Hand/wrist Pain- Adult Leeds
1. Background Information / Scope of Pathway
Quick info:
These pathways were developed to guide clinicians when managing adults with common musculoskeletal problems. The pathways are not provider specific and so the guidance and forms apply to all providers.
2. Information Resources for Patients and Carers
Quick info:
MSK TAS Patient Infromation Leaflet
Patient information
Please see attached patient information leaflet on Basal Thumb Osteoarthritis.
Please see attached patient information leaflet on Dupuytren's disease.
Please see attached patient information leaflet on Trigger Finger.
Please see the attached patient information leaflet on De Quervain's Tenosynovitis.
Please see attached patient information leaflet on ganglion cysts.
Please see the attached patient information leaflet on Carpal Tunnel Syndrome.
Decision Aid for Carpel Tunnel
Preoperative Information
Please see attached patient information leaflet for preoperative information on Basal Thumb Osteoarthritis.
Please see attached patient information leaflet for preoperative information on Dupuytren's disease.
Please see attached patient information leaflet for preoperative information on Trigger Finger.
Please see the attached patient information leaflet for preoperative information on De Quervain's Tenosynovitis.
Please see attached patient information leaflet for preoperative information on ganglion cysts.
Please see attached patient information leaflet for preoperative information on Carpal Tunnel Syndrome.
3. Development and Updates to this Pathway
Quick info:
Development
The pathway redesign was a clinicaly lead city wide process. It was conducted through the Musculoskeletal Steering Group which had representation from the 3 CCGs, Patients, NHS Leeds, Leeds Teaching Hospitals Trust and the Leeds Musculoskeletal Services.
The individual pathways were authored by the appropriate clinical staff involved in delivering the pathway, but chiefly comprised of GPs, Consultants and Therapists.
The pathways went live on the 2/7/2012
Updates
Referrals Forms Updated October 2012. Major Review and Update June 2013
This involved reformating of the pathway and referral forms.
4. Referral Forms
Quick info:
Referral Forms
Quick View - PDF
MSK12 Non Surgical Hand-Wrist Form V3
MSK13 Surgical Hand-Wrist V3
MSK14 Problem Not on Pathway Form V3
Mail Merged
The forms below are provided as a repository. They can be downloaded to your computer and be imported to your clinical system. This is so all practices have access to the most up to date forms.
EMIS - merged
MSK12 Non Surgical Hand-Wrist Form V3
MSK13 Surgical Hand-Wrist V3
MSK14 Problem Not on Pathway Form V3
SystmOne - merged
MSK12 Non Surgical Hand-Wrist Form V3
MSK13 Surgical Hand-Wrist V3
MSK14 Problem Not on Pathway Form V3
6. Pain in Base of Thumb
Quick info:
Patient information
Please see attached patient information leaflet on Basal Thumb Osteoarthritis.
GP Information
If a patient presents with pain in the base of the thumb then consideration should be given to the following:
- are features present suggestive of carpal tunnel syndrome (see carpal tunnel guidance)?
- are features present suggestive of De Quervain’s tenosynovitis (see De Quervain's guidance)?
- has there been recent or past trauma, or features suggestive of an inflammatory process?
- If the answer is yes to any of these questions then continue on the appropriate pathway/manage accordingly.
If the pain is likely to be due to osteoarthritis of the first carpo-metacarpal joint, then an X-ray of this joint should be requested to confirm the diagnosis.
If the diagnosis is confirmed see guidance on ‘First-line Management’.
If the diagnosis is not confirmed and symptoms persist, reconsider alternatives.
7. Dupuytren's Contracture
Quick info:
Patient information
Please see attached patient information leaflet on Dupuytren's disease.
GP information
This condition, caused by progressive shortening and thickening of the palmar fascia, presents with a varying degree of flexion deformity of the fingers and possibly disturbance of hand function.
Risk factors include:
- smoking
- alcohol excess
- diabetes
- hypercholesterolaemia
During assessment it is critical to assess the following factors:
- is tenderness present?
