GP triage – Hand Menu
Common Hand Problems
Progressive onset of stiffness and pain.
Decreased active range of movement esp abduction/ extension of thumb.
Pain around base of thumb.
Thumb often adducted at rest.
More common on women >55
Positive grind test
Not responding to conservative treatment
If inflammatory cause suspected, refer via Early inflammatory Arthritis pathway:
Suspected inflammatory arthritis first episode and symptoms are more than 10 days and not responding to primary care
Gradual onset dorsal wrist pain, spreading up into forearm & down to back of hand.
May have swelling +/-crepitus of affected tendons.
Aggravated by use, often but not always relieved by rest.
Includes work-related upper limb disorder / RSI / cumulative trauma.
Soft Immobile mass from 1-3cm
These common benign growths mainly affecting the wrist may change in size or even disappear completely.
May or may not be painful.
Pain may be made worse by joint motion.
When the cyst is connected to a tendon, a patient may report a sense of weakness in the affected finger
Surgery for ganglion of the wrist is a low priority procedure and will not be routinely funded.
Ganglion due to inflammatory or degenerative joint disease do not benefit from surgery but the underlying condition should be referred as appropriate.
If ganglion suddenly increases in size and raises suspicion of an alternative diagnosis.
Significant pain and functional limitation.
Neurological loss or weakness of the wrist and muscle wasting of the hand.
Possible Rheumatoid Arthritis
Conservative management undertaken and workup complete: -ve X-Ray and bloods – Refer to Physio/ Pain/ OT
Conservative management undertaken and workup complete: +ve X-Ray and bloods – Refer to Physio/ Pain/ OT
Tingling, numbness or pain in volar aspect of thumb, index, middle & radial ½ of ring finger.
Often starts and worse at night.
Symptoms may be intermittent to constant.
Weakness/ clumsiness with performing ADLs
Not improving with conservative treatment for 3/12
Surgery is only indicated if after 3 months symptoms remain moderate/severe
Severe Carpal Tunnel Syndrome should be immediately referred to Ortho for surgical consideration.
Severe Carpal Tunnel Syndrome: constant numbness or pain, objective loss of sensation, wasting of thenar muscles, reduced power of thumb muscles.
De Quervain’s Tendonitis
Thumb tendonitis/ tenosynovitis of extensor pollicis brevis and abductor pollicis longus
Pain on thumb extension and abduction
Radial sided dorsal wrist pain.
Positive Finkelstein’s manoeuvre
Education & Advice
Analgesia as required
Simple nodules in the palm are not an indication for surgery.
Injection(s) – Collagenase clostridium histolyticum (Xiapex)
Discharge with active monitoring and agreement with patient
Referral to Hand therapy
Referral indicated if:
Fixed flexion in one or more joints exceeding 25 degrees.
Young patients (under 45 years) with disease affecting 2 or more digits and fixed flexion exceeding 10 degrees.