Hand and Wrist Swellings
The presentation of a hand or wrist swelling has a low chance of being anything sinister or time-consuming. That said, the differential is wide and a definite diagnosis can be difficult.
Differential diagnosis
Common Diagnoses
- Ganglion
- Heberden’s (and Bouchard’s) Nodes
- Myxoid Cyst
- Acute Paronychia
- Dupuytren’s Contracture
Occasional Diagnoses
- Infection (e.g. Cellulitis, Pulp Infection, Septic Arthritis)
- Synovitis (Traumatic, Inflammatory)
- Gout (Acute Episode or Tophi)
- Tendon Xanthoma
- Trauma/Fracture
- Insect Bite (May Cause Marked Swelling on the Dorsum of the Hand)
- Pyogenic Granuloma
- Trigger Finger/Thumb
Rare Diagnoses
- Tenosynovitis (Common, but Usually Presents with Pain Rather Than Swelling)
- Garrod’s Pads
- Nephrotic Syndrome
- Synovial Giant Cell Tumour
Ready reckoner
Key distinguishing features of the most common diagnoses
| Ganglion | Heberden’s Nodes | Myxoid Cyst | Acute Paronychia | Dupuytren’s Contracture | |
|---|---|---|---|---|---|
| Multiple Swellings on Same Hand/Wrist | No | Possible | Possible | No | Possible |
| Painful | Possible | Possible | Possible | Yes | No |
| Closely Associated with Nail | No | No | Yes | Yes | No |
| Firm Swelling | Possible | Yes | No | No | Possible |
| Over a Joint | Yes | Yes | No | No | No |
Possible investigations
Likely: None.
Possible: Joint X-rays, FBC, CRP/ESR, autoantibodies, uric acid, fasting lipid profile.
Small Print: Urinalysis, U&E, LFT.
- Joint X-rays: May show joint erosions in suspected inflammatory arthritis; will show features of osteoarthritis (though not usually needed for diagnosis); will reveal any fracture.
- FBC, ESR, CRP: May be normochromic, normocytic anaemia in inflammatory arthritis; white count and ESR/CRP elevated in infection, though rarely required to confirm this in primary care.
- Autoantibodies: Rheumatoid factor (anti-CCP antibodies if negative) and anti-nuclear factor may be helpful in diagnosis of inflammatory arthritis.
- Uric acid: For suspected gout.
- Fasting lipid profile: To explore the possibility of familial hypercholesterolaemia in the presence of tendon xanthomata.
- Urinalysis: Proteinuria and possibly haematuria in nephrotic syndrome (the latter may also be present in inflammatory arthritis).
- U&E, LFT: U&Es may be abnormal in any renal disease causing nephrotic syndrome; this will also cause hypoalbuminemia.
Top Tips
- Ganglions can feel much harder than you’d expect, misleading the unwary into thinking that they are dealing with a bony lump.
- A myxoid cyst may cause a groove in the fingernail.
- Bouchard’s nodes can sometimes mimic inflammatory arthritis – the asymmetry and the presence of associated Heberden’s nodes should help make the correct diagnosis of osteoarthritis.
- Don’t overlook the possibility that hand and wrist swellings can sometimes be a marker for systemic issues such as hyperuricaemia or hypercholesterolaemia.
Red Flags
- Beware the single, hot swollen, painful joint, especially with marked limitation of movement, fever and systemic upset – this is septic arthritis until proven otherwise.
- Take finger pulp infections seriously – these are in a confined space and so can compromise the vascular supply. They can also spread rapidly to bone or tendon, so ensure that all but the most trivial are seen in hospital.
- Remember that inflammatory arthritis is a clinical diagnosis. Do not be delayed or misled by blood tests – refer urgently to rheumatology outpatients if suspected.
- Consider the rare possibility of nephrotic syndrome in the patient with bilateral oedematous hands.