Hand and Wrist Swellings

The presentation of a hand or wrist swelling may well be a welcome interlude in the average surgery, offering the opportunity for a quick spot-diagnosis, with a low chance of anything sinister or time-consuming. That said, the differential is wide and a definite diagnosis can be difficult.

Published: 2nd August 2022 | Updated: 15th August 2022

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

GanglionHeberden’s NodesMyxoid CystAcute ParonychiaDupuytren’s Contracture
Multiple Swellings on Same Hand/WristNoPossiblePossibleNoPossible
Closely Associated with NailNoNoYesYesNo
Firm SwellingPossibleYesNoNoPossible
Over a JointYesYesNoNoNo

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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.