Hand and Wrist Swellings

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

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


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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