Introduction
Swellings of the hand and wrist represent a frequent reason for presentation in orthopaedic, rheumatology, and primary care settings. The majority are benign; however, accurate diagnosis is essential to exclude sinister pathology and to guide appropriate management. This article provides a structured, scientific overview of common hand and wrist swellings, focusing on clinical examination, differential diagnosis, investigations, and treatment pathways.
Orthopaedic Terminology Relevant to Hand and Wrist Swellings
A clear understanding of standard orthopaedic terminology is essential for accurate diagnosis and communication:
Carpal Boss: A bony prominence arising from the dorsal aspect of the carpometacarpal joints.
Dupuytren’s Disease: A benign fibroproliferative disorder characterised by palmar nodules and cords.
Garrod’s Pads: Benign fibrotic thickening over the dorsal proximal interphalangeal or metacarpophalangeal joints, commonly associated with Dupuytren’s disease.
Giant Cell Tumour of Tendon Sheath: A benign but locally aggressive tumour arising from tendon sheaths.
Glomus Body: A specialised dermal structure involved in thermoregulation.
Glomus Tumour: A benign neoplasm originating from the glomus body.
Ganglion: A benign cystic swelling composed of compressed collagen containing joint or tendon sheath fluid.
Mucous Cyst: A ganglion variant arising at the dorsal distal interphalangeal joint, often associated with osteoarthritis.
Retinacular Cyst: A ganglion arising from the flexor pulley system.
Osteophyte: A bony spur forming at joint margins in degenerative joint disease.
Clinical Examination of Hand and Wrist Swellings
Inspection
Assess overall hand and wrist posture bilaterally
Identify signs of systemic pathology (e.g., inflammatory arthritis)
Ask the patient to demonstrate the swelling
Observe whether the swelling moves during fist formation
Palpation
Key features to assess include:
Shape and outline
Consistency and fluctuation
Tenderness and mobility
Pulsatility
Relationship to adjacent joints or tendons
Transillumination using a pen torch
Movement Assessment
Evaluate flexor and extensor tendon integrity
Perform tenodesis testing for extensor function
Isolate flexor digitorum superficialis and profundus function
Assess wrist and finger range of motion
Normal Range of Motion Values are summarised in clinical reference tables and should be used as comparison standards.
Functional and Vascular Assessment
Assess functional reach and grip patterns
Perform Allen’s test to evaluate radial and ulnar artery patency
Common Hand and Wrist Swellings
Ganglion Cysts
Overview
Ganglion cysts are the most common benign hand swellings. They arise from joints or tendon sheaths and are most frequently located dorsally.
Clinical Features
Atraumatic onset
Fluctuating size
Typically painless
May cause mechanical symptoms
Investigation
Imaging is usually unnecessary
Ultrasound or MRI may be used for atypical presentations
Management
First-line: reassurance and observation
Aspiration may be considered but has a high recurrence rate
Surgical excision carries a recurrence risk and limited patient satisfaction
Prognosis
60% resolve spontaneously
Recurrence is common after aspiration or surgery
Retinacular Cysts
These benign swellings originate from the flexor pulley system and do not move with finger motion.
Management
Primarily conservative
Surgery is reserved for persistent symptoms but is associated with poor outcomes
Mucous Cysts
Mucous cysts are associated with degenerative arthritis of the distal interphalangeal joint and may cause skin erosion in severe cases.
Key Points
Often painless but may cause mechanical irritation
Aspiration is unreliable
Surgery carries risks and variable outcomes
Glomus Tumours
Glomus tumours are rare but classically present with severe pain and cold sensitivity beneath the nail plate.
Diagnosis
Primarily clinical
Imaging is rarely required
Treatment
Surgical excision is the definitive treatment
Recurrence occurs in approximately 25% of cases
Giant Cell Tumour of Tendon Sheath
These benign yet locally aggressive lesions arise from tendon sheaths and can cause neurovascular compression.
Management
Surgical referral is mandatory
MRI is required for diagnostic confirmation
Carpal Boss
Carpal bossing presents as a firm dorsal bony prominence over the second or third carpometacarpal joint.
Management
Conservative treatment is effective in most cases
Surgery is reserved for refractory symptoms
Treatment Algorithms and Physiotherapy
Most hand and wrist swellings are managed conservatively. Physiotherapy may assist in symptom control, functional restoration, and patient education. Exercise programmes should be individualised, with emphasis on range of motion, strength, and activity modification.
Conclusion
The majority of hand and wrist swellings are benign and self-limiting. A structured clinical examination, combined with judicious use of imaging and appropriate referral pathways, allows for accurate diagnosis and effective management. Patient education and expectation management are central to achieving satisfactory outcomes.