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Sunday, August 17, 2025

Swollen arms and hands (oedema)


Introduction

Swelling of the arms and hands, medically termed upper limb edema, occurs when excess fluid accumulates in the soft tissues. It may be localized (affecting one limb or hand) or generalized (both arms/hands, often part of systemic fluid overload). While many cases are benign and transient (e.g., after injury or prolonged immobility), persistent or progressive swelling can indicate vascular, lymphatic, renal, cardiac, hepatic, or inflammatory disease.

Understanding the underlying cause is essential because treatment depends on whether the edema is due to circulatory obstruction, lymphatic dysfunction, systemic disease, infection, or medication side effects.

Mechanisms of Edema

Edema develops through one or more of the following processes:

  • Increased capillary hydrostatic pressure (e.g., heart failure, venous obstruction).

  • Decreased plasma oncotic pressure (e.g., low albumin in liver disease, nephrotic syndrome).

  • Increased capillary permeability (e.g., infection, inflammation, allergic reaction).

  • Lymphatic obstruction (e.g., lymphedema, malignancy, post-surgical changes).

Causes of Swelling in Arms and Hands

1. Vascular Causes

  • Deep vein thrombosis (DVT) of upper limb: painful swelling, redness, warmth. Often after IV lines, catheters, or trauma.

  • Venous obstruction (e.g., superior vena cava syndrome): swelling of face, neck, and upper limbs, usually due to tumor compression.

  • Venous insufficiency: poor venous return, chronic swelling, skin changes.

2. Lymphatic Causes

  • Primary lymphedema: rare congenital lymphatic abnormality.

  • Secondary lymphedema:

    • After breast cancer surgery (axillary lymph node dissection, radiotherapy).

    • Malignancy compressing lymph nodes.

    • Filariasis (parasitic infection in endemic areas).

3. Systemic Causes

  • Heart failure: usually bilateral hand/arm swelling with generalized edema (ankles, legs).

  • Kidney disease (nephrotic syndrome, chronic kidney disease): swelling in hands, face, and legs due to protein loss.

  • Liver disease (cirrhosis, hypoalbuminemia): generalized edema.

  • Endocrine causes: hypothyroidism (myxedema causes puffiness in hands/face).

4. Infections and Inflammatory Conditions

  • Cellulitis: bacterial infection of skin → red, warm, painful swelling.

  • Abscess: localized painful lump with surrounding swelling.

  • Septic arthritis or bursitis in upper limb joints.

  • Allergic reactions/angioedema: sudden, sometimes severe swelling of hands, face, lips.

5. Traumatic and Mechanical Causes

  • Injury, fracture, or sprain → localized swelling due to tissue damage.

  • Immobilization (tight casts, bandages).

  • Repetitive strain causing tendonitis or bursitis.

6. Medications

  • Calcium channel blockers (amlodipine, nifedipine).

  • NSAIDs.

  • Corticosteroids.

  • Hormone therapies (estrogens, androgens).

Clinical Presentation

  • Acute, painful, red swelling: infection, DVT.

  • Chronic, painless swelling: lymphedema, venous insufficiency.

  • Bilateral with systemic features: heart, liver, or kidney disease.

  • Accompanied by facial swelling and dyspnea: superior vena cava obstruction.

  • Associated with itching/rash: allergic reaction.

Diagnostic Evaluation

History

  • Onset (sudden vs gradual).

  • Recent trauma, surgery, or radiotherapy.

  • Medication history.

  • Associated systemic symptoms: fever, chest pain, shortness of breath, weight gain.

Examination

  • Location and symmetry (unilateral vs bilateral).

  • Signs of infection (warmth, redness, tenderness).

  • Lymph node enlargement.

  • Signs of systemic disease (ascites, leg swelling, facial puffiness).

Investigations

  • Blood tests:

    • CBC (infection).

    • Renal function, electrolytes.

    • Liver function and albumin levels.

    • Thyroid function (TSH, T4).

  • Imaging:

    • Doppler ultrasound (rule out DVT).

    • CT/MRI chest (if venous obstruction suspected).

    • Lymphoscintigraphy (for lymphedema).

