A middle-aged man with pain and swelling of the hands.

Figure 2 Answer Mr RA has chronic tophaceous gout. The swellings around the knuckles and on both index fingers are tophi (Figure 1). Terminal phalanx of right index finger is amputated. He also has tophi over lateral malleolus of right foot (Figure 2), olecranon bursa (Figure 3) and helix of the pinna (Figure 4). When they are on the dorsum of the hand, they may be confused with the tendon xanthoma or ganglion. It is then advisable to look for chalky material within the swelling (as in gouty tophus) or fixity to the tendons (which occur in tendon xanthoma).