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GP triage – Hand Menu

Common Hand Problems

OA Thumb
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
Step deformity
Positive grind test
Education & advice
Exercise
Simple analgesics
NSAIDS
Physio referral for patients > 6/52
Splint may be useful
Consider a steroid injection
X-ray: AP / lateral of CMCJ
+/- Wrist X-ray
Not responding to treatment
Functional disability significantly affecting work and ADL
Patient would consider further intervention (US injection/ surgery).
Finger pain
Pain and/ Stiffness of MCP/ PIP/ DIP joints.
Commonly caused by OA but can also be caused by inflammatory arthritis strains and injury.
Education & advice
Exercise
Simple analgesics
NSAIDS
Physio/ Hand therapy referral
Consider a steroid injection
X-ray: AP and lateral of MCP/ PIP/ DIP joints
If suspected inflammatory Arthritis:
FBC
Uric
U&E
CRP
ESR
Rh factor
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
Wrist pain
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.
Education & advice
Exercise
Simple analgesics
NSAIDS
Physio/ Hand therapy referral
Consider a steroid injection
X-ray: AP and lateral of wrist
If suspected inflammatory Arthritis:
FBC
Uric
U&E
CRP
ESR
Rh factor
Not responding to conservative treatment
Diagnostically uncertain
Ulnar nerve symptoms
Refer to Rheumatology if suspected new inflammatory Arthritis
non-obvious / unconfirmed diagnosis
Ganglion
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
Education & advice
Analgesics
Aspiration if swelling is large and limiting function
No investigations indicated
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.
Appropriate referrals: 
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
Painful joint
Hot/swollen joint
May be bilateral
Associated symmetrical small joint symptoms
Family history of inflammatory joint disease

Education & Advice
Rheumatology referral
Analgesia as required
X-ray: AP& lateral views
Blood screen:
Rheumatoid factor
ESR
CRP
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
Carpal Tunnel
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.
Nocturnal waking
Weakness/ clumsiness with performing ADLs
Education & advice
Exercise
Simple analgesics
NSAIDS
Physio referral for patients > 6/52
Splint may be useful
Consider a steroid injection
No investigations indicated at this stage
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
Exercise
Simple analgesics
NSAIDS
Physio/ Hand therapy referral for patients > 6/52
Splint may be useful
Consider a steroid injection
U/S for diagnosis and for guided injection
Not responding to treatment
Functional disability significantly affecting work and ADL
Patient would consider further intervention (US injection/ surgery).
Dupuytren’s Disease
Fibrosis of the palmar aponeurosis leading to contracture of the fingers.
Non-correctable contracture.
Familial history  common
Education & Advice
Analgesia as required
Simple nodules in the palm are not an indication for surgery.
Splint(s)
Injection(s) – Collagenase clostridium histolyticum (Xiapex)
Discharge with active monitoring and agreement with patient
Referral to Hand therapy
No investigations indicated
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.