Document type
Clinical pathways
Place
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Pathway
Hand and Wrist PainGanglionDupuytrens ContractureCarpal Tunnel Syndrome

Hand and Wrist including Dupuytren's, Trigger Finger and Carpal Tunnel

Pathway Publish Date: July 2023
Pathway Next Review Date: July 2025

GPs TO ONLY REFER DIRECT TO SECONDARY CARE IF:

  •  RED FLAGS

    OR

  • PRIOR APPROVAL HAS BEEN OBTAINED (see points immediately below)

NB:

1) GPs should only be applying for prior approval for DUPUYTREN’S and GANGLION surgery.

2) GPs should NOT be applying for either Carpal Tunnel Syndrome or Trigger Finger:

-  these should be referred by the GP to MSK in the first instance; (MSK will then apply for prior approval before referring to secondary care).

 

ONLY REFER DIRECT TO SECONDARY CARE IF RED FLAGS OR PRIOR APPROVAL HAS BEEN OBTAINED

The management of the following is covered below: wrist sprain, hand and wrist osteoarthritis, Dupuytren's contracture, carpal tunnel syndrome, tendinopathies including trigger finger and DeQuervain's disease and ganglion.

Wrist Sprain

  • Manage conservatively including rest (continue to move joints to prevent stiffness), elevation, compression bandage, pain relief and anti-inflammatories (see pathway).
  • If not improved after 2-4 weeks refer to physiotherapy.

Osteoarthritis

  • Treatment should focus on self-management; Consider steroid injections in exceptional circumstances or for advice refer to MSK triage.

Dupuytren's contracture

  • Management is mostly reassurance and monitoring.
  • Surgical treatment will only be considered if:
    • Metacarpophalangeal joint (MCPJ) joint contracture of 30° or more and/or

proximal Interphalangeal joint (IPJ) contracture of 10° or more (inability to place hand flat on table),

AND

  • The loss of extension results in significant functional disability interfering with activities of daily living for the patient.

If meets surgical criteria and patient wants surgery GP should apply for prior approval before referral. 

  • Surgery for mild Dupuytren’s contracture is not normally funded.

Carpal Tunnel

 

There are five main options for treating carpal tunnel syndrome. The choices are:

  • Changing lifestyle and working habits to put less pressure on hands, and self-managing symptoms
  • Pain medications, for quick relief from pain
  • Physical management of symptoms, including hand exercises and wrist splints
  • Corticosteroid injections into the carpal tunnel, to reduce pain, swelling, and pressure
  • Surgery to reduce pressure on the carpal ligament nerve.
  • GP needs to refer to MSK triage if appropriate, and MSK triage will apply for prior approval before referring to secondary care if the patient meets the criteria for surgery.
    • Please ensure sufficient details are included in the referral from GP to MSK triage
  • Severe symptoms:
    • constant numbness / pain OR
    • wasting / weakness of the thumb muscles should be referred to MSK triage.
  • Mild to moderate symptoms:
    • Any of:
      • intermittent/constant paraesthesia,
      • significant interference with activities of daily living, e.g. work, self-care, care duties
      • reversible numbness / pain
    • AND
      • has failed 3 months of conservative management, including at least one steroid injection and splinting. 

Work related tendinopathies

  • Advise liaison with employer or occupational health, rest and NSAIDs

Trigger finger/ thumb

  • Requires between 1-3 hydrocortisone injections in primary care or if not available refer to MSK triage
  • Surgery will only be considered in the following circumstances:
    • Patient has failed to respond to above conservative measures OR
    • Patient has fixed flexion deformity AND symptoms have significant impact on activities of daily living

De Quervain’s disease

  • Consider steroid injections or MSK triage if not available in primary care


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