- if so, it is important to exclude other conditions such as infection, but before proceeding with the pathway, tenderness must have settled, so a period of observation is indicated
- can the patient put the hand flat on the table top?
- if the answer is no, then assess whether the patient is willing and likely to benefit from surgery. If yes to both, then refer to a hand surgeon
- is this a ‘high demand hand’?
- if the patient is able to put the hand flat to the table but has an outstanding reason why surgery may be indicated due to a unique personal requirement for exceptional hand function, eg occupation, then referral to a hand surgeon is indicated
8. Trigger Finger/Thumb
Quick info:
Patient information
Please see attached patient information leaflet on Trigger Finger.
GP information
Trigger finger (digital flexor stenosing tenosynovitis), presents with difficulty in extending a digit, and a nodule may be palpable at the level of the A1, or less commonly A3, pulley. Trigger thumb presents similarly, involving flexor pollicis longus.
Management:
- corticosteroid injection up to 2 times:
- attempted in-house if expertise exists, or refer if not
- persistent symptoms can then be referred for ultrasound scan +/- corticosteroid injection
- if symptoms still persist, refer to a hand surgeon for consideration of surgical release
9. De Quervain's Tenosynovitis
Quick info:
Patient information
Please see the attached patient information leaflet on De Quervain's Tenosynovitis.
GP information
This condition, affecting the tendon sheaths of abductor pollicis longus and extensor pollicis brevis, produces local tenderness and swelling most notably over the radial styloid.
It may be provoked by thumb hyperabduction, eg during golf swing and other sports, picking up child under arms. Finkelstein's test may be diagnostic – flex the thumb in the palm and ulnar deviate the wrist, provoking pain along the tendon sheath.
Management:
- advise avoiding provocative activities
- corticosteroid injection (up to 2 attempts):
- in house if expertise exists
- refer for injection if no in house expertise
- refer for ultrasound +/- corticosteroid injection if no success after 2 attempts
- if symptoms persist despite the above measures consider referral to hand surgeon
10. Ganglion
Quick info:
Patient information
Please see attached patient information leaflet on ganglion cysts.
GP information
Ganglion:
- is a common benign smooth round swelling of the hand and wrist
- can vary in consistency from soft to bony hard according to the pressure inside it
- are seldom attached to skin, though they can be single or multi-loculated
- arise when synovial fluid leaks from a joint or tendon tunnel
- most can be confidently diagnosed without imaging because they arise in typical locations with typical features. If doubt on diagnosis exists, follow the 'Uncertain diagnosis' pathway
Management:
- there is no requirement for treatment unless the ganglion is symptomatic symptoms may include local pain, discomfort from nerve branch entrapment, and reduced range of movement of a part or joint
- about 40% resolve spontaneously
- most ganglions will have no clear cause; however, if treatment is felt to be necessary, and the ganglion is likely secondary to a condition such as osteoarthritis or rheumatoid arthritis, the patient should be managed according to the underlying condition
- if there is no underlying condition, the ganglion should be managed according to its location
Four types of ganglion exist:
- Dorsal Ganglion:
- typically occurring in young adults
- presents as a swelling on the dorsal aspect of the wrist
- may resolve spontaneously
- if required, and if local expertise exists in the practice, it is reasonable to consider aspiration on up to 2 separate occasions. If this proves unsuccessful, it is reasonable to refer to a Hand Surgeon.
- Volar (Palmar) Wrist Ganglion:
- typically occurring in young adults
- presents as a swelling on the volar aspect of the wrist (and in older adults possibly in association with arthritis)
- aspiration may damage local structures so if symptomatic and the patient wishes to consider treatment, referral to a Hand Surgeon is appropriate.
- Flexor Sheath Ganglion:
- typically occurring in young adults
- presents as a swelling at the base of the finger, arising from the flexor tendon
- can cause irritation and pain when gripping. If treatment is required, referral to a Hand Surgeon is appropriate.
- Mucoid Cyst Ganglion (Dorsal digital ganglion):
- typically occurring in older adults
- presents as a swelling at the distal inter-phalangeal joint of the finger, often due to underlying degenerative change
- aspiration may cause joint infection, and should be avoided. It is likely no treatment will be required, but if felt necessary, referral to a Hand Surgeon is appropriate.
