Reconstructive hand surgery Referral Access Criteria

• Open fracture or fracture with obvious deformity
• Amputations
• Complex injuries (e.g. crush injuries, multi-fracture)
• Dislocations unable or not appropriate to be managed in primary care
• Tendon laceration or open rupture
• High pressure injury (e.g. injection injury)
• Neurovascular compromise
• Suspected septic joint
• Suspected compartment syndrome
• Suspected necrotising fasciitis
• Upper limb cellulitis with suspicion of sepsis or septic shock, or not responding to oral antibiotics
• Infectious flexor tenosynovitis
• Acutely exposed fixation plates (e.g. post-fall)

• Acute closed hand fractures where alignment or management is uncertain
  
  • patients should be seen within 2-3 days of injury for best outcomes
• Acute closed tendon rupture
• Acute scapho-lunate ligament or triangular-fibrocartilage complex (TFCC) injury
• Failed internal fixation

• Secondary hand surgery following injury (>6 weeks since injury occurred)
• Avascular necrosis of a carpal bone, e.g. lunate (Kienbock’s disease)
• The following conditions not responding to maximal conservative management:
  
  • basal thumb arthritis
  • de Quervain’s tenosynovitis
  • dupuytren’s contracture
  • hand conditions causing functional issues, e.g. contractures, stenosing tenosynovitis (trigger finger), rheumatoid arthritis
  • ganglia with persisting symptoms causing functional impairment
  • painful/stiff wrist impacting function

Referrals missing 'mandatory information' with no explanation provided may not be accepted by site. If 'mandatory information' is not included, the explanation must be provided in the body of the referral (e.g. patient unable to access test in regional or remote areas or due to financial reasons). This information is required to inform accurate and timely triage.

If unable to attach reports, please include relevant information/findings in the body of the referral and advise where (provider) investigation/imaging was completed.

• Relevant history, onset, severity, and duration of symptoms (e.g. handedness, date of injury)
• Degree of functional impairment (e.g. impact on employment/ADLs)
• Current medication list
• Any known allergies

• Nil

• X-ray – for confirmed or suspected fracture or arthritic hand deformity
• X-ray – for painful/stiff wrist (consider scaphoid views)

• Details of current and previous treatment and outcome (e.g. any allied health input and steroid injections)
• Details of smoking and/or vaping (containing nicotine) status
• Advise whether or not your patient is taking any anti-platelets or anti-coagulants
  
  • if so, state the indication
• Occupational therapy/physiotherapy report

• Basic neurovascular assessment (e.g. strength, sensation, perfusion)
• BMI

• Nerve conduction studies (NCS) for nerve compression syndromes or nerve palsies referrals
• If performed, hand ultrasound (US) for soft tissue tumours

Category 1

Appointment within 30 days

• Soft tissue tumour of the hand with suspicion of malignancy

Category 2

Appointment within 90 days

• Secondary hand surgery >6 weeks after the injury
• Kienbock’s disease
• Dupuytren’s contracture with fixed flexion >30 degrees at any joint associated with functional disability
• Skin breakdown and/or infection secondary to severe contracture
• Contracture at multiple joints or recurrence after surgery with functional impairment
• Disproportionate severe pain or functional disability despite maximal conservative management (e.g. major impacts on ADLs and/or employment):
  
  • e.g. De Quervain’s, malunion affecting function, basal thumb arthritis
• Stenosing tenosynovitis (trigger finger) persisting despite maximal conservative management (e.g. treatment with ultrasound guided steroid injection)
• Rheumatoid hand conditions with impaired function or pain persisting despite maximal conservative management
• Limitation to weight bearing ability, e.g. scaphoid non-union, wrist osteoarthritis

Category 3

Appointment within 365 days

• Dupuytren’s contracture with fixed flexion <30 degrees at any joint associated with functional disability
• Symptomatic or enlarging ganglion of the hand

• Burns to hands
  
  • refer to State Burns Service
  • see Clinician Assist WA: Specialised Burns Management Requests

• Hand and wrist referrals can be managed by the following specialties:
  
  • Plastic and Reconstructive Surgery
  • Orthopaedics
• Consider conservative management options:
  
  • splint and activity modification
  • steroid injections as appropriate (e.g. stenosing tenosynovitis)
  • joint ROM exercises
  • occupational therapy/physiotherapy to maintain mobility/prevent stiffness and contracture/maintain extension/prevent/control pain/strengthening. See Clinician Assist WA: Occupational Therapy Requests or Clinician Assist WA: Physiotherapy Requests