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Hands and shoulder

Please see below for the policies relating to hands and shoulders. To view the policy, patient leaflet and additional information, please click on the relevant heading.


 

  • Carpal tunnel syndrome

    What is Carpal tunnel syndrome?

    Carpal tunnel syndrome (CTS) is pressure on a nerve in your wrist. It can cause tingling, numbness and pain in the patient’s hand and fingers. It can often be treated through self-care but it can take a few months to get better.

    The symptoms of carpal tunnel syndrome include:

    • An ache or pain in your fingers, hand or arm
    • Numb hands
    • Tingling or pins and needles
    • A weak thumb or difficulty gripping.

    These symptoms often start slowly and come and go. They are usually worse at night or when driving or holding a book, newspaper, or telephone. As the condition worsens, the altered feeling may become continuous, with numbness in the fingers and thumb together with weakness and wasting of the muscles at the base of the thumb.

    Sufferers often describe a feeling of clumsiness and drop objects easily and may also suffer from associated pain in the wrist and forearm.

    It has been found to be three times more common in women than in men and commonly affects women in middle age but can occur at any age in either sex. It can also be common in pregnancy and in patients with diabetes, thyroid problems and rheumatoid arthritis.

    The main aim of treatments is to prevent the condition getting any worse. Non-surgical (conservative) treatments include changing your lifestyle, the use of splints (especially at night), and injection into the carpal tunnel or a combination of these.

    Surgery involves opening the roof of the tunnel to reduce the pressure on the nerve. The surgery may be performed under local anaesthesia (injection in the area around the nerve to ensure the patient does not feel pain), regional anaesthesia (injected at the shoulder to numb the entire arm) or general anaesthesia (where the patient is unconscious during the procedure).

    The type of anesthesia used for a surgical procedure is determined by several factors including type and length of the surgery, the patient’s health or age and the preference of the patient and clinician.

    Patient eligibility criteria

    Surgical treatment for carpal tunnel syndrome can be undertaken where the patient meets the following criteria:

    • Symptoms persisting longer than three months, despite trying conservative treatments (by injection and/or wrist splint)

    AND EITHER:

    • The patient has had positive nerve conduction studies (NCS). NCS measures how fast an electrical impulse moves through your nerves and shows if the patient has nerve damage

    OR

    • Positive clinical symptoms which have been reviewed by a hand surgeon and demonstrate the patient has carpal tunnel

    OR the patient may proceed straight to decompression surgery as required

    • If the patient has constant loss of feeling in their hand or muscle wasting around the thumb, then the patient should be urgently reviewed by a hand surgeon.

    The NHS website defines nerve condition studies as: a nerve conduction test (NCS) – where small metal wires called electrodes are placed on your skin which release tiny electric shocks that stimulate your nerves; the speed and strength of the nerve signal is measured.

    Advice and further guidance

    There are a number of things that you can do to yourself to help treat carpal tunnel syndrome. These include:

    Wearing a wrist splint

    A wrist splint is something the patient wears on their hand to keep their wrist straight. It helps to relieve pressure on the nerve. It can often take at least four weeks of wearing a splint before the patient may start to feel better.

    Lifestyle changes

    It may help if the patient stops or reduces movements that cause frequent bending of the wrist or actions that involve gripping hard, such as using vibrating tools for work or playing an instrument.

    Painkillers

    Painkillers like paracetamol or ibuprofen may offer short-term relief from carpal tunnel pain.

    • For more information, search for ‘carpal tunnel’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Dupuytren’s contracture

    Dupuytren's contracture is a fairly common condition that causes one or more fingers to bend into the palm of the hand. The condition often occurs in later life, and is most common in men who are aged over 40. Around one in six men over the age of 65 are affected in the UK.

    The symptoms of Dupuytren's contracture are often mild and painless and do not require treatment. The condition most often starts with a small, hard lump or nodule in the skin of the palm and may stay the same for months or years. The lump sometimes feels tender to begin with, but this usually passes with time. More lumps may then develop. The lumps are non-cancerous (benign) and the condition isn't life-threatening for those who develop it, although it can be a nuisance to live with.

    Over time, the lumps can extend and form cords of tissue. These cords can shorten (contract) and, if the cords run along a finger or thumb, they can pull it, so it becomes bent towards the palm. These contractures are often mild and painless, but they can get steadily worse over time.

    Patients should be aware that up to 40% of people will have a recurrence following surgery: this means Dupuytren’s contracture can return to the same spot on the hand or may reappear somewhere else. Recurrence is more likely in younger patients; or if the original contracture was severe; or if there is a strong family history of the condition.

    Treatment

    Many cases of Dupuytren's contracture are mild and don't need treatment. Treatment may be helpful if the condition is interfering with the normal functioning of your hand.

    In July 2017 the National Institute for Health and Care Excellence (NICE) published guidance on the most appropriate treatments available for Dupuytren’s contracture and when these treatments should be used. 

