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)
    • May be local swelling and/or palpable crepitation .
    • Pain at wrist over affected
    • Aggravated by using hand, eased with rest.
  • Exclude red flags.


  • Optimal analgesia/NSAIDS/Ice
  • Avoid aggravating activities.
  • Wrist splint (request pharmacy advice re. fitting) use for 6 weeks to rest affected tendons; if de Quervain’s disease suspected thumb should be included in splint.
  • If no improvement; consider self referral or refer to Physiotherapy or Occupational Therapy for diagnosis (if not ascertained) and treatment.
  • Consider corticosteroid injection if no improvement after 3 weeks, followed by graded exercise programme in physiotherapy.


X-ray if suspicious of trauma, Infection, Tumour or Arthritis with radial sided wrist pain.

Physiotherapist or Occupational Therapist
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice.
  • Wrist/thumb splint.
  • Ergonomic considerations.
  • Graded exercise programme continued for 3 months.
  • Consider corticosteroid injection if service able to offer it.
  • If not responding consider referral to Interface Team.
Interface Team
  • Consider previous assessment and management.
  • Consider corticosteroid injection if not already undertaken.
  • If not responding to steroid after 6 weeks consider referral to surgeon or sooner if symptoms acute/severe or recurrent.
  • If patient does not wish to explore surgical option refer back to GP or Pain Consultant for advice regarding analgesia.


X-ray indicated if diagnosis not established or prior to surgical referral.

Surgical Criteria
  • The patient is suffering from significant pain related functional impairment.
  • Consider the following if patient still has pain or disability:
    • Willingness to undergo surgery
    • General Health
    • Understand recovery period post surgery
  • If patient willing and able to consider surgery refer to Surgeon.
  • De Quervain’s release- time to drive 3 weeks, time to recovery 3 months.
  • Corticosteroid injection under U/S guidance.