Hand & Wrist Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of adults presenting with Hand and Wrist Pain

This guidance does not cover:

  • Under 18s (Wakefield) Under 16s (North Kirklees)

Commissioning Statements:

  • Referrals for Carpal Tunnel Surgery are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Referrals for Dupuytrens Contracture are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Assessment

Signs and Symptoms

Ganglion - see Ganglia and Myxoid Cysts Care Pathway
Trigger finger or thumb
  • Pain, stiffness, clicking and a small lump in the palm at the base of the affected finger or thumb
Dupuytren's Contracture
  • Report the onset of thickening and nodules on the palmar surface of the hand.
  • Can induce fixed flexion contractures.
  • No treatment is required whilst the patient can still get their hands flat on the table.
Osteoarthritis
  • Report pain, stiffness and swelling of the wrist or affected hand joint.
  • May report a history of previous trauma e.g. fracture to the affected joint.
  • Wrist (Radiocarpal Joint): Equal limitation of flexion/extension +/- crepitus.
  • DRUJ: Pain at end range of passive pronation/supination.
  • 1st CMC OA: Squaring off at the base of the thumb, pain with gripping, more common in females, tender on palpation of the joint line, positive grind test.
De Quervain's
  • Reports insidious onset of pain and swelling over the distal aspect of the radial side of the forearm.
  • Often report a history of repetitive, sustained or unaccustomed activity.
  • Common in new mothers.
  • May present with swelling over the distal radial side of the forearm.
Carpal Tunnel Syndrome
  • Report paraesthesia +/- pain affecting the palmar side of thumb, index, middle +/- part of ring finger.
  • Usually worse at night.
  • Consider causes: pregnancy, diabetes, thyroid function
  • Rule out Cervical Spine referred: AROM of the neck, Spurling's Test
  • Check for thenar wasting (occurs in severe cases)
Acute Hand or Wrist Injury
  • Be vigilant to deformity, point tenderness and swelling with a history of acute trauma = A&E.
  • In the sub-acute setting, x-rays are only indicated to exclude fracture (include wrist and scaphoid views).
  • If no fracture: advise on relative rest, encourage regular movement, safe use of ice and consider a provision of a splint.
Inflammatory Wrist Pain
  • Often insidious onset of pain, stiffness and swelling.
  • May have a history of, or family history of an underling inflammatory condition e.g. RA
  • There will be evidence of synovitis in the wrist: boggy swelling, heat, erythema and marked loss of movement.
For additional information on signs and symptoms please click here - Signs and Symptoms

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Suspected fracture
  • Mallet finger
  • Septic Arthritis
  • Severe wasting and weakness

Or two-week rule/urgent cancer referral if suspicion of malignancy

Management

Dupuytren's Contracture
  • If mild/function not affected, no need to treat
  • Clinical diagnosis, but consider causes (alcohol, diabetes, anticonvulsants, genetic)
Trigger Finger
  • Many self-limiting; consider splinting, rest, analgesia
  • Consider steroid injection if not responding to conservative management (provided in primary care if available or referral to CONNECT Community MSK service)
Osteoarthritis (finger nodules)
  • Clinical diagnosis
  • Manage with analgesia (paracetamol, NSAIDs +/-PPI cover, low dose opiates
  • Consider steroid injection if significant pain
OA (base of thumb)
  • Conservative management (analgesia, OT referral, modification of activity)
De Quervain's Tenosynovitis
  • Consider causes (post-natal, work)
  • Conservative management in first instance (splints, physiotherapy, analgesia)
  • Steroid injection if not responding to conservative management (Refer to appropriate provider)
Carpal Tunnel Syndrome
  • Consider causes – pregnancy, bloods to rule out thyroid disorder, diabetes, autoimmune
  • Conservative management in first instance (splints, analgesia)
  • Consider steroid injection if not responding to conservative management (Refer to appropriate provider).
Ulnar nerve entrapment
  • Bloods to rule out causes of neuropathy (fbc, fasting glucose/hbA1c, autoimmune screen, TFTs)

Referral

Referral Criteria

  • Red Flags refer as identified
  • North Kirklees (MSK, Trauma and Orthopaedics and Physiotherapy)
    • All MSK referrals (excluding red flags) should be made to CONNECT COMMUNITY MSK who will undertake clinical assessment and triage and refer on as appropriate (including to physiotherapy). Choice of provider will be offered following triage
    • Please click here to open the Clinical Decision Making Aid for further guidance on which part of Connect's pathway to refer into i.e. Physioline, Physio or CATs
  • Wakefield
  • Wakefield
    • Referrals for Dupuytrens, OA (base of thumb) and Ulnar Nerve Entrapment should be made to MYHT
  • Wakefield - Physiotherapy
  • Wakefield – Trauma and Orthopaedics ·
    • Patients should be offered choice of provider for trauma and orthopaedics

Referral Requirements

  • For Carpal Tunnel Surgery and Dupuytrens Contracture documented evidence is required to demonstrate that the patient meets the commissioning statement criteria
  • For those patients who do not meet the eligibility criteria evidence of prior approval authorisation is required

Commissioning Statements:

  • Referrals for Carpal Tunnel Surgery are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Referrals for Dupuytrens Contracture are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Referrals Instructions

  • e-Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Prior to referral for surgery the patient should understand their options and the benefits and risks and the likelihood of these occurring. If relevant patients should be signposted to decision aids for: Dupuytrens Disease, Carpal Tunnel Syndrome or Trigger Finger

Patient Information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 04.2017
  • Publication Date: 05.2017
  • Updated : 06:2018
  • Review Date: 05.2019
  • Ref No: MSK7 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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