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The importance of identifying red flags in wrist-hand pain: A systematic review
Federico Rossi1, Matteo Cioeta2, Marco Cordella2
1Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise, Campobasso, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy.
Background:
Although current guidelines outline signs and symptoms of specific wrist-hand disorders, they provide limited support for early recognition of serious conditions so-called red flags---by non--hand-specialist physicians. No prior systematic review has synthesized these findings.
Purpose:
To identify, classify, and summarize clinical red flags reported in the literature that should prompt suspicion of serious wrist-hand pathology requiring referral.
Study Design:
Systematic review.
Methods:
A systematic search of seven databases and gray literature was conducted from June 2024-March 2025. Eligible studies included those reporting wrist-hand pain with or without comorbidities. Two reviewers independently performed screening, data extraction, and risk-of-bias assessment (Murad, Newcastle-Ottawa, AXIS tools). Reported red flags were categorized into seven etiological domains. Narrative synthesis and frequency analysis were conducted.
Results:
Of 129 included studies, most were case reports or case series. Red flags were associated with oncologic (32 studies, 25%), orthopedic (30, 23%), rheumatologic (22, 17%), infectious (15, 12%), vascular (12, 9%), neurologic (10, 8%), and other systemic disorders (8, 6%). Persistent pain, swelling, and limited range of motion were the most frequent symptoms. Clinical suspicion was heightened when these co-occurred with systemic signs, neurological deficits, vascular changes, or palpable masses. Red flags were more often recognized through patient history than physical examination. Overall, methodological quality was low to moderate.
Conclusions:
This is the first systematic synthesis of red flags in wrist-hand pain presentations. Despite low-level evidence, persistent pain combined with atypical swelling or restricted motion emerged as key nonspecific warning signs across multiple pathologies. In direct-access settings, clinicians should maintain a low threshold for referrals, guided by contextual symptom interpretation. Interdisciplinary collaboration is critical to ensure timely diagnosis and management. Prospective studies are needed to validate specific red flags and inform structured screening tools.