What is the appropriate management for left hand swelling with limited range of motion?

Management of Left Hand Swelling with Limited Range of Motion

Begin with immediate assessment for critical conditions requiring urgent intervention, followed by topical NSAIDs as first-line pharmacological treatment, combined with education on joint protection and a structured exercise program for range of motion and strengthening. 1, 2

Immediate Assessment for Critical Conditions

Before initiating routine management, you must exclude emergent pathology:

• Check for hand ischemia immediately by assessing digital pulses, capillary refill, skin temperature, and color—any pale/blue discoloration, coldness, or pain at rest requires emergent vascular surgery referral 1
• Evaluate for infection urgently through examination for erythema, warmth, purulent drainage, fever, or elevated inflammatory markers—infections in edematous hands progress rapidly and require immediate antibiotics 1
• Exclude venous outflow obstruction, particularly in patients with dialysis access, central venous catheters, or history of upper extremity procedures—persistent swelling beyond one week suggests venous stenosis requiring duplex ultrasound 1

Diagnostic Imaging Strategy

• Obtain plain radiographs (3 views) of the hand as the initial imaging study to evaluate for fracture, arthritis, or bone abnormalities 1
• Perform duplex ultrasound if venous obstruction, tenosynovitis, joint effusion, or soft tissue pathology is suspected—ultrasound is contributory in 76% of patients with hand pain and swelling 1

First-Line Non-Pharmacological Management

These interventions should be initiated for all patients:

• Provide education on joint protection techniques to minimize stress on affected joints and training in ergonomic principles, pacing of activity, and use of assistive devices 2, 3
• Prescribe a structured exercise regimen involving both range of motion and strengthening exercises—exercises specifically aim at improving joint mobility, muscle strength, and reducing pain 2, 3
• Apply local heat therapy (paraffin wax or hot packs) especially before exercise sessions for symptomatic relief—heat therapy has 77% recommendation strength compared to 25% for ultrasound 2, 3

First-Line Pharmacological Management

• Apply topical NSAIDs as the first-choice pharmacological treatment due to superior safety profile compared to systemic agents, particularly for mild to moderate pain 2, 1, 3
• Consider topical capsaicin as an alternative topical treatment option 3

Second-Line Pharmacological Management

If topical treatments provide insufficient relief:

• Prescribe acetaminophen up to 4g daily as the oral analgesic of first choice due to its efficacy and safety profile 2, 1, 3
• Use oral NSAIDs at the lowest effective dose for the shortest duration in patients who respond inadequately to acetaminophen—patient requirements and response should be re-evaluated periodically 2, 3
• Provide gastroprotection with a proton pump inhibitor in patients with increased gastrointestinal risk taking non-selective NSAIDs, or use a selective COX-2 inhibitor 2, 1, 3
• In persons age ≥75 years, use topical rather than oral NSAIDs due to safety concerns 3

Orthotic Management

If thumb base involvement is present:

• Prescribe custom-made neoprene or rigid orthoses for first carpometacarpal joint osteoarthritis with long-term use (at least 3 months) advocated for optimal symptom relief 2, 3
• Custom-made orthoses are preferred to ensure proper fit and improve patient compliance 3

Interventional Treatment

For painful flares or inadequate response to conservative management:

• Consider intra-articular injection of long-acting corticosteroid for painful flares, especially in the trapeziometacarpal joint 2, 3
• Avoid routine intra-articular injections in interphalangeal joints unless specifically indicated for painful interphalangeal joint flares 2

Follow-Up Strategy

• Reassess within 48-72 hours to evaluate response to initial management and ensure no progression of symptoms 1
• Schedule formal evaluation at 6 weeks if edema persists to detect delayed complications or maturation failure of underlying pathology 1
• Adapt long-term follow-up to individual patient needs based on underlying diagnosis and response to treatment 2, 1

Critical Pitfalls to Avoid

• Do not use conventional or biological disease-modifying antirheumatic drugs in patients with hand osteoarthritis 2, 3
• Avoid long-term oral NSAIDs due to potential gastrointestinal, cardiovascular, and renal adverse effects 3
• Ensure splinting is used consistently for at least 3 months—shorter periods may not show significant benefit 3
• Do not initiate forceful exercise programs—failure to control edema and improper exercise can extend the injury 4
• Recognize that hand swelling is present in 72.7% of stroke patients in rehabilitation—consider neurological causes if risk factors are present 5