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GP triage – Hand Menu

Common Wrist & Hand Conditions
OA Thumb​
Affected Area
  • 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 OA
Affected Area
  • 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
Finger pain - strain / injury​
Affected Area
  • 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​
Affected Area
  • 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
Affected Area
  • 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.   
Carpal Tunnel​
Affected Area
  • 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​
Affected Area
  • 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 conservative treatment
  • Functional disability significantly affecting work and ADL
  • Functional disability significantly affecting work and ADL
Dupuytren’s Disease
Affected Area
  • 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
  • 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.
Possible Rheumatoid Arthritis
Affected Area
  • 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 Rheumatology