    There are two types of treatment currently recommended by NICE for Dupuytren's contracture:

    • Injections with a medication called collagenase clostridium histolyticum (CCH)

    OR

    • Surgery with a fasciectomy or fasciotomy, where the surgeon will make an incision in the skin of your hand, so they can gain access to the connective tissue underneath. They'll then cut the thickened connective tissue to divide it up or remove the thickened tissue completely, allowing you to straighten your fingers. However, surgery for Dupuytren's contracture can't always fully straighten the affected finger or thumb, and the contracture can recur after surgery. If a contracture does recur, further surgery may be possible.

    Patient eligibility criteria

    Patients requiring treatment, either collagenase injection or surgery, must meet the following clinical criteria:

    • Evidence of at least moderate disease OR first web contracture
    • For patients where treatment with collagenase injections is the most clinically appropriate treatment, one injection should be given per treatment session, in an outpatient setting, the injection should be performed by a suitably qualified clinician.

    Your Right of Patient Choice and Shared Decision Making

    • The choice of treatment (injection with collagenase or surgery) is made on an individual basis after discussion between the responsible hand surgeon and the patient about the risks and benefits of the treatments available.

    This means for patients who DO NOT meet the specified criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

    For the purposes of this guidance the baseline for moderate disease is classified as:

    • Functional problems AND
    • Moderate metacarpo-phalangeal joint contracture (at least 30 degrees) OR
    • Any proximal inter-phalangeal joint contracture OR
    • First web contracture.

    Advice and guidance

    • For more information, search for ‘Dupuytren's contracture' at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Ganglion

    What is a ganglion?

    A ganglion is a non-cancerous fluid-filled lump or cyst which can occur near joints or tendons. It is most commonly found on the wrist (particularly the back of the wrist) or hands. The cyst can range from the size of a pea to the size of a golf ball.

    Ganglions are harmless, but can sometimes be painful. If they do not cause any pain or discomfort, they can be left alone and may disappear without treatment, although this can take a number of years. It's not clear why ganglions form. They seem to occur when the synovial fluid that surrounds a joint or tendon leaks out and collects in a sac.

    Patient eligibility criteria:

    Surgical treatment of ganglion cysts is restricted. The patients local NHS commissioning organisation will only fund this treatment if the patient meets the following criteria:

    • Surgery for ganglion will be funded where painful lump causing disabling pain and restricting activities of daily living and/or work
    • Surgery for a fluid filled swelling (mucous cysts) will be funded when causing distortion of nail growth and discharge which can lead to arthritis in the joint (septic arthritis).

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    There are two ways surgery can be used to remove a ganglion cyst:

    • Draining the fluid out of cysts with a needle and syringe (the medical term for this is aspiration)
    • Cutting the cyst out using surgery.

    Both techniques can be performed under either local anaesthetic, where the patient is awake but won't feel any pain, or general anaesthetic, where the patient is asleep during the operation.

    For more information search for ‘ganglion cyst’ at www.nhs.uk

    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Image guided injections – high volume

    Image guided high volume intra-articular injections are used to treat severe joint pain related to osteoarthritis or inflammatory joint disorders such as rheumatoid arthritis and psoriatic arthritis.

    Joint pain can also occur as a result of a traumatic injury, joint surgery or crystal build up in the joints such as gout. Other causes of joint pain include sports injuries, general sprains and strains, frozen or unstable shoulder, and bleeding into joint spaces caused by torn ligaments.

    Treatment:

    Hydrodilatation is the procedure of injecting a high volume (between 10ml and 55ml) of saline solution into the joint. The solution may also contain some corticosteroid which contains someanaesthetic to provide quick pain relief and the steroid ‘cortisone’ to provide longer relief toease pain and swelling. The high volume of liquid is injected into the joint using imaging guidance through an x-ray(fluoroscopy), ultrasound or computed tomography (CT), which may help to identify the correct path to place the needle.

    Risks:

    There is a small risk of infection, worse pain, stiffness and damage to the nerves and bloodvessels around the joint.

    Eligibility criteria:

    Due to the limited quality of clinical evidence to support the use of image-guided high volume intra-articular injections, these injections are not routinely commissioned. This means the patient’s NHS commissioning organisation (CCG), who is responsible for buying healthcare services on behalf of patients, will only fund the treatment if an IndividualFunding Request (IFR) application has shown exceptional clinical need and the CCG supports this.

    Advice and further guidance:

  • Image guided therapeutic injections

    Image guided therapeutic intra-articular joint injections are anaesthetic and steroid based injections (corticosteroid injections) used to relieve severe joint pain and jointinflammation. The injections may be given with the aid of image guidance in the formor x-ray or ultrasound.

