What is the appropriate workup and management for a patient presenting with hand swelling and pain?

Workup and Management of Hand Swelling and Pain

The initial imaging evaluation of hand or wrist pain and swelling should begin with radiographs (posteroanterior, lateral, and oblique views), which may be the only imaging examination needed to establish a diagnosis in many cases. 1

Initial Assessment

Clinical Evaluation

• Assess for:
  • Joint swelling, tenderness, and range of motion limitations
  • Distribution pattern (single joint vs multiple joints)
  • Presence of erythema, warmth, or skin changes
  • Neurovascular status (pulses, capillary refill, sensation)
  • Recent trauma or procedures (including IV access, dialysis fistulas, surgeries)
  • Systemic symptoms (fever, fatigue)

First-Line Diagnostic Testing

1. Radiographs (3 views: posteroanterior, lateral, and oblique) 1

   • Evaluates for:
     • Fractures or dislocations
     • Arthritis (osteoarthritis, inflammatory arthritis)
     • Bone tumors or lesions
     • Soft tissue swelling

2. Laboratory studies (if inflammatory or infectious etiology suspected):

   • Complete blood count
   • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
   • Urinalysis
   • Liver function tests (transaminases)
   • Antinuclear antibodies 1

Further Diagnostic Workup Based on Initial Findings

If Radiographs Are Normal or Show Nonspecific Findings

1. Ultrasound (US) 1

   • Particularly useful for:
     • Synovitis
     • Joint effusions
     • Tenosynovitis and tendon injuries
     • Soft tissue masses
     • Retained foreign bodies
     • Carpal tunnel syndrome
   • Advantages: Dynamic assessment possible, can compare with contralateral side

2. MRI without IV contrast 1

   • Indicated when ultrasound is inconclusive or for deeper structures
   • Can demonstrate:
     • Arthritis
     • Tendinopathy
     • Ligament injuries
     • Chondral injuries
     • Bone marrow edema

For Specific Clinical Scenarios

If Dialysis Fistula-Related Hand Swelling/Pain

1. Duplex Doppler Ultrasound 1

   • Evaluates for:
     • Flow reversal distal to arterial anastomosis
     • Bidirectional flow
     • Venous outflow obstruction

2. Fluoroscopic Fistulography 1

   • If dialysis-associated steal syndrome (DASS) is suspected
   • Provides visualization from aortic arch to palmar arch

If Compartment Syndrome Suspected

• Emergent surgical consultation for compartment pressure measurement 2, 3
• CT may help evaluate compartment anatomy and identify collections 4

If Infection Suspected

• Ultrasound to identify collections
• MRI to evaluate for osteomyelitis or deep space infections
• Consider blood cultures if systemic symptoms present 1

Management Approach

For Inflammatory Conditions

1. First-line treatment:

   • Topical NSAIDs (e.g., diclofenac gel) 5
   • Rest, elevation, and ice for acute swelling

2. Second-line treatment:

   • Oral acetaminophen (up to 4g/day) 5
   • Oral NSAIDs at lowest effective dose (e.g., naproxen) 5, 6

3. For persistent symptoms:

   • Consider intra-articular corticosteroid injections for painful joints with inflammation 5
   • Use 25-27 gauge needle with 5-10mg triamcinolone acetonide per joint 5

For Vascular Causes (e.g., Dialysis Fistula-Related)

• Persistent hand swelling requires urgent evaluation to exclude major outflow obstruction 1
• Patients with new findings of ischemia should be referred to a vascular access surgeon emergently 1
• Treatment may include:
  • Angioplasty of stenotic lesions
  • Surgical revision of the access
  • Ligation of venous tributaries if persistent hand edema 1

For Infectious Causes

• Surgical drainage for collections/abscesses
• Appropriate antibiotic therapy based on likely pathogens
• For primary AVF infections: treat as subacute bacterial endocarditis with 6 weeks of antibiotic therapy 1

For Compartment Syndrome

• Emergent surgical fasciotomy/compartment release 2, 3, 7
• Post-surgical wound care and rehabilitation

Special Considerations and Pitfalls

1. Post-procedural complications:

   • Hand swelling after carpal tunnel surgery may indicate complex regional pain syndrome (occurs in ~2% of cases) 8
   • IV infiltration injuries can lead to compartment syndrome requiring urgent surgical intervention 2, 7

2. Delayed diagnosis risks:

   • Compartment syndrome can develop even in sedated/anesthetized patients who cannot report pain 7
   • Persistent swelling after dialysis access creation requires prompt evaluation to prevent permanent hand dysfunction 1

3. Diagnostic challenges:

   • Normal radiographs do not exclude significant pathology
   • MRI may be needed even with normal radiographs if symptoms persist 1
   • Ultrasound is highly operator-dependent but offers real-time assessment

By following this structured approach to the workup and management of hand swelling and pain, clinicians can efficiently diagnose and treat the underlying cause while minimizing morbidity and preserving hand function.