11. Carpal Tunnel Syndrome
Quick info:
Patient information
Please see the attached patient information leaflet on Carpal Tunnel Syndrome.
GP information
Carpal Tunnel Syndrome:
- is the most common median nerve lesion
- is caused by an increase in pressure in the anatomical tunnel formed by the carpal bones and the flexor retinaculum, through which the median nerve passes this increase in pressure produces ischaemia of the median nerve, generating the symptoms
- ssociated with Carpal Tunnel Syndrome
- will cause symptoms in the distribution of the median nerve, thus most commonly affecting the thumb, index and middle finger; however, variation does exist, and it is possible for all the fingers to be affected
- sensory symptoms include paraesthesiae, numbness, burning and pain, and motor symptoms include weakness, clumsiness and the patient may report dropping things.
- symptoms tend to be worse at night, and as the condition progresses during the day too. Movements such as shaking the hand, or hanging it out of bed at night are often attempted to relieve symptoms. Symptoms may radiate to the arm, elbow and shoulder.
Aetiology:
- generally the condition is idiopathic
- however, it is associated with a variety of conditions including:
- hypothyroidism
- diabetes mellitus
- rheumatoid disease
- pregnancy
- previous Colles fracture
- acromegaly
- it may be worth checking TFTs and a fasting glucose in new presentations
- a first degree relative may have suffered the condition in up to 1 in 4
Examination:
- should include:
- Phalen’s test a positive test is indicated by reproduction of sensory symptoms upon flexing the wrist for 1 minute
- Tinel’s test a positive test is indicated by reproduction of sensory symptoms by tapping lightly over the median nerve at the wrist
- an assessment can also be made for muscle wasting at the thenar eminence, which may be noticed with advanced presentations
Assessment of severity:
- when a patient presents with typical signs and symptoms of Carpal Tunnel Syndrome an assessment should be made as to whether the condition is mild, moderate or severe
- severe cases may include constant unrelenting symptoms, problems with function and possibly some muscle wasting it would be reasonable to refer these patients immediately to a Hand Surgeon
- mild or moderate symptoms may be treated conservatively, and the pathway indicates the management options
- atypical signs and symptoms, which do not fit into a clear pattern, perhaps with an unusual distribution, or a suspicion that the nerve lesion exists elsewhere, perhaps in the neck, or possibly an ulnar nerve lesion, should be referred to the MSK-MDT for further assessment
12. Diagnosis Uncertain
Quick info:
GP information
A patient may have hand or wrist pain requiring referral and diagnosis is uncertain. A variety of referral options exist, so factors to consider include (but not limited to):
- are there features of inflammation, multi-joint involvement or raised inflammatory markers? If so, consider rheumatology referral.
- for undifferentiated problems consider MSK-MDT referral.
- Please note if there a recent or past history of trauma or wrist/hand surgery, then a hand surgeon opinion may be desirable. For these cases it may be most appropriate to follow the 'Problem not on pathway' stem and provide as much information as possible to facilitate onward referral through the MSK-TAS.
13. Problem Not on Pathway
Quick info:
There are 2 broad groups of patients who fall into this category:
Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.
Those with a clear problem and course of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.
14. Unguided Steroid Injection, In House or Refer MSK-MDT Referral Form (MSK12)
Quick info:
Referral Form:
MSK12 Non Surgical Hand-Wrist Form V3
If the skills exist within the practice then please undertake the unguided injection, otherwise: Choose & Book
You can find this clinic on Choose & Book under
Speciality: Orthopaedics
Clinic type: Hand & Wrist
Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.
This clinic provides diagnosis, investigation, treatment and onward referral if needed.
This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.
15. Unguided Steroid Injection, In House or Refer MSK-MDT Referral Form (MSK12)
Quick info:
Referral Form:
MSK12 Non Surgical Hand-Wrist Form V3
If the skills exist within the practice then please undertake the unguided injection, otherwise:
Choose & Book
You can find this clinic on Choose & Book under
Speciality: Orthopaedics
Clinic type: Hand & Wrist
Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.
