From the Research
The appropriate workup for a patient with unilateral painless hand swelling every morning should begin with a thorough history and physical examination, focusing on timing, duration, and associated symptoms. This approach is crucial in identifying potential underlying causes, which can range from inflammatory arthritis to lymphatic or venous obstruction.
Initial Evaluation
The initial evaluation should include:
- Laboratory tests such as complete blood count, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, anti-CCP antibodies, and antinuclear antibodies to evaluate for inflammatory or autoimmune conditions 1
- Imaging studies starting with plain radiographs of the affected hand to assess for bony abnormalities or joint space narrowing, followed by ultrasound to evaluate soft tissues and detect synovitis or tenosynovitis
Considerations
If morning stiffness accompanies the swelling, consider inflammatory arthritis such as rheumatoid arthritis. For persistent unexplained swelling, MRI may be necessary to evaluate for subtle joint pathology or soft tissue abnormalities. Additional tests to consider include:
- Uric acid levels for gout
- Thyroid function tests
- Renal function tests, as hypothyroidism and renal disease can cause peripheral edema
Specialist Referral
Referral to a rheumatologist is appropriate if initial workup suggests inflammatory arthritis, while vascular studies may be indicated if vascular etiology is suspected. It's also important to consider rare conditions such as Red puffy hand syndrome, which can be mistaken for inflammatory arthritis 2, and Maffucci syndrome, which can present with soft-tissue swelling 3.
Key Takeaway
A systematic approach to the workup of unilateral painless hand swelling is essential to identify the underlying cause and provide appropriate treatment, and this should be guided by the most recent and highest quality evidence available, such as the systematic review on carpal tunnel syndrome 1.