Reasoning GP · Algorithm · 1-page summary
Hand pain in adults
For: adults with hand or wrist pain, swelling, stiffness, numbness or reduced grip. Not for: children (local paediatric pathway); one painful finger, widespread joint pain or Raynaud's alone (their own algorithms).
Core rule: exclude the septic joint, tendon-sheath infection, ischaemia and injection or bite injuries before any reassurance. Persistent synovitis → urgent rheumatology, without waiting for blood results.
0Stop — call 999 now — before any history
- Cold, painful, pale/blue or mottled hand or digit with sensory or motor change → 999 / immediate ED. An absent radial pulse is not required; Allen's test must not delay referral.
- Necrotising fasciitis (rapidly spreading redness, pain out of proportion, bullae, crepitus, toxicity) or compartment syndrome after trauma or casting (pain on passive stretch, tense swelling) → 999. A palpable pulse does not exclude it.
- Shocked, septic or rapidly deteriorating, or threatened limb → 999. Never delay transfer for community bloods or imaging.
1Triage by pattern — stiffness and distribution
| Finding | Points to → action |
|---|---|
| Hot swollen joint | Septic until excluded → Same-day ED |
| Soft MCP/PIP swelling | Stiffness >30 min → Urgent rheumatology |
| Bony nodes, thumb base | Stiffness <30 min: OA, primary care |
| Night median tingling | CTS; wasting → Urgent surgical |
| Radial styloid; locking | de Quervain's, trigger finger: primary care |
2Screen — one row is enough
- Septic joint or flexor sheath infection (fusiform, held flexed, pain on passive extension) → Same-day ED / hand surgery
- Grease or paint-gun injection, even a tiny wound → Immediate hand / plastics; do not explore or close.
- Fight-bite over a knuckle, or bite into joint, tendon or bone → Same-day ED / hand surgery; do not close.
- Open fracture, dislocation, rotation, tendon or neurovascular injury → Same-day ED / hand trauma
- Gout or pseudogout if sepsis not reasonably excluded, or unwell → Same-day ED / hand surgery
- Lump increasing in size → consider Urgent ultrasound ≤2 weeks (NG12); sarcoma suggested → suspected-cancer pathway; never biopsy.
3Assess — only once blocks 0–2 are answered
☐ Joints, symmetry, stiffness ☐ Swelling: bony, soft or fusiform ☐ Tinel's, Phalen's, Finkelstein's, grind ☐ Grip, thenar wasting, sensation, capillary refill ☐ Psoriasis, IBD, gout, diabetes, thyroid ☐ Vibrating tools; fluoroquinolones
Inflammatory: CRP/ESR, FBC, RF + anti-CCP; normal results never delay referral. Gout: urate; if <360 µmol/L in a flare, repeat ≥2 weeks after it settles. Not routine: X-ray for typical OA, MRI, ANA; NCS before a splint trial.
4Classify — only if the screen is negative
- Inflammatory — bilateral MCP/PIP synovitis sparing DIPs; nail pitting → Urgent rheumatology (NG100), even with normal bloods.
- OA — Heberden's/Bouchard's nodes, 1st CMC squaring; age ≥45, activity-related. X-ray only if atypical.
- Carpal tunnel — night or activity median paraesthesia; NCS if uncertain, atypical, severe or motor deficit.
- Tendon — de Quervain's (Finkelstein's positive); trigger finger (A1 pulley, locking).
- Other — gout/CPPD (urate supports, crystals confirm); Dupuytren's; HAVS (vibration, cold blanching).
- Uncertain hot swollen joint — say so → Same-day hospital. Treat as septic until excluded.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Hand OA: exercise, hand therapy; consider a topical NSAID, then an oral NSAID with a PPI after GI, renal, liver and CV risk. No routine paracetamol or weak opioids.
- Carpal tunnel: neutral night wrist splint trial; consider steroid injection if trained.
- Gout flare (septic joint reasonably excluded): NSAID, colchicine or a short oral steroid, by renal, hepatic, CV/GI risk and interactions.
6Refer routinely
- Carpal tunnel failing conservative care → surgery; thenar wasting, objective weakness, severe/progressive sensory loss → Urgent.
- Thumb-base OA failing conservative treatment; de Quervain's failing steroid injections; trigger finger grade III–IV; Dupuytren's affecting function → orthopaedics.
- OA, mild–moderate carpal tunnel, tendinopathy → hand therapy. HAVS → occupational health.
7Never reassure by
- Normal CRP/ESR or negative RF or anti-CCP when synovitis persists.
- A tiny puncture wound after a grease or paint gun, or a bite over a knuckle.
- A palpable radial pulse with a cold, pale digit, or a palpable pulse after trauma or casting.
- A gout history in a hot swollen joint: exclude sepsis first.
- A normal serum urate during a flare.
- A normal X-ray in early RA.
8Safety-net — say it, then document it
999 “Call 999 for rapidly spreading redness or swelling with severe pain or feeling very unwell, a cold, pale, blue or mottled hand or finger with numbness or weakness, or severe worsening pain with tight swelling after an injury or in a plaster cast.”
Same day “Go to A&E or the hand unit today for a hot swollen joint, a swollen, bent, very tender finger, any grease or paint-gun injury, or a bite or punch wound over a knuckle. See us today for severe worsening pain, loss of hand function, new numbness or weak grip, or feeling unwell with joint pain.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 feature (sepsis, ischaemia, injection, bite, fracture)
Joint pattern, stiffness and neurovascular status recorded
Synovitis looked for; urgent rheumatology sent if persistent
Cause named, or uncertainty stated, with a review date
Safety-net given and documented
Summary of the full Reasoning GP hand pain algorithm, which holds the detail, examination, gout and DMARD management, lifestyle and evidence. Sources: NICE NG100, NG226, NG219, NG12 (updated April 2026); BSSH; Control of Vibration at Work Regulations. Clinical reference — follow local hand-surgery and rheumatology pathways and check doses: NICE/SPC, BNF.