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Symptom sorter – Hand and wrist swellings



The fifth in our series of abridged chapters from the expanded and updated Symptom Sorter, which gives a grassroots analysis of common presenting symptoms in primary care

The GP overview

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

Differential diagnosis

Common

• Ganglion.

• Heberden’s (and Bouchard’s) nodes.

• Myxoid cyst.

• Acute paronychia.

• Dupuytren’s contracture.

Occasional

• Infection (such as cellulitis, pulp infection, septic arthritis).

• Synovitis (traumatic, inflammatory).

• Gout (acute episode or tophi).

• Tendon xanthoma.

• Trauma or fracture.

• Insect bite (may cause marked swelling on the dorsum of the hand).

• Pyogenic granuloma.

• Trigger finger or thumb nodule.

Rare

• Tenosynovitis (common, but usually presents with pain rather than swelling).

• Garrod’s pads.

• Nephrotic syndrome.

• Synovial giant cell tumour.

Possible investigations

Likely

None.

Possible

Joint X-rays (may show joint erosions in suspected inflammatory arthritis, and may reveal features of osteoarthritis, though not usually needed for diagnosis), FBC, CRP/ESR, autoantibodies, uric acid, fasting lipid profile (to explore possible familial hypercholesterolaemia in the presence of tendon xanthomata).

Small print

Urinalysis (for nephrotic syndrome and renal involvement in inflammatory arthritis), U&E, LFT.

Top tips

• Ganglions can feel much harder than you’d expect, and the unwary may think they are dealing with a bony lump.

• A myxoid cyst may cause a groove in the fingernail.

• Bouchard’s nodes can 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 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 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.

Dr Keith Hopcroft is Pulse’s clinical adviser and a GP in Basildon, Essex