Hand and Wrist PainClinical Presentation

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ExaminationClick for

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RED FLAG

Refer urgently tospecialist

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Investigations

Wrist sprain management

Advise on osteoarthritis self-management and

OTC analgesia

Referral criteria

Refer to MSK triage

Dupuytren's contracture - clinical presentation

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See pathway Dupuytren's Contracture –

Assessment

Carpal tunnel syndrome (CTS) - clinical presentation

See pathway Carpal Tunnel Syndrome

(CTS)

Tendonopathies management

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Work related tendonopathies• Advice/ liaison with employer/ OH• Rest / avoidance of triggers• NSAIDs

Trigger finger/thumb De Quervain's disease

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Primary Care / Initial self-management

3rd line: Consider intra-articular corticosteroids or

MSK service if not available in primary care

2nd line: Consider topical capsaicin cream for hand

OA

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Surgical treatment will only be considered if

• Patient has failed to respond to conservative measures (e.g. up to 2 hydrocortisone injections) or

• Patient has fixed deformity

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for MSK triage

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Consider Hydrocortisone injections or MSK service if

not available in primary care

Consider steriod injections or MSK service if not

available in primary care

Refer to MSK triage

Ganglion

See pathway:Ganglion

If not improving after 2-4 weeks refer to Physiotherapy

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Refer to MSK triage if no improvement – if trigger finger please describe if patient meets prior approval criteria to allow MSK to seek prior approval before referral if appropriate

MSK triage to consider hydrocortisone injections

If not improving With physio - Physiotherapy to refer to MSK triage

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Clinical Presentation

Osteoarthritis:

• Pain, stiffness, swelling and deformity of finger joints or thumb CMC joint

Dupuytren's contracture:

• Progressive shortening and thickening of the palmar fascia, usually painless

Carpal tunnel syndrome:

• Tingling and numbness in median nerve distribution and reduced fine dexterity

Tendonopathies:

• De Quervain's disease

• thickening of the thumb extensor tendon sheath with tenosynovitis

• Trigger finger/thumb

• Flexor tendon nodule prevents smooth gliding within sheath

• Finger/thumb locks in flexion

Complex regional pain syndrome:

• Continued pain and hypersensitivity disproportionate to initiating event

• Oedema, alterations in vascular perfusion or autonomic activity

• See complex regional pain syndrome information http://patient.info/doctor/complex-regional-pain-syndrome-pro

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Examination

Dupuytren's contracture:

• Assess degree of flexion contracture of thumb or fingers and number involved.

Carpal tunnel syndrome:

• Wasted thenar eminence

• Phalen's test/ Tinel’s test

De Quervain's disease:

• Pain, swelling and crepitus on radial aspect of the wrist

• Pain on thumb movement with weak pinch grip

Trigger finger:

• Firm palpable nodule in the line of the flexor tendons

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RED FLAG - serious injury, infection, inflammatory conditions

Refer to A&E:

• Likely fracture

• Dislocation

• Osteomyelitis

Refer to secondary care as urgent case:

• Neurovascular compromise

Refer to orthopaedics:

• Acute tendon rupture

Refer urgently to physiotherapy:

• Complex regional pain syndrome and proceed as per guidance at https://patient.info/doctor/complex-regional-pain-syndrome-pro

• Provide adequate analgesia

• Advise necessity to mobilise limb despite pain

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Differential diagnoses

• Inflammatory conditions, e.g. RA:

• Check inflammatory markers

• Refer to rheumatology

• Ulnar nerve compression

• Cervical nerve root compression

• Diabetic neuropathy

• Mononeuritis multiplex

• Gout

• Work related conditions (repetitive action/movement, tendonopathies, vibration)

Differential diagnoses

• Inflammatory conditions, e.g. RA:

• Check inflammatory markers

• Refer to rheumatology

• Ulnar nerve compression

• Cervical nerve root compression

• Diabetic neuropathy

• Mononeuritis multiplex

• Gout

• Work related conditions (repetitive action/movement, tendonopathies, vibration)

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Investigations

Only arrange X-ray:

• to confirm OA if in doubt

• to exclude fracture if history of injury

Consider blood tests for inflammatory markers if any concerns re inflammatory conditions:

• FBC

• ESR

• CRP

• anti CCP

• RhF

Investigations

Only arrange X-ray:

• to confirm OA if in doubt

• to exclude fracture if history of injury

Consider blood tests for inflammatory markers if any concerns re inflammatory conditions:

• FBC

• ESR

• CRP

• anti CCP

• RhF

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Self-help

· Protect from further injury

· Rest the joint for 48-72hrs following injury

· Ice as soon as possible after the injury for 10-30 minutes as it can relieve damage to the ligament

· Compression bandage for 48hrs after injury

· Elevate arm to reduce swelling

· Continue to move the joints as normal to prevent if becoming stiff

· Do not play sports or do vigorous exercise for 3-4 weeks after sprain

· Painkillers such as paracetamol and/or Ibuprofen

· Consider topical anti-inflammatories

Self-help

· Protect from further injury

· Rest the joint for 48-72hrs following injury

· Ice as soon as possible after the injury for 10-30 minutes as it can relieve damage to the ligament

· Compression bandage for 48hrs after injury

· Elevate arm to reduce swelling

· Continue to move the joints as normal to prevent if becoming stiff

· Do not play sports or do vigorous exercise for 3-4 weeks after sprain

· Painkillers such as paracetamol and/or Ibuprofen

· Consider topical anti-inflammatories

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Osteoarthritis self-help

· Explain condition to the patient

· Offer verbal and written information - Signpost to http://www.arthritisresearchuk.org/

· Strengthening exercises

· Assistive devices e.g. tap turners

· Ibuprofen +/- paracetamol

Osteoarthritis self-help

· Explain condition to the patient

· Offer verbal and written information - Signpost to http://www.arthritisresearchuk.org/

· Strengthening exercises

· Assistive devices e.g. tap turners

· Ibuprofen +/- paracetamol

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Referral Criteria

Refer if:

• Specialist advice and splinting required

• CMC joint causing significant functional impairment

• Consideration of joint replacement surgery

• Consideration of joint injections when indicated and cannot be performed in primary care

• Treatment failures

• Symptoms having a substantial impact on quality of life

Referral Criteria

Refer if:

• Specialist advice and splinting required

• CMC joint causing significant functional impairment

• Consideration of joint replacement surgery

• Consideration of joint injections when indicated and cannot be performed in primary care

• Treatment failures

• Symptoms having a substantial impact on quality of life

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Dupuytren's contracture - clinical presentation

• Skin thickening or pitting on the palm

• Firm nodules that are fixed to the skin and deep fascia of the palm or fingers

• Fibrous, tendon-like cords

• Contractures of the cords:

• Flexion deformity at the metacarpophalangeal and proximal interphalangeal joints

• Confirmed if the person is unable to lay their palm and fingers flat on a table top

• The ring finger is most commonly affected, followed by little and middle fingers

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Carpal tunnel syndrome (CTS) - clinical presentation

• Tingling numbness or pain in the distribution of the median nerve

• Symptoms are often worse at night, causing wakening

• Some people present atypically, e.g. sensory changes in all digits

Carpal tunnel syndrome (CTS) - clinical presentation

• Tingling numbness or pain in the distribution of the median nerve

• Symptoms are often worse at night, causing wakening

• Some people present atypically, e.g. sensory changes in all digits

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Tendonopathies management

De Quervain's disease:

• Splints

• Steroid injection x2 if can be provided in primary care

• Refer to physiotherapy

Trigger finger/thumb:

• NSAIDs

• MCP joint immobilisation

• Consider steroid injection x2 if can be provided in primary care

• Refer to secondary care only if meets criteria (see below)

Work related tendonopathies

• Advice +/- liaison with employer rest/NSAIDs

• Avoidance of triggers

• Advise employer re OH referral

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Trigger finger/thumb

• NSAIDs

• Metacarpo-phalangeal joint immobilisation

Give patient information leaflet - Trigger finger: http://www.bupa.co.uk/health-information/directory/t/trigger-finger

• Consider steroid injection x2 if can be provided in primary care (refer to MSK if not available in GP practice)

• Surgical treatment will only be considered if:

• Patient has failed to respond to conservative measures (e.g. up to 2 hydrocortisone injections)

or

• Patient has fixed deformity

Trigger finger/thumb

• NSAIDs

• Metacarpo-phalangeal joint immobilisation

Give patient information leaflet - Trigger finger: http://www.bupa.co.uk/health-information/directory/t/trigger-finger

• Consider steroid injection x2 if can be provided in primary care (refer to MSK if not available in GP practice)

• Surgical treatment will only be considered if:

• Patient has failed to respond to conservative measures (e.g. up to 2 hydrocortisone injections)

or

• Patient has fixed deformity

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De Quervain's disease

This is a common condition that affects the tendons that are used to extend the thumb. The typical symptom is pain over the wrist at the base of the thumb that is made worse by activity and eased by rest.