This clinic provides diagnosis, investigation, treatment and onward referral if needed.
This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.
16. Refer to MSK-MDT Referral Form (MSK12)
Quick info:
Referral Form:
MSK12 Non Surgical Hand-Wrist Form V3
Choose & Book
You can find this clinic on Choose & Book under
Speciality:Orthopaedics
Clinic type:Hand & Wrist
Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.
This clinic provides diagnosis, investigation, treatment and onward referral if needed.
This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.
17. Refer to MSK-TAS (Telephone Assessment Service) Form (MSK14)
Quick info:
MSK TAS Patient Infromation Leaflet
Referral Form:
MSK14 Problem Not on Pathway Form V3
Choose & Book
You can find this clinic on Choose & Book under:
Speciality: Orthopaedics
Clinic Type: Hand & Wrist
The MSK Telephone Assessment Service (MSK-TAS) is offered as a way of esuring patients get into the right clinic when it is not clear from the pathways what the right coarse of action is.
This is distinct from the Diagnosis Unclear Pathway which is there to offer quick access to diagnostic assessment when patients present with symptoms that don't immediately fall into a diagnostic group.
Patients who are appropriate for the MSK-TAS fall into two categories:
Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient. Those with a clear problem and coarse of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.
When you book the patient into the MSK-TAS via Choose & Book you are booking them a telephone appointment.
Once the referral form has been completed and sent via Choose & Book a senior Physiotherapist will review the referral form within 48 hours. They will then decided the appropriate coarse of action and the patient will be contacted by phone at the allotted time in order to make the necessary arrangements for onward referral.
20. Refer for Ultrasound Guided Steroid Injection
Quick info:
Provider Information
Please refer to the appropriate radiology department of patient's choosing.
21. Refer for Ultrasound Guided Steroid Injection
Quick info:
Provider Information
Please refer to the appropriate radiology department of patient's choosing.
22. Refer Hand Surgeon Referral Form (MSK13)
Quick info:
Referral Form:
MSK13 Surgical Hand-Wrist V3
Patient information
Please see attached patient information leaflet for preoperative information on Trigger Finger.
Choose & Book
All providers except LTHT appear under;
Speciality: Orthopaedics
Clinic type: Hand & Wrist
LTHT appears under;
Speciality: Surgery - Plastics
Clinic: Upper Limb
Service: Adult Upper Limb - Surgery Plastics
Provider information
Common providers of this procedure to Leeds patients include:
- LTHT
- Spire please note, exclusions apply
- Yorkshire Clinic please note, exclusions apply
- BRI
- Harrogate
- Mid Yorks
- Calderdale Royal Infirmary
- Eccleshill please note, exclusions apply
Where exclusions apply common exclusions include:
- anaesthetic risk
- previous anaesthetic complication
- significant co-morbidity
- severe psychiatric morbidity
Please see Choose & Book Directory of service for additional information.
23. Refer to Hand Surgeon Referral Form (MSK13)
Quick info:
Referral Form:
MSK13 Surgical Hand-Wrist V3
Patient information
Please see the attached patient information leaflet for preoperative information on De Quervain's Tenosynovitis.
Choose & Book
All providers except LTHT appear under;
Speciality: Orthopaedics
Clinic type: Hand & Wrist
LTHT appears under;
Speciality: Surgery - Plastics
Clinic: Upper Limb
Service: Adult Upper Limb - Surgery Plastics
Provider information
Common providers of this procedure to Leeds patients include:
- LTHT
- Spire please note, exclusions apply
- Yorkshire Clinic please note, exclusions apply
- BRI
- Harrogate
- Mid Yorks
- Calderdale Royal Infirmary
- Eccleshill please note, exclusions apply
Where exclusions apply common exclusions include:
- anaesthetic risk
- previous anaesthetic complication
- significant co-morbidity
- severe psychiatric morbidity
Please see Choose & Book Directory of service for additional information.
Key Dates
Published: 16-Dec-2015, by Leeds
Valid until: 19-Feb-2016