Red flags for elbows, wrists and 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 inflammatory cause.
  • Herberdens and/or Bouchards nodes in fingers.
  • Deformity.
  • May be a positive grind, test thumb CMC joint.
  • Exclude red flags.


  • Functional ROM; encourage self-management.
    • Activity modification
    • Optimal analgesia/NSAIDS
    • Heat/ice
    • TENS
  • ROM poor and affecting ADL; refer to physiotherapy for mobilisation.
  • Joint unstable or painful and function poor refer to physiotherapy or occupational therapy for custom made splint.

If no improvement; consider self-referral or refer to Physiotherapist or Occupational Therapist for diagnosis (if not already ascertained) and treatment.


Consider X-ray.

Physiotherapist / Occupational Therapist
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice/ADL advice.
  • General joint protection advice,  exercise, splint.
  • Consider corticosteroid injection.

If not responding, consider referral to Interface Team.

Interface Team
  • Consider previous assessment, diagnosis and management.
  • If not responding consider corticosteroid injection.
  • If none of the above effective, consider referral to surgeon.

If patient does not wish to explore surgical option refer back to GP or Pain Consultant for advice regarding analgesia.


Consider X-ray.

Surgical Criteria
  • The patient is suffering from significant pain related functional impairment.
  • Consider the following:
    • Willingness to undergo surgery
    • General health
    • Understanding of recovery period post surgery
  • Corticosteroid injection under image intensification for small joints of hand.
  • Wrist; Fusion or joint replacement.
  • Thumb CMC joint;
    • Grade 1-3 Corticosteroid injection under U/S guidance if required
    • Grade 3-4 Trapeziectomy +/- sling suspension- return to driving 12 weeks, recovery up to 1 year.
    • Grade 3-4 Joint replacement - return to driving at least 12 weeks, recovery up to 1 year.
  • Thumb MCP joint;
    • Joint fusion - return to driving 6 weeks, return to function 3 months.
  • PIPJs and DIPJs fingers;
    • If pain severe and persistent with poor ROM options of fusion for DIPJs and fusion or joint replacement for PIPJs
    • If PIPJ pain severe but joint ROM good consider HCI under image intensification.
  • MCP joint fingers;
    • Joint replacement - return to driving approximately 12 weeks, recovery up to 1 year.