  • Other:

    • Urinalysis (proteinuria in nephrotic syndrome).

    • Echocardiogram (heart failure).

Treatment

1. General Measures

  • Elevate the affected arm(s).

  • Avoid tight clothing/jewelry.

  • Compression garments for lymphedema or venous insufficiency.

  • Gentle exercises to improve lymphatic/venous drainage.

2. Pharmacological Management

Pain and Inflammation

  • Paracetamol (acetaminophen): 500–1000 mg every 6 hours (max 4 g/day).

  • NSAIDs:

    • Ibuprofen: 200–400 mg every 6–8 hours.

    • Naproxen: 250–500 mg twice daily.

Infections (Cellulitis, Abscess)

  • Flucloxacillin: 500 mg orally every 6 hours × 7 days.

  • Clindamycin: 300 mg orally every 8 hours (penicillin allergy).

  • IV antibiotics (if severe): ceftriaxone, vancomycin (hospital setting).

DVT of Upper Limb

  • Anticoagulation:

    • Enoxaparin: 1 mg/kg subcutaneously every 12 hours (initial).

    • Transition to oral anticoagulants: Warfarin (dose adjusted to INR 2–3) or DOACs (e.g., apixaban 10 mg BID × 7 days, then 5 mg BID).

Heart Failure–Related Swelling

  • Loop diuretics:

    • Furosemide: 20–40 mg orally daily, titrated as needed.

  • ACE inhibitors/ARBs, beta-blockers for long-term management (specialist guidance).

Renal or Liver Disease–Related

  • Address underlying disease.

  • Diuretics as supportive therapy (spironolactone in cirrhosis: 100 mg/day, often with furosemide).

  • Albumin infusion in severe hypoalbuminemia (specialist use).

Allergic Reaction/Angioedema

  • Antihistamines:

    • Cetirizine: 10 mg orally daily.

  • Corticosteroids (for severe cases):

    • Prednisone: 30–40 mg daily × 3–5 days.

  • Epinephrine (adrenaline) 0.3–0.5 mg IM (1:1000) if anaphylaxis.

3. Non-Drug Therapies

  • Lymphedema:

    • Complex decongestive therapy (manual lymph drainage, bandaging, compression).

  • Venous obstruction:

    • Surgical or endovascular intervention in selected cases.

  • Abscess:

    • Incision and drainage plus antibiotics.

Red Flags (Require Urgent Medical Attention)

  • Sudden swelling with pain and redness (possible DVT or infection).

  • Swelling with fever, chills (cellulitis, sepsis).

  • Progressive swelling with shortness of breath or chest pain (SVC obstruction, heart failure, pulmonary embolism).

  • Hard, immobile mass or persistent unexplained swelling (possible malignancy).

  • Swelling associated with facial or airway involvement (anaphylaxis).

Prognosis

  • Traumatic or mild inflammatory swelling: usually resolves with rest and symptomatic treatment.

  • Infections: excellent prognosis with antibiotics and drainage if needed.

  • DVT: good prognosis if treated promptly with anticoagulation.

  • Lymphedema: chronic but manageable with compression therapy.

  • Systemic causes: prognosis depends on underlying heart, liver, or kidney disease.

Summary of Key Treatments with Doses

  • Paracetamol: 500–1000 mg PO q6h (max 4 g/day).

  • Ibuprofen: 200–400 mg PO q6–8h.

  • Naproxen: 250–500 mg PO BID.

  • Flucloxacillin: 500 mg PO q6h × 7 days.

  • Clindamycin: 300 mg PO q8h (penicillin allergy).

  • Enoxaparin: 1 mg/kg SC q12h (initial anticoagulation).

  • Apixaban: 10 mg PO BID × 7 days, then 5 mg PO BID.

  • Furosemide: 20–40 mg PO daily.

  • Spironolactone: 100 mg PO daily (cirrhosis-related).

  • Cetirizine: 10 mg PO daily.

  • Prednisone: 30–40 mg PO daily × 3–5 days (severe allergic swelling).

  • Epinephrine: 0.3–0.5 mg IM (1:1000) if anaphylaxis.



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