| History and physical exam |
Basic history, focused exam, and search for red flags (C) |
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| Patient education |
Patient education regarding prevention, diagnosis, prognosis, and expectations of medical treatment (D) |
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| Medication (See Chapter 3 in the original guideline document) |
Acetaminophen (C)
Non-steroidal anti-inflammatory drugs (NSAIDs) (B)
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Opioids, short course (C)
Rarely, corticosteroids (C)
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Use of opioids for more than 2 weeks (C) |
| Physical treatment methods |
Instructions for home exercises |
At-home applications of heat or cold packs (D) |
Passive modalities
Transcutaneous electrical neurostimulation (TENS) units (C)
Biofeedback (D)
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| Injections |
Injection of corticosteroids into carpal tunnel in mild or moderate cases of carpal tunnel syndrome (CTS) after trial of splinting and medication (C)
Initial injection into tendon sheath for clearly diagnosed cases of DeQuervain's syndrome, tenosynovitis, or trigger finger (D)
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Initial injection of corticosteroids in moderate cases of tendinitis (D) |
Repeated or frequent injection of corticosteroids into carpal tunnel, tendon sheaths, ganglia, etc. (D) |
| Rest and immobilization |
Splinting as first-line conservative treatment for carpal tunnel syndrome, DeQuervain's syndrome, strains, etc. (C) |
Prolonged splinting (leads to weakness and stiffness) (D)
Prolonged post-operative splinting (C)
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| Activity and exercise |
Stretching
Aerobic exercise
Maintaining strength and mobility of all remaining body parts while recovering from wrist problems (C)
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Reduced general activities while recovering (D) |
| Detection of neurologic abnormalities |
Nerve conduction velocity (NCV) for median (B) or ulnar (C) impingement at the wrist after failure of conservative treatment |
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Routine use of NCV or electromyography (EMG) in diagnostic evaluation of nerve entrapment or screening in patients w/o symptoms (D)
Use of vibrometry for screening (C)
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| Radiography |
Plain films for suspected scaphoid fractures, repeat films in 7-10 days (D) |
Limited bone scan to detect fractures if clinical suspicion exists (C) |
Routine use for evaluation of forearm, wrist, and hand (D) |
| Other imaging procedures |
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Use of arthrography, magnetic resonance imaging (MRI), or computed tomography (CT) scans prior to history and physical examination by a qualified specialist (D) |
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| Surgical considerations |
Early surgical intervention for severe carpal tunnel syndrome (CTS) confirmed by NCV may be indicated (B)
Tendinitis (DeQuervain's), ganglion, or trigger finger: referral to surgeon only after patient education and conservative treatment, including splinting and injection, have failed (C, D)
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| Psychosocial factors |
Consider counseling for severe hand injuries (D)
Awareness by treating practitioner of interplay between physical, economic, and psychological factors in patients with muscular skeletal disorders (MSDs) (C, D)
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