REFREC016

ORTHOPAEDICS REFERRAL RECOMMENDATIONS

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Problems are categorised by the following anatomical headings:
·  Ankles and feet
·  Back
·  Elbows
·  Hands and wrists
·  Hips
·  Knees
·  Miscellaneous
·  Neck
·  Shoulders / A thorough history and examination is required to determine a specific diagnosis and its degree of urgency.
Appropriate investigation by the referrer will facilitate the referral process. / Specific treatments depend on specific problems identified as noted below. / These guidelines are provided (below) to give greater clarity in situations of the primary/secondary interface of care. Clearly telephone/fax communication/e-mail would enhance appropriate treatment.
In the event that a general practitioner wishes to discuss the management of a patient with a severe and urgent problem, he/she should contact the registrar or consultant on-call for that hospital for that day.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Ankles and feet
Arthritis / Standard history and examination.
·  X-rays. / ·  Analgesics/anti inflammatories.
·  Physiotherapy.
·  Activity modification.
·  Walking aids.
·  Consider steroid injection. / Refer if functional impairment despite conservative treatment after six months. Routine Category 4.
Pain and deformity in forefoot (including bunions) / Standard history and examination.
·  X-rays standing.
·  Weight-bearing AP. / ·  Modification footwear.
·  Orthoses.
·  Consider steroid injections for intermetatarsal bursal/neuroma. / Refer for routine assessment Category 4 if severity of symptoms warrants after three months conservative treatment.
Pain and instability in hind foot. / Standard history and examination.
·  X-rays. / ·  Modification footwear.
·  Orthoses.
·  Physiotherapy.
·  Consider steroid injection. / Refer for routine assessment Category 4 if severity of symptoms warrants after three months’ conservative treatment.
Achilles tendon pathology. / Standard history and examination.
·  X-rays. / ·  Physiotherapy.
·  AVOID steroid injections.
·  Heel cups/raise. / Refer for routine assessment Category 4 in three months if conservative treatment fails or if patient has tender nodule.
Heel Pain. / Standard history and examination.
·  X-rays.
X-rays allow exclusion of some diagnoses.
NB: Plantar spurs on an x-ray does not infer plantar fascitis. / ·  Physiotherapy.
·  Steroid injections for plantar fascitis.
·  Heel cups/raise. / Refer as routine Category 4 after failure to respond to three months of conservative treatment.
Ankles and feet (paediatric deformities)
Club Foot / Features to be looked for are fixed equinus and varus. / Refer immediately Category 1.
Calcaneo Valgus Foot / Almost always correctable to neutral, but check the hips for stability. / Reassurance. / If not flexible or not looking normal by three weeks, should be referred Category 2.
Flat Feet / Under the age of three years, flat feet are normal.
Ask the child to stand on tip toes. If the arch corrects, the foot is normal.
In Toeing / Standard history and examination. / Reassurance. / Only for a second opinion beyond walking age – Category 4.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Back

·  Mechanical low back pain without leg pain.
·  Mechanical low back pain with leg pain but without neurological deficit / Key points:
·  Duration of symptoms.
·  Functional impairment.
·  Time off work.
·  Treatment to date.
·  Previous spinal surgery.
·  General medical condition and medication.
Investigations:
·  X-rays.
·  FBC ESR Biochemistry.
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(Consider calcium and phosphate, electrophoresis, immunoglobulins, PSA, Rheumatoid serology in specific cases.)
Key points:
·  Note key points above
·  Weight loss
·  Loss of appetite
·  Lethargy
·  Fevers and sweats
·  Previous malignant disease
·  Urinary difficulties / ·  Activity modification.
·  Analgesics and NSAIDs.
(See ACC Guidelines Booklet). / Persistent severe symptoms refer as category 4
If these symptoms present, refer as category 2
If these symptoms absent, refer as category 4
·  Back pain and sciatica with neurological deficit.
·  Spinal stenosis with limitation of walking distance.
·  Back pain secondary to neoplastic disease or infection. / As above. / Refer as Category 2.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Elbows

