Reasoning GP · Algorithm · 1-page summary
Finger pain in adults
For: adults with finger pain, swelling, stiffness, locking or deformity. Not for: children (local paediatric pathway); wrist or whole-hand pain, nail problems or Raynaud's alone (their own algorithms).
Core rule: a hot swollen joint, a sausage finger with tendon-sheath tenderness or a cold pale digit is an emergency until proven otherwise. Persistent synovitis → urgent rheumatology, without waiting for blood results.
0Stop — call 999 now — before any history
- Threatened digit or hand: cold, pale or blue digit, rapidly progressive colour change, sensory loss, absent Doppler signals → 999. A palpable radial pulse does not exclude digital artery occlusion.
- Ischaemia with systemic illness, major trauma or vascular compromise; finger infection with sepsis or instability → 999. Other acute digital ischaemia → Immediate ED / vascular or hand surgery. Do not delay transfer for Allen's testing, bloods or imaging.
1Triage by pattern — by the swelling
| Finding | Action |
|---|---|
| Hot swollen joint | Diagnosis uncertain → Same-day hospital (aspiration) |
| Whole digit, sheath tender | Kanavel signs → Same-day ED / hand surgery |
| Soft warm MCP/PIP | Persistent synovitis → Urgent rheumatology |
| Bony DIP/PIP nodes | OA: clinical diagnosis, primary care |
| Locking or clicking | Trigger finger (A1 nodule): primary care |
2Screen — one row is enough
- Flexor tenosynovitis (Kanavel: fusiform swelling, held flexed, pain on passive extension, sheath tender) → Same-day ED / hand surgery
- Septic finger joint: acutely swollen, hot, tender; fever may be absent → Same-day hospital / hand surgery
- Spreading infection from a wound or paronychia, red streak up the forearm → Same-day ED / hand surgery; ask about bites, water.
- Major tendon injury; mallet finger that is open, with volar subluxation, a large bony avulsion or extension not held → Same-day hand surgery
- Sensory loss, intrinsic muscle wasting and Horner syndrome (Pancoast) → Urgent CXR (NG12) + CT chest; lung cancer pathway if suggestive.
- Persistent focal bone pain or swelling, lytic lesion, pathological fracture → X-ray; sarcoma suspected → Suspected-cancer pathway (NG12)
3Assess — only once blocks 0–2 are answered
☐ Exact digit and joint; active vs passive restriction ☐ Swelling: bony, synovial, tendon-sheath or diffuse; warmth, fever ☐ Neurovascular status, capillary refill ☐ Skin and nail psoriasis; trauma, bite or puncture ☐ Triggering, extensor lag, tabletop test ☐ Diabetes, immunosuppression, anticoagulants, vibration tools
Synovitis: RF (anti-CCP if RF negative), ESR/CRP, X-ray hands and feet, without delaying referral. Gout: serum urate; if <360 µmol/L in a flare, repeat ≥2 weeks after it settles. Not routine: imaging for typical OA; HbA1c just for trigger finger or Dupuytren's.
4Classify — only if the screen is negative
- Inflammatory — symmetrical MCP/PIP synovitis, stiffness >30 min (RA); DIP, nail pits, dactylitis (psoriatic) → Urgent rheumatology
- OA — Heberden's or Bouchard's nodes, thumb base, stiffness ≤30 min. MCP swelling: think RA, gout, CPPD, haemochromatosis.
- Gout — acute, very painful, red, hot; any finger joint. Uncertain → aspirate.
- Tendon — trigger finger (locking, A1 nodule); de Quervain's (Finkelstein's supports only); mallet (drooping DIP; boutonnière is not the mallet pathway).
- Structural — Dupuytren's (nodule, cord, contracture); ganglion. Secondary Raynaud's features → local rheumatology pathway.
- Uncertain hot swollen joint — say so → Same-day hospital. Crystals do not exclude infection.
5Treat today — doses: NICE/SPC, BNF, local formulary
- OA: topical NSAID first; oral NSAID + PPI if ineffective or unsuitable, after GI, renal, liver and CV risk. No routine paracetamol or weak opioids. Hand therapy, joint protection.
- Gout flare: NSAID (consider a PPI), colchicine or a short oral steroid, by renal function, age, anticoagulants, ulcers, interactions, pregnancy. Keep any allopurinol going; discuss urate-lowering therapy after every flare.
- Trigger finger, de Quervain's: activity change, analgesia, splint; consider steroid injection if trained and locally permitted — never if infection suspected.
- Mallet finger: continuous DIP extension splint, typically 6–8 weeks; any DIP flexion usually restarts the period.
6Refer routinely
- Trigger finger locked, disabling, persisting or injection unsuitable → hand surgery / MSK.
- Dupuytren's affecting function, MCP ≈30°+, progressive PIP, hand not flat → hand surgery (sooner if rapid).
- Failed mallet splinting, symptomatic ganglion, de Quervain's failing → hand surgery.
- Vibration tools with white or numb fingers (HAVS) → occupational physician.
7Never reassure by
- Normal ESR/CRP or negative RF or anti-CCP when synovitis persists.
- No fever in a hot swollen joint.
- Crystals or a negative Gram stain: infection can coexist.
- A palpable radial pulse with a cold, pale digit.
- A normal serum urate during a flare.
- Calling MCP swelling "OA".
8Safety-net — say it, then document it
999 “Call 999 if a finger or your hand turns cold, white or blue, or you feel very unwell.” Same day “Contact us, NHS 111 or A&E today for rapidly increasing pain or swelling, fever, a finger you cannot move, spreading redness or red streaks, new numbness or weakness, worsening night pain or bone swelling, or increasing pain after a wound, bite or puncture.”
On allopurinol: “Stop it and get urgent advice if you get a rash, mouth ulcers or fever.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 feature (Kanavel, septic joint, ischaemia, spreading infection)
Digit, joint and neurovascular status recorded
Synovitis looked for; urgent rheumatology sent if persistent
Cause named, or uncertainty stated, with a review owner
Safety-net given and documented
Summary of the full Reasoning GP finger pain algorithm, which holds the detail, examination, gout and DMARD management and evidence. Sources: NICE NG100, NG219, NG226, NG12 (updated April 2026); BSSH; RCOphth; local shared care. Clinical reference — follow local hand-surgery and rheumatology pathways and check doses: NICE/SPC, BNF.