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Hand and Wrist Disorders

Consider Red Flags

Signs of infection / acute hot/red joints

Systemically unwell patient
Signs of inflammatory disease (stiffness >30mins, fever, rash, weight loss, warm/swollen
joints)
Suspicion of malignancy and previous history of malignancy / unexpected weight loss
History of trauma and suspicion of fracture

Click on individual condition for primary care management and referral advice

Carpal Tunnel Syndrome

Trigger Finger

OA 1st CMC

De Quervain,s Tenosynovitis

Dupuytren’s Disease

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Carpal Tunnel Syndrome
A common disorder resulting in a spectrum of symptoms including pain in the wrists, tingling and numbness in the
fingers. Even if untreated 34%-49% can significantly improve or resolve spontaneously.

History, Assessment & Examination
• Symptom longevity & severity (see below)
• Co-morbidities
• Phalen manoeuvre, A positive Phalen sign is defined
as pain and/or paraesthesia in the median-innervated
fingers within one minute of wrist flexion.
Tinel test A positive Tinel test is defined as pain and/or
paraesthesia of the median-innervated fingers that
occurs with percussion over the median nerve.
 Useful question – Does your hand feel normal?
 Symptoms can extend proximal in forearm
 Assess for objective evidence of reduced
sensation - more likely to be permanent or fixed
in severe and late presentation
 Assess for thenar wasting – test thumb abduction
power
 Assess for limitation in activities of daily living
 Neurological examination if neck symptoms

Clinical Questionnaire (see over) - A score of 5 or more is recommended for use of the test as a diagnostic screening
tool to replace nerve conduction studies.

Investigations • Bilateral symptoms (eg to exclude peripheral

FBP ESR/CRP TFT Glucose neuropathy)
Nerve conduction studies are NOT required unless:
• Suspicion of neck involvement
• Atypical symptoms • Nerve conduction studies are not required before
• Diagnostic uncertainty surgery and can unnecessarily delay treatment

Mild Moderate Severe

Intermittent Paraesthesia Constant Paraesthesia Objective sensory loss
Nocturnal Wakening +/- Pain Interference with activities of daily living Disabling pain
Reversible numbness and or pain Muscle wasting
Clumsiness/Weakness Weakness

Management
Explanation of cause and natural history (PIL) Arthritis Research UK Leaflet
Analgesia

Mild
• Night splinting - straight (neutral) splint (wrist splints can be purchased from most pharmacies or online)
• Advice on mobilisation but not overuse
• Review and monitor for resolution of symptoms for up to 3 months

Moderate
• Steroid injection for un-resolving mild cases or earlier if moderate to severe symptoms.
• This can be performed at local GP MSK clinic if skills are not available in practice.
• Do not delay referral for surgery if failure to respond or recurrence

Severe
 Refer to Secondary Care for surgical intervention
 Consider patents fitness and willingness for surgery before referral

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Patient ID: Date:

Clinical questionnaire for the diagnosis of CTS Circle* YES or NO

Has pain in the wrist woken you at night?

YES 1 NO 0
Has tingling and numbness in your hand woken you during the night?
YES 1 NO 0
Has tingling and numbness in your hand been more pronounced first thing in the morning?
YES 1 NO 0
Do you have/perform any trick movements to make the tingling, numbness go from your
hands?
YES 1 NO 0
Do you have tingling and numbness in your little finger at any time?
YES 0 NO 3
Has tingling and numbness presented when you were reading a newspaper, steering a car
or knitting?
YES 1 NO 0
Do you have any neck pain?
YES –1 NO 0
Has the tingling and numbness in your hand been severe during pregnancy?
YES 1 NO –1 N/A 0
Has wearing a splint on your wrist helped the tingling and numbness?
YES 2 NO 0 N/A 0
TOTAL: .........................

A score of 5 or more is recommended for use of the test as a diagnostic screening tool to
replace nerve conduction studies.

