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)


  • Previous fracture/dislocation.
  • MCL laxity.


  • Pain (e.g. after carrying).
  • Swelling post/lateral elbow .
  • May be intermittent locking.
  • Stiffness after inactivity.
  • Loss of function.
  • Crepius.
  • Loss of end of range flexion/extension.


If Serious pathology suspected, refer directly to Surgeon via Interface.


If no serious pathology suspected:

  • Self management with exercise.
  • NSAIDs.

Consider referral to Physiotherapy or self referral for Mobilisation/Strengthening/ Activity modification/ TENS.

Consider referral to Occupational Therapy for provision of aids for daily living.

If no improvement after interventions above:

  • Consider Steroid injection (this should be undertaken in conjunction with an exercise programme).
  • Consider surgical criteria.


AP & Lateral X-ray to confirm diagnosis especially if history is suggestive of loose bodies causing internal derangement.



Physiotherapist or Occupational Therapist
  • Assessment / Diagnosis (exclude neural components and referral from cervical spine).
  • Detailed advice/ activity modification/ Self management.
  • Mobilisations/ Muscle strengthening/ splinting.
  • Consider referral to OT for provision of aids for daily living and functional and joint protection advice or splinting/bracing.
  • If non-resolving - consider local steroid injection or referral to Interface team.
Interface Team
  • Consider  previous assessment diagnosis and management.
  • Local steroid injection may be considered.
  • If no response to corticosteroid injection, consider onward referral as surgical criteria below.
  • If patient does not wish to explore surgical option refer back to GP or Pain Consultant for advice regarding analgesia.
  • If patient fits the criteria below refer to Surgeon.


AP & Lateral X-ray to confirm diagnosis especially if history is suggestive of loose bodies causing internal derangement or prior to surgical referral.

Surgical Criteria

Referral is appropriate if surgery is an option or for complex diagnosis

  • Symptomatic and limiting activity with no response to corticosteroid injections.
  • Discuss the following:
    • willingness to undergo surgery
    • general health
    • understand recovery period post surgery.

Surgical for interventions include:

  • Elbow Arthroscopy (for R/O loose bodies or inflammatory or degenerative tissue- sometimes relatively short term relief): Recovery period 2 weeks away from work and 4-8 weeks for full recovery.
  • Elbow replacement surgery (not common).  May require help with ADL activity in first few weeks. No weight through elbow for 6 weeks. Up to a year for full recovery.