Tendonitis. / ·  Standard history and examination. / ·  Consider Cortisone injection.
·  Anti inflammatories.
·  Bands. / Refer as routine Category 4 if fails to respond to treatment after four weeks or recurrence.
Locking. / ·  Standard history and examination. / ·  None. / Routine Category 4 referral with x-ray, but consider occupation and functional disability.
Painful/stiffness in elbow. / ·  Standard history and examination.
·  Consider FBC & ESR. / ·  Anti inflammatories.
·  Physiotherapy. / Refer routinely Category 4 if not responding to treatment after three months.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Hands and wrists

·  Contractures.
·  Dupuytrens. / Standard history and examination.
Key points:
·  Duration and speed of progression.
·  Functional impairment.
·  Family history of Dupuytrens.
·  Previous surgery.
·  General medical conditions (especially diabetes, epilepsy, liver disease).
·  Medications (especially for epilepsy). / Refer progressive contractures (especially PIP contractures) with functional impairment as routine. Referral Category 4.
Stenosing tenovaginitis (eg Trigger fingers, de Quervains). / Standard history and examination. / Consider injection with steroids. / Refer as routine referral Category 4 if functional impairment or if unresponsive to treatment after one injection.
Rheumatoid conditions (cf Rheumatology Recommendations). / Standard history and examination. / Referral to Orthopaedic Surgeon is via Rheumatologist/General Physician.
Basal Thumb Arthritis. / Standard history and examination x-ray. / ·  Anti inflammatories.
·  Activity modification.
·  Consider steroid injection. / Refer after six months as routine Category 4 if fails to respond.
Ganglia. / Standard history and examination. / Consider aspiration (18g needle) and injection of steroid. / Refer as routine Category 4 for symptomatic ganglia. Cosmesis alone usually is not a reason for referral.
Painful/Stiff Wrists. / ·  Standard history and examination.
·  X-rays to include scaphoid views. / ·  Anti inflammatories.
·  Trial of wrist splint.
·  Physiotherapy. / Refer as routine Category 4 after six months.
Congenital upper limb abnormalities (cf Plastic Surgery Referral Recommendation). / Refer to local service as available.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Hips

Hip Arthritis
·  Osteoarthritis.
·  Inflammatory Arthritis.
·  Post Traumatic Arthritis.
·  Avascular Necrosis. / Standard history and examination.
Key points:
·  Walking distance.
·  Rest pain and disturbance of sleep.
·  Locking and/or instability
·  Ability to put on shoes.
·  Use of walking aids.
·  Treatment including NSAIDs and analgesics.
·  Previous joint surgery.
·  General medical conditions and medication.
·  History of recurrent infections and prostatism.
Investigations:
·  X-ray (AP pelvis, AP affected hip showing proximal 2/3 femur, and lateral affected hip).
(Note: NHC Criteria for major joint replacement.) / ·  Anti inflammatories.
·  Analgesics.
·  Physiotherapy.
Activity modification including the use of a walking stick.
Home modification and use of ADC. / Refer if significant pain, problems relating to mobility, sleep disturbance, and unresponsive to therapy over several weeks – Category 3.
Paediatric Hip Conditions
(Perthes, SUFE, Synovitis). / History, examination and x-ray. Beware of pain in the knee as a symptom of hip disease. / Bed rest and simple analgesics. / Acute referral for admission if systemically unwell, febrile, or on suspicion of SUFE – Category 1. Otherwise re-assess at 24 hours.
Age ranges usually:
Transient synovitis 18 months to 6 years.
Perthes 4-10 years.
SUFEs usually 8-14 years.
If hip dysplastic, refer as Category 3.

Diagnosis / Symptomatology

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Referral Guidelines

Knees

Knee Arthritis:
·  Osteoarthritis.
·  Inflammatory Arthritis.
·  Post Traumatic Arthritis.
·  Avascular Neurosis. / Standard history and investigation.
Key points:
·  Walking distance.
·  Rest pain and sleep disturbance.
·  Use of walking aids.
·  Treatment including NSAIDs and analgesics.
·  Previous joint surgery.
·  General medical condition and medication.
·  History of recurring infections and prostatism.
Investigations:
·  X-rays – four standard views plus standing AP total knees.
(Note: NHC criteria for major joint replacement.) / ·  Anti inflammatories/analgesics.
·  Physiotherapy.
·  Activity modification including the use of a walking stick.
·  Home ADC. / Refer if significant pain, problems relating to mobility, sleep disturbance and unresponsive to therapy over several weeks – Category 3.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Miscellaneous