* Reproduced from Appendix A from J Hand Surg [Br] 29(1):95-6 Kamath and Stothard, ‘Erratum
to: A clinical questionnaire for the diagnosis of carpal tunnel syndrme

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Trigger Finger / Thumb
A painful condition in which a finger or thumb clicks or locks as it is flexed. Thickening of
the mouth of a tendon tunnel leads to roughness and catching of the tendon. People
with insulin-dependent diabetes are especially prone

Examination, history & assessment

• Pain level
• Longevity of symptoms
• Assess for limitations of range of movement and activities of daily living.
• Co-morbidities
• Palpate for flexor tendon nodule

Investigations
Not indicated

Management
• Explanation of cause and natural history (PIL)
• Suggest the use of anti-inflammatory gels and monitor for few weeks
• Steroid injection on up to 2 occasions if first successful
• This can be performed at local GP injection clinic if skills are not available in practice.

Patient Information Leaflet

Trigger Thumb
Trigger Finger

Referral on to plastic surgery or orthopaedic surgery for trigger finger:

• Failure to respond to conservative measures (i.e. up to 2 steroid injections)
• Where the patient has a fixed deformity that cannot be corrected
• Consider patents fitness and willingness for surgery before referral

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 OA 1st CMC

History, Assessment & Examination

• Main symptoms are pain aggravated by use at base of thumb

• Assess for activities of daily living limitation

• Co-morbidities / other joints affected

• Examination pain on passive backward movement of the thumb in extension and
tenderness at the joint line at the base of the thumb

Investigations
• Thumb x-ray: not indicated unless severe symptoms and surgical referral
contemplated

Management

• Explanation of cause and natural history - use PIL

• Prescribe analgesia and or Topical/Oral NSAIDs (unless contraindicated) for a
minimum of 2 weeks

• Advise thumb mobilisation but not overuse

• Review resolution of symptoms & activities of daily living
• If persisting functional limitation Refer to OT for joint protection advice / ADL
assessment / splints

• Injection of 1st CMC joint may provide symptomatic relief for up to 6 months and can
be repeated if effective. Click here for injection procedure

• This can be performed at local GP injection clinic if injection is not available in practice
• Radiologcially guided injection may be considered if anatomically guided injection not
successful

• Surgical Referral if significant functional problems despite conservative

treatment (e.g. splints/joint injection)

• Consider patents fitness and willingness for surgery before referral

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 De Quervain,s Tenosynovitis

Thumb tendonitis of extensor pollicis brevis and abductor pollicis longus within the 1st dorsal
compartment.
Caused by irritation or inflammation of the wrist tendons at the base of the thumb. The inflammation
causes the tendon tunnel or sheath to thicken and narrow, making thumb and wrist movement painful.
Making a fist, grasping or holding objects is painful

History, Assessment & Examination

• Assess for limitations of range of movement and activities of daily living.
• Pain level
• Finkelsteins manoeuvre
• Assess activities of daily living

Investigations
• Not indicated

Management
• Explanation of cause and natural history - use Pateint Information Leaflet
• Avoid repetitive tasks
• Advice on mobilisation but not overuse
• Advice on the use of over the counter splints
• Course of analgesia and / or NSAIDs for a minimum of 2 – 3 weeks, review for
resolution of symptoms and monitor subjectively in line with activities of daily living
• Splint(s):
• Steroid Injection(s)
• Functional analysis / retraining
• ie Referral to Hand therapy
Referral onto Secondary care for surgery if
o Intrusive symptoms after all conservative management options 1-4 options have
been tried AND patient wants surgery

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 Dupuytren’s Disease

This is a condition characterised by fibrosis of the palmar aponeurosis leading to contracture of the
fingers, and is often confused with trigger finger but is characteristically not painful in most cases. This
seems to run in families and has no known cause, but may be associated with diabetes, smoking and
alcohol excess

History, Assessment & Examination

• Longevity of problem & symptoms
• Family history
• Check for nodule, cord, finger range of movement
• Assess for limitations of range of movement & activities of daily living.

Investigations
• Not indicated

Management
 Explanation of cause and natural history – Use Patient Information Leaflet
 Advice on treatment options
 Advice on surgical intervention
 Patient to self-monitor the degree of contracture if it does not meet the requirement
for surgical intervention
 Refer if patent cannot get a flat hand or has a functional problem
 Consider patents fitness and willingness for surgery before referral

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