Q. My son's finger are swollen with psoriasis history without pain. What could this be?

Answered by
Dr. Naval Mendiratta
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Mar 22, 2020

Hello doctor,

I would like an opinion as to why the ring finger on my son’s left hand is swollen, the middle finger is a little swollen and possibly some fingers on his right hand are too (but less so). They are not painful. This started about a year ago, a rheumatologist saw him then and thought that it was not arthritis. X-rays are taken last year were normal.

This is what the x-ray report says:

Technique: PA, lateral, and oblique views of the bilateral hands were obtained.

Findings: The alignment and joint spaces are normal. There is no fracture, osseous lesion, or dislocation. The soft tissues are normal.

Impression: No osseous or soft tissue lesion noted. MRI may be of value.

Blood work taken a year ago was normal (images attached).

Dr. Naval Mendiratta

Rheumatology
#

Hello,

Welcome to icliniq.com.

I have gone through the history and the pictures along with the reports. (attachment removed to protect patient identity).

I would like to ask you a few more questions to conclude the diagnosis and how to proceed further with it. Does he complain of early morning stiffness? That he has to move his hands to open it. Anyone in the family has any degenerative arthritis like osteoarthritis? Any complaints of backache or neck pains?

As of the reports, your rheumatologist are right it is not inflammatory arthritis. We are looking at some metabolic causes of these swellings or some other genetic ones.


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Thank you doctor,

No morning stiffness, osteoarthritis in the family, backache or neck pains, although he was diagnosed with mild kyphosis when he was young.

Also, he may have psoriasis, he has not been formally diagnosed but he has white scaly patches on his elbows and knees. I am wondering if psoriatic arthritis might be behind the swollen fingers? I would be very interested to know possible metabolic or genetic conditions that could cause this.

Dr. Naval Mendiratta

Rheumatology
#

Hello,

Welcome back to icliniq.com.

Well, if it was due to psoriatic arthritis it would have been quite a painful condition. As of the picture, it looks like a mild benign swelling which will not be restricting the daily activities. So we can rule out the inflammatory arthritis part.

As of further history, I do have come across a few cases where adolescent males/females develop bony thickening of either the PIP or DIP joints. But mostly my patients have been girls which always give this picture of some advanced arthritis or early osteoarthritis. And most common joints for them were DIP. But all the inflammatory markers, x-rays were normal. But we finally concluded it all fitted in with a condition known as pachydermodactyly.

It is a mild condition where the soft tissues undergo thickening. Eventually, not much treatment is needed for it unless the swelling increases further and causes restriction of daily activities.

For your son also, I feel he fits into this condition quite well. But you can read up on it and see if the symptoms match his current state.

But yes, from my side confirmation would be an ultrasound of the hands or MRI (magnetic resonance imaging) to conclude the final diagnosis.

But as of now, I can assure you, it does not look very alarming. It is a benign condition that will settle with time.

I hope this helps.


Investigations to be done:

Ultrasound of the hands. MRI of the hands.

Treatment plan:

Conservative.


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Thank you doctor,

That really does seem like a good match for his symptoms. I had been stressing over this, and this is very informative.

We actually had an ultrasound done on his right hand (where there were several nodules but less overall swelling than his left hand). Here is what it said. Can you tell me if that is also consistent with pachydermodactyly?

Findings:

The metacarpal phalangeal joints are normal with no evidence of synovitis (no fluid collection or hyperemia as per OMERACT protocol).

In the area of clinical concern fourth digit, there is isoechoic soft tissue thickening that is very compressible with micro cysts measuring up to 2 mm. No significant hyperemia is identified on the Doppler exam. The adjacent extensor tendon demonstrates normal movement.

Similar changes are noted in the third and fifth digit with microcysts and compressible isoechoic soft tissue thickening.

No discrete macro cyst is identified.

Impression:

Avascular soft tissue thickening in the area of clinical concern mostly in the radial aspect of the fourth proximal phalanx with microcysts and compressible tissue. No evidence of discrete tumor mass or synovitis. No drainable fluid collections.

Dr. Naval Mendiratta

Rheumatology
#

Hi,

Welcome back to icliniq.com.

I have gone through the ultrasound report. (attachment removed to protect patient identity).

It does seem like a no- vascular swelling which means there is hardly any inflammation or activity. I think it pretty much adds up to our diagnosis. So nothing for you to worry about here. The only precaution is avoiding strenuous activity of hands like in boxing or anything if he does.


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