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.

Consider Diagnosis (discuss within peer review).

  • Non-union/ missed scaphoid fracture (send direct to fracture clinic).
  • TFCC tear.
  • DRUJ or Carpal Instability.
  • Occult ganglion.
  • Kienbock’s disease.


  • Optimal analgesia/ NSAIDS.
  • With low risk patients encourage self management.
    • Activity modification.
    • Limit weight bearing through extended wrist.
    • Heat/ice.
    • TENS.
  • If no improvement; consider self referral or refer to Physiotherapy or Occupational Therapy for diagnosis (if not ascertained).
  • Consider referral to Interface Team if complex.


X-ray if suspicious of trauma, infection, tumour or OA.

Physiotherapist / Occupational Therapist
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice.
  • General joint protection advice/Wrist strengthening exercise /Splint.

If not responding consider referral to Interface Team.

Interface Team
  • Consider previous assessment and management .
  • If not responding to comprehensive conservative management consider referral to surgeon if surgical criteria applicable.
  • If patient does not wish to explore surgical option refer back to GP or Pain Consultant for advice regarding analgesia.


X-ray if suspicious of trauma, infection, tumour or OA or if scaphoid collapse, non union or Keinbocks suspected.

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
  • Understanding of recovery period post surgery.
  • ORIF +/- bone graft; return to driving 6 weeks, return to function 12 weeks.
  • Diagnostic Arthroscopy; return to driving 1-2 weeks, return to function 2-3 weeks.
  • TFCC repair; return to driving 6 weeks, return to function 3-6 months.
  • Soft tissue reconstruction; return to driving 10 weeks, return to function 3-6 months.
  • Joint  fusion; return to driving 6 weeks, return to function 3 months.
  • Excision of bone;  return to driving 4-6 weeks, return to function 6-12 weeks.
  • Ulnar shortening; return to driving 6 weeks, return to function 3 months.