Chronic tophaceous gout – an uncommon culprit of median nerve compression in the wrist and distal forearm

Objective: Chronic tophaceous gout can lead to significant complications beyond joint damage, including compression neuropathies. Gouty tophi involving the flexor tendons are a rare but notable cause of median nerve entrapment. This report aims to highlight the clinical presentation, diagnostic process, and surgical management required for effective treatment. Case: We present the case of a male patient in his 60s with chronic tophaceous gout, who developed median nerve entrapment due to intratendinous gouty tophi compressing the nerve. The patient reported numbness in the right hand, specifically over the median nerve distribution, accompanied by thenar muscle atrophy and a palpable mass over the volar wrist. Magnetic resonance imaging (MRI) confirmed the presence of gouty tophi within the flexor tendons causing median nerve compression. The surgical intervention included an extended open carpal tunnel release, debulking of the tophi, removal of adhesions, and excision of inflamed tendon sheaths. Six months post-surgery, the patient showed significant improvement in hand numbness and grip strength, with no wound complications noted. Conclusion: This case underscores the importance of considering tophaceous gout as a differential diagnosis in cases of atypical median nerve entrapment. Routine carpal tunnel release alone may be insufficient. Comprehensive management, including the debulking of tophi, adhesiolysis, and tenosynovectomy, is essential to relieve nerve compression and enhance tendon mobility.