Hand swelling can be a result of pathology in the bones, joints, tendons, blood vessels, or soft tissues. Many systemic diseases, such as Kawasaki disease, sickle cell disease (SCD), juvenile idiopathic arthritis (JIA), viral arthritides, and serum sickness, can produce hand swelling. In these cases, hand involvement tends to be symmetric, and other constitutional symptoms lend important clues to the etiology. More localized causes of hand swelling include osteomyelitis, septic arthritis, tenosynovitis, cellulitis, trauma, and soft-tissue tumors. Careful examination of the hand, paying close attention to joint motion, range of motion, and areas of tenderness, swelling, or erythema, can narrow the differential diagnosis based on the anatomic structures involved.

• Osteomyelitis in the hands can result from hematogenous spread of infection, direct inoculation as seen with a puncture wound, or contiguous spread from adjacent structures as may be seen with septic arthritis. In infants, osteomyelitis commonly causes swelling of adjacent soft tissues.

• Septic arthritis, most commonly caused by Staphylococcus aureus, is usually monoarticular and associated with swelling, erythema, and pain on movement.

• Cellulitis may occur at the site of minor trauma. Patients may also report a “spider bite” that becomes larger and more erythematous, as the initial papular lesion often resembles an insect bite.

• JIA has a variety of manifestations. Of the seven subtypes of JIA, polyarticular rheumatoid factor positive (2%–7% of JIA), systemic (4%–17%), and psoriatic (2%–11%) are most likely to have hand involvement.

• Dactylitis associated with SCD presents with tender, erythematous, and edematous hands or feet in patients. It is frequently the presenting sign, occurring in 25% of affected individuals by 1 year of age and in 40% by 2 years of age. The pathophysiology is thought to be similar to other vasoocclusive crises.

• Clenched fist injuries are caused by the closed fist striking the teeth during a fight. These are not often recognized as bite injuries, but can become infected with mouth flora. They also have a high rate of extensor tendon and joint capsule injuries.

• A boxer’s fracture is a fracture of the fourth or fifth metacarpal neck. The mechanism is usually a closed fist striking a hard, immobile object such as a wall.

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