Pictorial case study: Swelling of finger joints

A 55-year-old woman presented because she was concerned about the appearance of swelling in some of her fingers. She had also noticed discomfort at times which was worse in cold weather and stiffness in those swollen joints. She was on no medication.

On examination, there was swelling over the distal inter-phalangeal joints of several fingers which was tender to touch. There was no inflammation and her hands appeared normal.

What is the diagnosis, management and differential diagnoses?

Diagnosis and management

The diagnosis is Heberden’s nodes, which are bony excrescences of the phalanges found always over the dorsal surface of the base of the distal phalanges. They may be red on first appearance.

The diagnosis is clinical on appearance and history. The development of Heberden’s nodes in middle-age is a marker for strong genetic predisposition to develop osteoarthritis of the knee in the future as part of nodal generalised osteoarthritis.

Often reassurance is all that is needed, with advice to keep the hands active. If the joints are particularly painful, then analgesia may be taken as necessary.

Possible different diagnoses
  • Ganglion.
  • Exostosis.
  • Granuloma annulare.

Differential diagnosis

  • Ganglion
  • Asymptomatic soft tissue tumour of the hand and wrist.
  • More common in women than in men.
  • Pain and tenderness if pressure to near areas.
  • Observation, aspiration, and surgical excision are the treatment modalities of choice.

- Contributed by Dr Gwen Lewis, a GP in Windsor, Berkshire

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