• Splints

• Steroid injection x2 if can be provided in primary care (refer to MSK if not available in GP practice - see referral information at the top of this pathway)

De Quervain's disease

This is a common condition that affects the tendons that are used to extend the thumb. The typical symptom is pain over the wrist at the base of the thumb that is made worse by activity and eased by rest.

• Splints

• Steroid injection x2 if can be provided in primary care (refer to MSK if not available in GP practice - see referral information at the top of this pathway)

Back to pathway Dupuytren's Contracture

Please note GPs will be required to seek prior approval for Dupuytren's Contracture before referring to secondary care

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Refer to MSK triage if no improvement

· Assessment by ESP

· Self-management / life style advice

· Investigations as required

· MDT discussions with specialists

· Signposting to other MSK provision e.g. pain /physio

· Onward referral to secondary care if required

Refer to MSK triage if no improvement

· Assessment by ESP

· Self-management / life style advice

· Investigations as required

· MDT discussions with specialists

· Signposting to other MSK provision e.g. pain /physio

· Onward referral to secondary care if required

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Referral information for HCT MSK Triage Service

The administration team are based at the New QE2 hospital.

Appointments and General Enquires: 01707 247411 or 01707 247412 or 07884 547579

E- referral enquiries via the MSK e-referral administration on: 01707 247416

Referral to the service is via the NHS e-referral system (previously Choose and Book). Electronic screening of referrals takes place on a daily basis by clinicians. The referrals are either referred directly to secondary care where they manage the Choose and Book process, or seen for clinical assessment by the team to decide the appropriate pathway of care.

Clinics for assessment are held at The New QE2, Hertford County Hospital, Cheshunt Community Hospital and Lister Hospital.

The MSK Triage Service and the MSK Physiotherapy Service are both part of the whole integrated HCT MSK Service, and as such can refer directly to each other as appropriate.

The MSK Physiotherapy Service is a team of therapists specialised in the treatment and management of MSK Conditions and based over 6 sites in East and North Herts. (Referral for this team is currently paper referral but we are working towards referral by email when we have transferred to full electronic records).

The MSK Triage Service is a team of ESP (Physiotherapists by background) but with training and advanced skills for specialist assessment, referring for diagnostics and providing injection therapy. This team meets regularly for 3 MDT meetings with the appropriate Consultant Surgeons for the upper limb, lower limb and spine. Complex cases are discussed at these meetings to provide integrated care as necessary.

Referral information for HCT MSK Triage Service

The administration team are based at the New QE2 hospital.

Appointments and General Enquires: 01707 247411 or 01707 247412 or 07884 547579

E- referral enquiries via the MSK e-referral administration on: 01707 247416

Referral to the service is via the NHS e-referral system (previously Choose and Book). Electronic screening of referrals takes place on a daily basis by clinicians. The referrals are either referred directly to secondary care where they manage the Choose and Book process, or seen for clinical assessment by the team to decide the appropriate pathway of care.

Clinics for assessment are held at The New QE2, Hertford County Hospital, Cheshunt Community Hospital and Lister Hospital.

The MSK Triage Service and the MSK Physiotherapy Service are both part of the whole integrated HCT MSK Service, and as such can refer directly to each other as appropriate.

The MSK Physiotherapy Service is a team of therapists specialised in the treatment and management of MSK Conditions and based over 6 sites in East and North Herts. (Referral for this team is currently paper referral but we are working towards referral by email when we have transferred to full electronic records).

The MSK Triage Service is a team of ESP (Physiotherapists by background) but with training and advanced skills for specialist assessment, referring for diagnostics and providing injection therapy. This team meets regularly for 3 MDT meetings with the appropriate Consultant Surgeons for the upper limb, lower limb and spine. Complex cases are discussed at these meetings to provide integrated care as necessary.

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Information for patientsInformation for patients

Managing Pain, link to leaflet: https://www.arthritiscare.org.uk/living-with-arthritis/managing-pain-and-fatigueManaging Pain, link to leaflet: https://www.arthritiscare.org.uk/living-with-arthritis/managing-pain-and-fatigue

Referral to triage service - http://www.enhertsccg.nhs.uk/pathway-leaflets?field_pathway_keywords_tid=msk&field_specialty_tid=All&=ApplyReferral to triage service - http://www.enhertsccg.nhs.uk/pathway-leaflets?field_pathway_keywords_tid=msk&field_specialty_tid=All&=Apply

Carpal tunnel syndrome exercises: https://www.csp.org.uk/publications/carpal-tunnel-syndrome-exercises