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

Exclude red flags - inflammatory joint disease.

Consider Diagnosis (discuss within peer review).

Commonly presenting:

  • Dupuytren’s  nodules (separate pathway).
  • Heberden’s / Bouchards nodes (OA Pathway).
  • Ganglion: usually located dorsal or volar-radial aspect of wrist or  flexor aspect base of finger (e.g. seed Ganglia) and transluminate.
  • Epidermal inclusion cyst
  • Undiagnosed lump / possible sarcoma




Interface Team
  • Consider previous assessment diagnosis and management.
  • For undiagnosed lump or suspected carcinoma refer for urgent surgical appointment regardless of general health etc.
  • If ganglion is causing significant pain and restricting activities of daily living (refer to surgical guidelines) refer to surgeon after obtaining INNF approval from GP).
  • If Inflammatory Joint Disease suspected refer as urgent appointment to Rheumatologists.


As for GP.

Surgical Criteria

Ganglion removal is listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please the attached link for details of access criteria and funding arrangements.


  • Ganglion: Surgical removal if symptomatic, funding authorisation required. Recurrence possible.
  • Epidermal Inclusion cyst: Surgical removal if symptomatic.

  • Osteochondroma/ tumour: surgical removal +/- bone graft.