Nerve Entrapment Syndromes. / Standard history and examination. / Consider one steroid injection for carpal tunnel.
Splintage. / Refer semi urgently – Category 3 – if muscle wasting, otherwise, after three months refer routinely – Category 4.
Bone and/or Joint Infection. / Standard history and examination. / Acute referral to Orthopaedics – Category 1.
Bone and Soft Tissue Tumours. / Standard history and examination.
Do not needle biopsy. / Refer urgently if tumour or suspicion of tumour – Category 2.
Bursitis (Pre Patella, Trochanteric, Olecranon). / Standard history and examination.
Acute/inflammatory, consider aspirating for diagnosis. Will either be traumatic, gouty or infected. / If acute, consider aspirating for relief of symptoms. Do not incise.
If chronic, consider steroid injection. / Refer if non responsive to treatment after three months, and symptomatic as routine assessment – Category 4.
Apophysitis, eg Osgood Schlatters,
JL Disease. / Standard history and examination.
Consider x-ray. / Activity modification, reassurance. / If second opinion or confirmation required only – Category 4.
Gait. / Standard history and examination.
·  Symmetrical bow legs up to two years are usually physiological
·  Knock knees from age 2 – 4 are also usually normal
·  Angular deformities are usually pathological / Reassurance. / Refer for second opinion or severe deformity outside the normal age range – Category 4.
Sterno Mastoid Tumour (congenital Muscular Torticollis).
cf Paediatric Surgery Referral Recommendations. / Standard history and examination. / Passive stretching by parent or physiotherapist. / If failure to respond after one year of age, routine assessment – Category 4.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Neck

·  Mechanical neck pain without arm pain.
·  Neck pain associated with referred pain to the upper arm without neurological deficit. / Key points:
·  Duration of symptoms.
·  Work status.
·  Treatment to date.
·  General medical condition.
Key points:
·  Presence of neurological symptoms and signs including evidence of lower limb spasticity.
·  Weight loss, appetite loss and lethargy.
·  Fever and sweats.
·  Previous malignant disease.
Investigations:
·  X-ray.
·  FBC & ESR.
·  Biochemistry.
(Consider calcium and phosphate, protein electrophoresis, immunoglobulins, PSA, Rheumatoid serology in specific cases.) / ·  Trial of soft collar.
·  Activity modification.
·  Analgesics and non steroidal anti-inflammatories. / If symptoms and signs persist more than 6 weeks – refer as Category 4.
If any of these adverse features are present refer as category 2. If not present, refer as category 4.
·  Neck pain associated with radicular symptoms and neurological deficit.
·  Cervical myelopathy.
·  Neck pain secondary to malignant disease.
·  Neck pain secondary to infection. / Routine history and examination noting the key points as above. / Refer for an immediate opinion – Category 1.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Shoulders

Rotator Cuff Tendonitis/Tears. / ·  Standard history and examination particularly neurological examination.
·  X-rays (standard views).
·  Consider FBC & ESR.
·  Ultrasound examination. / ·  Anti inflammatories.
·  Physiotherapy.
·  Consider Cortisone injections. / Refer if patient fails to respond to treatment after three months unless evidence of weakness suggestive of an acute rotator cuff tear which should be referred as Category 3.
Pain/stiffness in shoulder. / ·  Standard history and examination particularly neurological examination.
·  X-rays (standard views).
·  Consider FBC & ESR. / ·  Anti inflammatories.
·  Physiotherapy.
·  Consider Cortisone injections. / Refer after three months – Category 3.
AC joint problems. / ·  Standard history and examination particularly neurological examination.
·  X-rays (standard views).
·  Consider FBC & ESR. / ·  Anti inflammatories.
·  Physiotherapy.
·  Cortisone injections. / Refer after six months if persisting symptoms as Category 4.
Recurrent dislocated shoulder/shoulder instability. / ·  Standard history and examination particularly neurological examination.
·  In older patients difficulty elevating the arm following a dislocation. Consider ultrasound examination.
·  X-rays (standard views).
·  Consider FBC & ESR. / Shoulder rehabilitation programme (Physiotherapy) / Refer as routine referral (Category 4) if recurrent functional instability and/or pain and has not responded to the rehab programme after three months. Consider referral after recurrent shoulder dislocation – Category 4.
Rotator cuff tear following shoulder dislocation – Category 2

Last updated February 2006 Page 2 of 10