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 cervicogenic causes and red flags.


  • Tight fascial band; subluxing ulnar nerve over medical epicondyle.
  • Valgus deformity;  hyperextending elbow.
  • Blow to elbow/ Prolonged elbow flexion (e.g. frequent guitar playing or sleeping pattern).
  • Repetitive and/ or heavy motion at extreme of elbow/flexion/extension (e.g shovelling or working underneath car).


  • Paraesthesia ring and little fingers.
  • Aching medial side elbow / arm; worse leaning on elbow.
  • Sensory changes more common than motor (motor fibres deeper).
  • May be weakness of grip.
  • May be wasting of small muscles of hand.
  • May be clawing of little and ring fingers.
  • If Nerve Conduction Studies are Positive; refer to Surgeon via Interface team.


If Serious pathology suspected or rapidly increasing neurological symptoms refer directly to Surgeon via Interface.

If serious pathology not suspected:

  • Avoid direct pressure and sustained elbow flexion.
  • Limit elbow flexion to less than 45° at night using towel or pad.
  • Avoid Heavy Lifting.
  • Ergonomic and sport related advice/ Ice.
  • NSAIDs.
  • Graduated exercise programme including stretching.
  • Local steroid injection into cubital tunnel should not be undertaken.

Refer to Physiotherapist/ Occupational Therapist if:

  • There are no neurological changes.
  • Diagnosis not ascertained.
  • The patient require more specialist advice and would consider nocturnal splinting.
  • The patient does not want surgery.


Consider Nerve Conduction Studies.


Physiotherapist or Occupational Therapist
  • Assessment / Diagnosis (consider cervicogenic / thoracic outlet component)
  • Detailed advice/ activity modification.
  • Nocturnal Elbow Splint.
  • Mobilisations/ Muscle strengthening

If not responding consider referral to Interface Team.

Interface Team
  • Consider  previous assessment diagnosis and management
  • Local steroid injection into cubital tunnel should not be undertaken.

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


  • X ray if OA & RA suspected.
  • Nerve conduction Studies.
Surgical Criteria
  • Referral is appropriate if surgery is an option or for complex diagnosis
  • Surgery may be considered if the patient is suffering from significant pain related functional impairment
  • Consider the following:
    • Willingness to undergo surgery
    • General health
    • Understand recovery period post surgery

Ulnar nerve decompression =/- transposition: Recovery period 2-6 weeks away from work and  up to a year for full recovery