Hand

• Hand Surgery deals with the management of all patients with musculoskeletal (MSK) conditions of the hand which might benefit from surgical management or other specialist procedures (e.g. difficult joint injections).
• Hand surgery deals with disorders of the hand including fractures, joint disorders, tendon disorders, ligament injuries, cartilage injuries.
• Hand Surgery opinion in NHS Tayside is provided by specialist Plastic surgeons, Orthopaedic hand and upper limb surgeons, Physiotherapists and Occupational therapists.
• Many Hand conditions are self-limiting and can be managed appropriately in primary care by a GP or by a First Contact Physiotherapists (FCP)

• Some acute cases e.g fractures, dislocations, significant soft tissue injuries, bone or joint infections, possible cancer, clearly require urgent referral for specialist assessment and management and can be referred to our on-call hand service via Ninewells switchboard. 
• Most non-urgent MSK referrals should have been seen and assessed by the FCP or MSK Physiotherapy service. If onward referral is needed this should be completed by the Physiotherapist. 
• We are happy to accept referrals where the diagnosis of an MSK problem is unclear. Such patients should have appropriate work-up and should have been seen by a Physiotherapist unless there is a suspicion of cancer or infection where urgent referral is required.
• Where a non-acute hand and wrist condition which fails to respond to initial Primary Care management, requires specialist referral for advice, assistance with management or possible surgical intervention they should be referred to the Joint plastic surgery/ Orthopaedic Hand Service. The referral will be vetted by any member of the multidisciplinary team, and assigned to the most appropriate member of the team. Please be aware that the first point of contact may be an advanced practice Physiotherapist
• Where a referred patient may be more appropriately seen by another speciality, the referral may be redirected appropriately.
• Referred patients may be appointed to attend one of our elective orthopaedic or plastic surgery surgical clinics or to one of our specialist physiotherapy clinics where this is considered appropriate.  

• Insufficient information or work-up. Occasionally, referrals have insufficient information to vet accurately or appropriately. Some referrals may be more appropriately seen by rheumatology, neurosurgery, or specialist allied health professional services. Appropriate clinical work-up (history examination, relevant preliminary investigation) facilitates more efficient referral management such that the patient is directed to the most appropriate clinician or given advice without the need to attend a specialist clinic. Where there is insufficient information to guide referral management, we may ask for further information or investigation to assess the need for referral.
• Sensory neuropathies of less than 12 weeks duration (Carpal tunnel) or 6 weeks (Cubital tunnel)with no conservative treatment tried. Post-partum CTS of less than 1 year duration.
• Volar or dorsal ganglia – see info

Emergency Referrals
For hand injuries or suspected hand infection, referral for advice or assessment should be made to the on-call Hand Surgery Registrar via the Ninewells switchboard (01382 660111)

Outpatient referrals or non-urgent advice - SCI Gateway/Hand Surgery (Joint Plastic Surgery/ Orthopaedics hand service), flagged as urgent (suspected cancer), urgent, routine or advice.

Named Referrals to specific consultant or other clinician may be appropriate if the patient has previously been seen by that clinician for the same problem, however an appointment with that consultant cannot be guaranteed. For referrals regarding a new problem, a named referral request cannot be guaranteed. Please let the patient know that the vetting team will take preferences into account, but the patient may be seen by any member of the team. 

Suspected Cancer. For assessment / opinion on tumours or possible cancer, we do not have a specialist tumour clinic. Referrals should be made to the appropriate subspecialty clinic according to the location of the tumour or age of the patient (paediatric patients). Where there is a possibility or suspicion of malignancy, the 'urgent - suspected cancer' priority option should be selected on SCI Gateway or the written referral marked appropriately (see referral guidance on Referrals of Musculoskeletal Tumours).

British Society for Surgery of the Hand
NHS Fife Patient Information Leaflets