Rotherham Hand Pathway
Patient presents with wrist or hand symptoms
Confirm diagnosis (see attached notes)
Secondary Care
Please refer the
following directly
to Secondary
Care
History of or suspected
malignancy, investigate
and refer as appropriate.
Consider red flags of
unexplained weight loss,
night pain and high
inflammatory markers.
Primary Care
Acute wrist or
hand injury
Dupuytren’s
contracture
Suspected inflammatory
condition, investigate
and refer to
Rheumatology
Acute tendon rupture or
severe carpal tunnel
syndrome, urgent
referral to Orthopaedic
Surgeon
Carpal Tunnel
Syndrome
Tendinopathies
Investigations
X-rays are indicated
to exclude fracture
including scaphoid
and wrist views.
Investigations
Investigations
Investigations
NOT indicated
NOT indicated
NCT to be
considered if
positive CTS history
but negative
examination findings
Management
Consider analgesia
or /NSAIDs/ splints
Management
Consider analgesia
and NSAIDs
Suspected fracture,
dislocation or infection,
refer to A&E
Hand/wrist
OA
Injection
NOT indicated
Referral
If no improvement
after 2 weeks of
conservative
management, refer
to MSK
Physiotherapy
Service.
Dupuytren’s contracture
as described: Refer to
Orthopaedic Surgeon.
www.patient.co.uk
Injection
NOT indicated
Referral
Any contracture
at PIP joint or at
MCP joint over 30
degrees, or
significant
limitation of
lifestyle, refer to
Orthopaedic
Surgeon,
otherwise
reassure and
monitor.
www.nhs.uk/con
ditions/dupuytre
ns-contracture
Injection therapy
can be considered if
no improvement
after 4/52 of
conservative
management
Management
Advise patient on
provision of a wrist
splint for up to 8
weeks.
Investigations
NOT indicated
Management
Consider analgesia
Injection therapy
can be considered
if no improvement
after 4/52 of
conservative
management
Referral
NOT indicated
If no response to
one injection refer
to MSK CATS
Referral
Referral
If no response to
one injection refer
to MSK CATS.
Consider referrals to
social support
www.cks.nhs.uk
If severe symptoms
affecting function or
neurological deficit:
refer immediately
for surgical opinion
www.cks.nhs.uk
Investigations
NOT indicated
Injection
If unresponsive refer
to MSK CATS.
Ganglions
or finger
cysts
If symptoms recur
after a second
injection, refer to
Orthopaedic
Surgeons
www.medicine
net.com
Complex
Regional
Pain
Syndrome
Investigations
NOT indicated
Management
Review pain
management.
Consider referral
to pain clinic
Injection
Injection
NOT indicated
NOT indicated
Referral
Referral
If painful,
recurrent or
affecting
function, refer
to MSK CATS
Refer urgently to
MSK CATS.
www.netdoctor.
co.uk
Consider
referrals to social
support services
and / or
psychologist
Acute hand and wrist injury
X-rays are only indicated to exclude fracture including wrist and scaphoid views. Consider NSAID’s and analgesia.
Advise patient regarding initial relative rest, encouraging gentle, pain free movement, ice, elevation, use of
support/splint/bandage intermittently. – See PRICE guidelines. If no improvement after 2 weeks, refer to MSK
Physiotherapy service.
Complex Regional Pain Syndrome (Previously known as Sudeck’s Atrophy)
Patient will present with shiny, red skin which is hypersensitive to touch and temperature. There will be associated with swelling,
abnormal sweating of the skin and nail and hair changes. Patient may present not using the hand. Symptoms can be associated
with surgery or minor injury. In later stages symptoms may involve the contralateral limb. Review pain management. Imaging and
blood tests are not indicated. Consider referrals: to psychologist or social support services, to social services for a home assessment
as required and / or to pain clinic. Urgently refer to MSK CATS.
Carpal Tunnel Syndrome
Patient presents with: Paraesthesia / pain affecting thumb, index and middle finger. Typically at night, but can occur during the
daytime. Late signs will include objective sensory change in median nerve distribution, weakness of thumb abduction and thenar
eminence wasting. Positive provocative tests: Phalen’s test, Durkins compression test and Tinel’s sign. Exclude nerve root
involvement from cervical spine. Reassure patient that most cases resolve within 6/12. Do not refer for imaging. Do not inject. Do
not provide diuretics. Provide wrist splints at night for up to 8 weeks, if unresponsive refer to MSK CATS. If symptoms are severe
with sensory blunting, wasting and weakness, in line with median nerve involvement at the wrist, refer for urgent hand surgeon
opinion.
Dupuytren’s Contracture
Patient presents with nodules or thickening in palm or digits + / - flexion contracture of digits. No investigations are indicated. If
there is there a fixed flexion deformity more than 30 degrees at MCP, any flexion contracture at an IP joint, or significant functional
loss, refer to hand surgeon for routine appointment. If not, advise patient re-benign nature of condition and how to monitor
deformity.
Ganglions / finger cysts
Patient presents with a mobile, fluid-containing mass, usually attached to a tendon sheath or connected with an underlying joint,
located distal to the distal palmar crease. Reassure patient that most ganglia/ cysts resolve spontaneously. If condition is recurrent,
painful or affecting function: refer to MSK CATS.
Insidious wrist pain
Patient presents with wrist pain and inflammation. Area will be hot and swollen with limited movement and usually marked
functional loss. Blood tests are indicated: inflammatory markers for infection and urate levels for gout. If septic arthritis refer
urgently to on-call orthopaedics. If RA refer to rheumatology.
OA hand and wrist
Patient presents with pain, swelling of wrist or hand joint. Advise patient on use of a wrist splint (if required), to use intermittently
with advice to rest the hand, but to maintain gentle, functional movement. Advise on use of ice treatment. Review medications and
consider prescription of Paracetamol, topical NSAIDS and Capsaicin. If ineffective, oral NSAIDS can be prescribed. Consider referral
to social services for home assessment if required. Medical imaging / blood tests are not indicated. If no improvement after 4
weeks, injection therapy can be considered. If no response, (i.e. Symptomatic relief for over 2 months) to one injection, refer to
MSK CATS.
Trigger digit (Stenosing flexor tendinopathy) / Dequervain’s tendinopathy
Local pain on use and palpation of the tendon(s) involved. Condition occurs due to degeneration and overuse. Advise relative rest
from repetitive hand use / gripping activities and consider prescription of NSAIDS/ gel. Splinting and imaging are not advised. If no
improvement after 4 weeks from onset consider steroid injection therapy. If no response, (i.e. Symptomatic relief for over 2
months) to one injection, or if patient requires more than 2 injections over time to manage condition: refer to hand surgeon.
Author: rachel.lewis@rotherham.nhs.uk