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)

Characterised by:

  • Skin thickening, pitting or nodules in the palm.
  • Fibrous cords in the palm and/or digits.
  • Flexion deformity at the MCP and/or PIP joints.
  • Ring finger most commonly affected, followed by little and middle fingers.
  • Risk factors include; diabetes, epilepsy, family history, smoking, alcohol consumption and previous trauma.
  • Garrod’s knuckle pads may be present.
  • Exclude red flags.


  • No functional problems.
  • Mild metacarpo-phalangeal joint contracture (< 30 degrees).
  • Observe and follow advice listed.


  • Notable functional problems.
  • Moderate metacarpo-phalangeal joint contracture (30-60 degrees).
  • Moderate inter-phalangeal joint contracture (> 30 degrees).
  • First Web Contracture.
  • Consider referral to surgeon if patient considers surgical treatment.


  • Severe contracture of both metacarpo-phalangeal joint (>60 degrees and proximal inter-phalangeal joint (.30 degrees).
  • Refer to surgeon if patient fits criteria for surgery.

If diagnosis uncertain refer to Interface Team


If contracture <30 degrees at affected joint/s:

  • Use hand as normally as possible.
  • Reassure that tender nodules likely to become pain-free with time.
  • No evidence that splinting reduces contractures before surgery.
  • Smoking cessation if applicable.
  • Teach patients table top test.
  • Referral to physiotherapy or Occupational Therapy is not indicated pre operatively.

Referral for Orthopaedic opinion via Interface Team.


Not indicated.

Interface Team
  • Consider previous assessment diagnosis and management.
  • If contracture > 30 degrees at any joint in a finger and function affected consider referral to surgeon using criteria below.


Not indicated.

Surgical Criteria

Dupuytren's surgery and/or Xiapex is listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please the attached link for details of access criteria and funding arrangements.

  • Percutaneous fasciotomy if single band in palm- drive after 1-3 weeks if safe, recovery period 3 months, night splint required for 3 months.
  • Dermofasciectomy- drive after 1-4 weeks if safe, recovery period and wearing night splint for 3- 6 months.
  • In advanced cases of contracture amputation of a digit may be required.
  • Collagenase Injection is carried out in Gloucestershire only as part of a trial (at present) within GHT. Recovery - drive after 5 days if safe. Recovery period 2-3 weeks, night splint required for 3 months.