Any history of significant hand or wrist trauma within 6 weeks? Refer urgently to hand surgeons.
Dorsal MCP (Metacarpal Phalangeal) joints
Single MCP joint stiffness, swelling and pain
- Consider OA
- Work up:
- analgesia & advice
- x-ray confirmation (AP and lateral of specific joint)
- If not improving:
- hand therapy at Community Physiotherapy (pending MSK Hub development)
- ultrasound guided steroid injection (radiology dept)
- severe symptoms refer to hand surgeons
Bilateral/Multiple MCP joint stiffness, swelling and pain
- Consider inflammatory
- Work up:
- analgesia & advice
- x-ray (both hands +/- wrists AP/lateral and oblique)
- If not improving &/or persistent for more than 6 weeks:
- consider bloods & referral to Rheumatology
- hand therapy at Community Physiotherapy (pending MSK Hub development)
- ultrasound guided steroid injection (radiology dept)
- severe symptoms refer to hand surgeons
Dorsal PIP (Proximal Interphalangeal) joints
Single PIP joint stiffness, pain and swelling
- Consider OA
- Work up:
- analgesia & advice
- x-ray confirmation (AP and lateral of specific joint)
- If not improving:
- hand therapy at Community Physiotherapy (pending MSK Hub development)
- ultrasound guided steroid injection (radiology dept)
- severe symptoms refer to hand surgeons
Bilateral/Multiple PIP joint stiffness, pain and swelling
- Consider inflammatory
- Work up:
- analgesia & advice
- x-ray (both hands: AP/lateral and oblique)
- If not improving &/or persistent for more than 6 weeks:
- consider bloods & referral to Rheumatology
- hand therapy at Community Physiotherapy (pending MSK Hub development)
- ultrasound guided steroid injection (radiology dept)
- severe symptoms refer to hand surgeons
Dorsal DIP (Distal Interphalangeal) joints
Single DIP joint stiffness, pain and swelling
- Consider OA or trauma
- May have associated mucous cyst over dorsal aspect DIPJ
- Work up:
- Trauma: consider mallet injury
- extension splint
- xray
- refer to hand trauma service
- No trauma
- analgesia & advice
- x-ray confirmation (AP and lateral of specific joint)
- Trauma: consider mallet injury
- If not improving:
- refer to Community Physiotherapy (pending MSK Hub development) for hand therapy
- ultrasound guided steroid injection (radiology dept)
- severe symptoms &/or symptomatic nail growth problems or recurrent discharge refer to hand surgeons
- BSSH terminal finger joint arthritis
Bilateral/Multiple DIP joint pain, stiffness and swelling
- Consider inflammatory
- Work up:
- analgesia & advice
- x-ray (both hands +/- wrists AP/lateral and oblique)
- If not improving &/or persistent for more than 6 weeks:
- consider bloods & referral to Rheumatology
- hand therapy at Community Physiotherapy (pending MSK Hub development)
- ultrasound guided steroid injection (radiology dept)
- severe symptoms refer to hand surgeons
Dorsal/Radial Wrist
Bone / joint consider:
- 1st CMC &/or STT OA
- Xray (specify 1st CMC and STT joint), analgesia
- affecting quality of life refer to Community Physiotherapy (pending MSK Hub development) for hand therapy and splint +/- USS guided steroid injection (no blind injections)
- failure to manage symptoms at hub refer to hand surgeons
- BSSH basal thumb arthritis
- Radiocarpal pain - no trauma
- Xray (90/90 PA and lateral of wrist)
- analgesia
- severe symptoms refer to hand surgeon
- Radiocarpal pain + history of trauma (scaphoid fracture or non union?)
- Xray (PA and lateral of wrist)
- analgesia
- if fracture - refer to hand surgeon
- no fracture - refer to Community Physiotherapy (pending MSK Hub development)
Soft tissue consider:
- deQuervains (1st dorsal compartment tendons)
- analgesia
- affecting quality of life refer to Community Physiotherapy (pending MSK Hub development) for splint +/- USS + guided steroid injection
- failure to manage symptoms at hub refer to hand surgeons
- BSSH De Quervain's syndrome
- EPL (extensor policis longus)
- More dorsal and worse with active thumb flexion or resisted retropulsion
- Mild give analgesia advice and refer to Community Physiotherapy (pending MSK Hub development) (splint and hand therapy)
- Severe refer to hand surgeon
Dorsal/Central Wrist
Bone / joint
- Consider OA or trauma
- Xray (PA and lateral of wrist)
- if symptoms affecting quality of life, refer to hand surgeons (unilateral) or Rheumatology (bilateral)
Soft tissue + lump
- Ganglion
- Severe symptoms refer to hand surgeons
- BSSH ganglion cysts
- Extensor tendon tenosynovitis
- pain and swelling +/- crepitus over tendons when moving
- Work up:
- Check finger extension:
- Can the patient extend themselves (active extension)?
- urgent referral to hand surgeons if lacking
- wrist splint in neutral, rest and analgesia
- Check finger extension:
- If fails to settle
- consider inflammatory and refer to Rheumatology
- Consider inflammatory refer rheumatology or refer to Community Physiotherapy (pending MSK Hub development)
Soft tissue - no lump
Dorsal/Ulnar Wrist
Bone / joint
- Consider OA or trauma
- Xray (PA and lateral of wrist)
- if symptoms affecting quality of life, refer to hand surgeons
Soft tissue
- ECU tear or subluxation:
- refer to Community Physiotherapy (pending MSK Hub development) for hand therapy
- if fails to settle then refer to hand surgeons (MRI?)
- Pain with loss of function consider tendon rupture:
- refer urgently to hand surgeons
Volar Wrist Pain
Bone / joint
- Consider OA or trauma (wrist/scaphoid/pisiform)
- Xray (PA and lateral of wrist)
- if symptoms affecting quality of life, refer to hand surgeons
Soft tissue
- Ganglion
- Severe symptoms refer to hand surgeons
- BSSH ganglion cysts
Volar Finger Pain
Soft tissue
- + Lump consider ganglion or lipoma or GCT (benign giant cell tumour)
- Severe symptoms refer to hand surgeons
- BSSH ganglion cysts
- + Swelling of digit and colour change consider Reynauds or inflammatory
- refer to Rheumatology
- + Lack of movement consider trigger finger
- no movement / severe symptoms refer to hand surgeons
- mild / moderate / intermittent symptoms refer to Community Physiotherapy (pending MSK Hub development) for steroid injection
- BSSH trigger finger/thumb
- consider Low Priority Procedure Policy prior to referral
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