distinctly different under the microscope, and this difference is the single most reliable way to tell the two conditions apart. Monosodium urate crystals in gout are needle-shaped and strongly negatively birefringent under polarized light. Calcium pyrophosphate crystals in pseudogout are rhomboid or parallelogram-shaped and only weakly positively birefringent (StatPearls, CPPD; MacMullan & McCarthy, Ther Adv Musculoskelet Dis). Uric acid crystals themselves don't show up on plain x-ray, though chronic gout can produce characteristic erosions with overhanging edges near the joint over time (ASSH HandCare). Chondrocalcinosis, the radiographic sign of CPPD, appears as fine calcific deposits within cartilage, but plain x-ray only detects it in about 40 percent of clinically significant cases; ultrasound is more sensitive, and dual-energy CT is the most sensitive imaging test available and can even help distinguish crystal types (StatPearls, CPPD).

Because an acute crystal flare can look exactly like a joint infection, including fever and abnormal blood markers, we generally send aspirated joint fluid for Gram stain and culture as well as crystal analysis before treating a presumed flare, to be sure we aren't missing an infection (MacMullan & McCarthy). The American College of Rheumatology and the European League Against Rheumatism jointly published the first validated classification criteria for CPPD in recent years, which combine clinical findings and crystal identification into a scoring system used to support the diagnosis, and similarly updated criteria exist for gout (StatPearls, CPPD; StatPearls, Gout). These criteria are tools used alongside clinical judgment rather than a replacement for it.

Treatment options

Both conditions are managed primarily with medication. Surgery is reserved for structural damage that has already occurred, not for treating an acute flare itself.

NSAIDs and colchicine for acute gout

Anti-inflammatory medication and colchicine are first-line treatment for an acute gout flare, with oral or injected corticosteroids used when those aren't sufficient or are contraindicated.

When used: Acute gout attacks, along with splinting and compression to reduce swelling during the flare (ASSH HandCare).

Urate-lowering therapy

Ongoing medication, generally managed by a primary care physician or rheumatologist, to lower baseline uric acid and prevent future flares and tophus formation.

When used: Patients with frequent gout flares rather than occasional isolated attacks (ASSH HandCare).

Corticosteroid injection and oral steroids for pseudogout

An injection of corticosteroid directly into the joint after aspiration is described as extremely effective for a single involved joint such as the wrist. For attacks in multiple joints, a short course of oral steroids with a rapid taper, supported by a 2023 randomized trial, is considered effective first-line therapy.

When used: Acute pseudogout flares, particularly isolated wrist attacks (StatPearls, CPPD; MacMullan & McCarthy).

Colchicine for recurrent or chronic CPPD

Low-dose colchicine used regularly to reduce the frequency of recurrent attacks, with methotrexate as a second-line option for chronic inflammatory CPPD. Unlike gout, there is no medication that reduces the crystal deposits themselves; treatment addresses symptoms rather than the underlying deposition.

When used: Recurrent acute attacks or chronic CPP inflammatory arthritis.

Recovery & rehabilitation

Acute pseudogout attacks are generally self-limited, typically lasting 7 to 10 days, though some persist up to 3 months despite treatment (StatPearls, CPPD; MacMullan & McCarthy). Because there is no medication that reduces the calcium pyrophosphate crystal burden itself, chronic CPPD wrist arthritis tends to progress gradually over years and is managed symptomatically until a joint becomes damaged enough to need salvage surgery.

Gout, by contrast, is one of the few forms of arthritis where the underlying disease can genuinely be controlled with medication. When urate-lowering therapy is maintained consistently after tophus removal, results are durable; when it is not, new tophi and flares can recur quickly. In one surgical series, a patient who was not adequately controlled on urate-lowering medication developed a new acute gout flare in the opposite wrist within a month of having a tophus removed elsewhere (Kirschenbaum et al.), which illustrates why we emphasize that surgery addresses the existing damage but does not substitute for ongoing medical management of uric acid levels.

Frequently Asked Questions

How can I tell if I have gout or pseudogout in my wrist?

The two conditions can look nearly identical during an attack: sudden pain, redness, warmth, and swelling. The only reliable way to distinguish them is by aspirating fluid from the joint and examining it under a polarized light microscope. Gout crystals are needle-shaped, while pseudogout crystals are rhomboid-shaped, and each has a different pattern of light bending (birefringence) that a lab can identify. Blood tests for uric acid and x-rays provide supporting information but are not definitive on their own.

Why does my wrist hurt from gout when I thought gout only affects the big toe?

Gout classically starts in the big toe, but it commonly affects other joints too, including the wrist, elbow, and finger joints. If you've had gout elsewhere before, a new attack in your wrist is entirely consistent with the same underlying disease, and the diagnosis and treatment approach are the same regardless of which joint is affected.

Is pseudogout the same thing as gout, just a milder version?

No, they are caused by entirely different crystals and have different long-term treatment. Gout comes from uric acid crystals and can be effectively controlled long-term with urate-lowering medication that prevents future flares. Pseudogout comes from calcium pyrophosphate crystals, and unfortunately there is currently no medication that reduces those crystal deposits once they've formed; treatment manages symptoms during flares and over the long term rather than reversing the underlying process.

Do I need surgery for gout or pseudogout in my hand?

Most people never need surgery for either condition; medication controls the great majority of cases. Surgery becomes relevant for gout when large tophi have caused skin breakdown, significantly limited joint motion, or pressed on a nerve, and it's typically only recommended once you are committed to ongoing urate-lowering medication, since surgery removes existing tophi but doesn't prevent new ones without medical control. For pseudogout, surgery is reserved for advanced wrist joint damage that has developed over years and isn't responding to symptom-directed treatment.

What are those hard lumps on my knuckles, and are they dangerous?

If you have a history of gout, hard, sometimes chalky-feeling lumps near joints or tendons are likely tophi, deposits of uric acid crystals that accumulate under the skin when gout goes untreated or undertreated over time. They are usually painless at first but can eventually erode through overlying skin or weaken a nearby tendon to the point of rupture, so they shouldn't be ignored even if they don't currently hurt. Bringing uric acid under control with medication is the most important step, and surgical removal is an option if a tophus is causing functional problems.

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Peter G. Fitzgibbons, MD

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Medically reviewed by Peter G. Fitzgibbons, MD, MD

Last reviewed August 5, 2026