If rapidly growing lump or features like night pain / skin tethering / irregularity consider 2 week wait referral pathway.
If swelling of multiple joints in both hands / wrists consider inflammatory cause and referral to Rheumatology
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 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 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
Volar aspect of fingers/palm
Dupuytrens
- benign painless condition affecting palmar and finger fascia, often strong family history
- Refer to hand surgeons if:
- contracture PIP joint more than 20 degrees and/or MCP joint contracture 30 degrees or more
- in thumb: any contracture affecting function
- BSSH Dupuytren's disease
- Consider Low Priority Procedure Policy prior to referral
Seed (pearl, A1 pulley) ganglion (flexor tendon sheath ganglion cyst)
- small pea like lump, at the base of the finger, can be tender to palpate
- Work up:
- Reassure
- refer to radiology for ultrasound guided aspiration
- advise of risk of recurrence
- If symptomatic &/or recurrent
- refer to hand surgeon
- BSSH ganglion cysts
Giant cell tumour of tendon sheath
- a benign lump usually over volar aspect of base of finger and a more diffuse, ill defined swelling, can be painful
- Work up:
- Reassure if no red flag signs
- If symptomatic, refer to hand surgeons
Inclusion cyst
- Often history of trauma – may be small foreign body present
- Work up:
- Reassure
- Refer to hand surgeons if symptomatic
Dorsal Wrist
Ganglion
- lump commonly on dorsal radial aspect of joint
- may be history of trauma and /or pain
- can vary in size
- Work up:
- Can it transilluminate?
- no: refer to hand surgeon
- yes: reassure and advise
- please do not aspirate
- Can it transilluminate?
- If continues to be symptomatic:
- refer to hand surgeons
- BSSH ganglion cysts
- 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
- often local swelling and pain with active or passive stretch
- Work up:
- advice and analgesia
- wrist splint with thumb extension
- If not improving
- hand therapy at Community Physiotherapy (pending MSK Hub development)
- ultrasound guided steroid injection Community Physiotherapy (pending MSK Hub development)
- very rarely severe &/or persistent symptoms need referral for surgical release
- BSSH De Quervain's syndrome
- usually volar radial, can sit close to radial artery
- Work up:
- Can it transilluminate?
- No: refer to hand surgeons
- Yes: reassure and advise
- please do not aspirate
- Can it transilluminate?
- If continues to be symptomatic:
- refer to hand surgeons
- BSSH ganglion cysts
Extensor tendon tenosynovitis
Dorso-radial Wrist
deQuervains (1st dorsal compartment tendons)
Volar Wrist
Ganglion
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