    Arthritis is a chronic musculoskeletal disorder, which may be either degenerative or inflammatory in nature and is characterised by involvement of all joint structures including the synovial membrane, cartilage and bone. Knees, hips, feet and small hand joints are the common areas affected by arthritis where joints are unable to repair themselves. However, it can affect most joints and cause severe pain and inflammation resulting in reduced mobilityand quality of life.

    Treatment:

    Intra-articular corticosteroid injections are used when other forms of treatment such as physiotherapy, painkillers or lifestyle changes that have not worked well.

    Corticosteroid injections

    The corticosteroid injection includes an anaesthetic to provide quick pain relief and the steroid ‘cortisone’ provides longer inflammatory relief to ease pain and swelling.

    Hyaluronan injections

    Hyaluronan injection are lubricating injections to replace the natural hyaluronic acid in thejoint fluid.

    Image Guided Injections

    Ultrasound image guidance may be used to help the clinician to place the needle in the correct position for the injection to be given.

    Palpated injections

    Instead of using image guidance, the trained clinician feels the joint to identify the correct position for the injection to be given.

    Risks:

    include post-injection pain, crystals forming in the joint fluid (crystal synovitis), bleeding in the joint (haemarthrosis), severe infection of the joint (joint sepsis), cells of the tissue dying (necrosis), worsening of the smooth white tissue that covers the ends of bones (atrophy) and fluid retention. Hypertension or diabetes may worsen by the injection.

    Advice and guidance:

  • Trigger finger

    What is trigger finger?

    Trigger finger is a condition that affects one or more of the hand's tendons, making it difficult to bend the affected finger or thumb.

    If the tendon becomes swollen and inflamed it can 'catch' in the tunnel it runs through (the tendon sheath). This can make it difficult to move the affected finger or thumb and can result in a clicking sensation.

    Patient eligibility criteria:

    The patient's local NHS commissioning organisation will only fund this treatment if the patient meets the following eligibility criteria below:

    • The patient has moderate trigger finger which has failed to respond to conservative measures and at least 2 steroid injections; or
    • The patient has a permanently bent (fixed deformity) that cannot be corrected.

    This is because management of trigger finger should be in accordance with British Society for Surgery of the Hand (BSSH) recommendations:

    Mild (pre-triggering):

    • History of pain or of catching or click
    • Tendon pulling, but fully mobile finger
    • Use of pain killers.

    Moderate:

    • Triggering with difficulty actively extending finger and need for passive finger extension
    • Option for steroid injection.

    Severe:

    • Fixed bent finger
    • Option for surgery.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Request (IFRs).

    Advice and further guidance:

    • For more information search for ‘trigger finger’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Subacromial pain syndrome

    What is subacromial pain in adults?

    Subacromial pain in adults is one of the most common causes of non-traumatic shoulder pain and is a normal part of ageing. It also can be known as ‘rotator cuff disease’, which is thought to be the wear and tear of the rotator cuff tendons.

    The rotator cuff tendons hold the shoulder joint in place and allow people to lift the arm and reach overhead. When the arm is lifted, the rotator cuff tendon passes through a narrow space at the top of the shoulder, known as the sub-acromial space. Most rotator cuff tears occur within the tendon or on the 'under-side' of the tendon.

    Shoulder impingement (pain in the top and outer side of the shoulder) will often improve in a few weeks or months, especially with prescribed shoulder exercises.

    Treatment:

    Arthroscopic sub-acromial decompression is a series of surgical ‘keyhole’ procedures to different parts of the shoulder. It involves decompressing the sub-acromial space by removing bone spurs and soft tissue arthroscopically.

    Risks:

    There is a small risk of infection, worse pain, stiffness and damage to the nerves and blood vessels around the shoulder. In some cases, the surgery may need to be done again.

    Eligibility criteria:

    Due to the limited quality of evidence of clinical and cost effectiveness, surgery for sub-acromial pain syndrome is not routinely commissioned.

    This means the patient’s NHS commissioning organisation (CCG), who is responsible for buying healthcare services on behalf of patients, will only fund the treatment if an Individual Funding Request (IFR) application has shown exceptional clinical need and the CCG supports this.

    Advice and further guidance:

  • Shoulder radiology

    This guidance is produced by The Academy of Medical Royal Colleges (the Academy) as part of the Evidence-based interventions programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE).

    All guidance has been reviewed by the Birmingham and Solihull & Sandwell and West Birmingham CCGs’ Treatment Policy Clinical Development Groups (TPCDG). This was reviewed to establish if existing CCG policies were already in place which covered the proposed intervention / treatment in question.

    Where there was no current CCG policy for the area in question, the NHSEI policy has been implemented in full into the CCG’s Clinical Treatment Policy portfolio.

    Where there was a current CCG policy for the area in question, then the existing CCG policy has been reviewed by the TPCDG considering the NHSEI EBI policy rationale and evidence base.  A decision has then been taken by TPCDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population.

    The aims of the Evidence Based Interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste.

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