Red flags for elbows, wrists & hands

Prior to referral consider / screen to exclude:

Key Clinical Observations of concern

  • Hot / red / swollen joint with raised body temperature
  • Rapidly worsening deformity
  • Neuro-vascular compromise
Urgent elbow / wrist / hand referral

Patients with any of the following suspected should be sent to A&E

  • Fracture or dislocation
  • Suspected infection
  • Recent tendon or ligament rupture

Urgent appointments can be made in elective Hand Clinics for patients with:

  • Rapidly worsening symptoms
  • Hand pain with confirmed presence of cancer on imaging.
  • Constant unrelenting hand or forearm pain / especially unrelenting night pain in presence of cancer
  • Progressive or significant neurological loss suggestive of acute peripheral nerve compression
GP / Primary Clinician
  • Consider Diagnosis (discuss within peer review)
  • Exclude cervicogenic cause/component.
  • Tinels Tap over median nerve at Wrist (84% specific).
  • Phalens’ Test (80% specific).
  • Carpal Tunnel Compression (62% specific)
  • Sensory testing in median nerve distribution.
  • APB strength/wasting.

Who is most affected:

  • Biomodal age distribution with peak in early 50’s and second peak between 75-84 years.
  • More common in women (11%) than men (3.5%).


  • Pain, numbness or tingling in the hands are common in the general population (14.4% prevalence), but only 20-50% symptomatic patients found to have carpal tunnel syndrome (CTS).


34% patients with idiopathic carpal tunnel syndrome have spontaneous improvement after 6 months.


  • Manage contributory factors e.g. pregnancy, Thyroid dysfunction, diabetes, obesity.
  • Explain that symptoms may resolve within 6 months, especially in people younger than 30 years of age, those with unilateral symptoms of short duration and pregnant women where fluid retention is the precipitating factor.     
  • Advise purchase of a wrist splint (request pharmacy advice re fitting) to use at night. Improvement should be apparent within 2-8 weeks of use.
  • Minimise activities that exacerbate symptoms.
  • Optimal analgesia.
  • Do not recommend the use of non-steroidal anti inflammatory drugs (NSAIDs) or diuretic medication.
  • Consider corticosteroid injection if there is no improvement within 2 months of conservative   treatment.
  • If patient fits the surgical criteria below, refer for orthopaedic opinion via interface team.

If GP is unable to provide the options above this can be carried out within physiotherapy (PT) or occupational therapy (OT) including splinting.


Nerve conduction studies rarely required as often clinical diagnosis can be made without. However may be useful for unconfirmed symptoms.

Physiotherapist or Occupational Therapist
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice including/Nerve glide exercise/ Soft tissue stretches/ splinting.
  • Sensory testing in median nerve distribution (Weinstein Enhanced Sensory Testing 80% specific).
  • If not responding consider referral to Interface Team for onward referral to Orthopaedics as appropriate.


Interface Team
  • Consider  previous assessment diagnosis and management.
  • Onward referral if complies with surgical criteria below.
  • If surgical option declined refer back to GP or Pain Consultant.


For clinically unconfirmed Carpal Tunnel Syndrome, refer for Nerve Conduction Studies.

Surgical Criteria

Carpal tunnel surgery is listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please click on the attached link for details of access criteria and funding arrangements.


Carpal Tunnel Decompression:

  • recovery period: 2 weeks.
  • scar tenderness and pillar pain may persist for up to 3 months.