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Orthopaedics Referral Guidelines

In 2011 the Cairns Base Hospital Orthopaedic Department conducted a survey which provided valuable feedback from GP's on the management of orthopeadic patients


Ankles & Feet  |  Back  |  Elbows  |  Fracture |   Hip  |  Knees  |  Miscellaneous  |  Paediatric Conditions  |  Shoulders  |  Ulna Neuritis  | Wrist & Hand
Specialist Clinics Home


Ankles and Feet

 Diagnosis

 Evaluation

 Management

 Referral Guidelines & Data Required

Arthritis Standard history and examination
X-rays
Analgesics/anti inflammatories
Physiotherapy
Activity modification
Walking aids / shoe inserts
Consider steroid injection

Refer if functional impairment despite conservative treatment

Minimum Data Required

  • X-ray report
Pain & deformity in
Forefoot
(including Bunions and Mortons Neuroma)
Standard history and examination
X-rays
US to define Mortons Neuroma
Modification footwear
Orthoses
Consider steroid injections for intermetatarsal Bursa/Neuroma

Refer if conservative treatment fails
Categoriation likely to be low

Minimum Data Required

  • X-ray report
  • Acute or Chronic
Pain & Instability in
Hind Foot
Standard history and examination
X-rays
Check Tibialis Posterior function
Modification footwear
Orthoses
Physiotherapy

Refer if conservative treatment fails

Minimum Data Required

  • X-ray report
  • Acute or Chronic
Achilles Tendon
Pathology

Standard history and examination
X-rays

+/- Ultrasound

Physiotherapy
Avoid steroid injections
Heel cups/raise

Refer if conservative treatment fails

Minimum Data Required

  • X-ray

&

  • U/S report desired
Heel Pain Standard history and examination
X-rays
X-rays allow exclusion of some diagnoses
NOTE: Plantar spur on an X-ray does not imply plantar fasciitis
Physiotherapy
Steroid injections for plantar fasciitis
Heel cups/raise

Refer if conservative treatment fails

Minimum Data Required

  • X-ray report

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Back

 Diagnosis

 Evaluation

 Management

 Referral Guidelines & Data Required

Mechanical low back pain without leg pain.
Back pain and sciatica without neurology.
Spinal stenosis with limitation of walking
distance


Arthritis

Key points:
Duration of symptoms
Presence of neurological symptoms and signs
Functional impairment
Time off  work
Weight loss, loss of appetite and Lethargy
Fever and sweats
Treatment to date
Previous spinal surgery
Previous malignant disease
General medical condition and
Medication
Investigations if symptoms persist
X-ray and CT
FBC & ESR Biochemistry
(Consider calcium and phosphate, protein electrophoresis, immunoglobulins, PSA,
Rheumatoid serology in specific cases)
Consider Bone Scan if failure of conservative care to  determine if Facet Joint Injection appropriate especially if spinal extension as opposed to flexion is uncomfortable

Activity modification
Analgesics and NSAID's

  • Core strength exercises
  • Weight loss
  • Back education
  • Physiotherapy
  • Acupuncture
  • Chiropractic help

If symptoms persist greater than 6 months with failure of conservative care

**Refer**

**Include Disability Index

Minimum Data Required

  • X-ray report
  • Relevant Questionnaire
  • CT with any symptoms of Neuropathy and/or Radiculopathy
  • Acute or Chronic
  • Please note your interim treatment whilst waiting for OPD
     
Acute back pain and sciatica with lower limb motor function deficit As above  

Refer  immediately

Minimum Data Required

  • X-ray report
  • Relevant Questionnaire
  • CT
Back pain secondary to neoplastic disease or infection     Refer urgently
Back pain with neurological bladder / bowel involvement (cauda equina syndrome)     Refer urgently - contact orthopaedic registrar on call and refer to Emergency Department

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Elbows

 Diagnosis

 Evaluation

 Management

 Referral Guidelines & Data Required

Tennis/Golfer's
Elbow
Standard history an examination  
X-Ray  
Forearm Bands
Anti inflammatories
Modify activity (eg patient with tennis elbow to use wrist in supination as much as possible.
Physiotherapy
Consider Cortisone injection

Refer if fail to respond to treatment.
Natural history of resolution in most cases

Minimum Data Required

  • X-ray
  • Acute or Chronic

Painful/stiffness in
Elbow Locking

Arthritis

History & examination
Consider FBC & ESR & X-Ray
Anti inflammatories
Physiotherapy
Refer is not responding to treatment

Minimum Data Required

  • X-ray
  • Acute or Chronic

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Hip

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

HIP ARTHRITIS
(Osteoarthritis
Inflammatory Arthritis
Post traumatic Arthritis)
Avascular Necrosis
Standard history and examination
Key Points:
Walking distance
Rest pain & disturbance of sleep
Ability to put on shoes
Use of walking aids
Treatment including NSAID's and analgesics
General medical conditions and medication
Examination of range of movement
Investigations
X-ray (AP pelvis, AP affected hip showing proximal 2/3 femur and lateral affected hip)

Anti inflammatories/
Analgesic/physiotherapy
Activity modification
Including the use of a walking stick
Weight reduction
Glucosamine

Further Resources for Conservative Management:

Refer if significant pain,
Disability, sleep disturbance and unresponsive to therapy.

 

Previous Total Hip replacement (THR)
Infection, Loosening,
Wear

Key Points:
New pain
Limp
Peri Prosthetic radiolucency on XR
Investigations:

FBC, ESR, CRP
X-Ray AP pelvis + upper femora

Lat view affected hip

 

Pain in a previous  well functioning arthroplasty should be referred.
If infection suspected make acute referral to ED (do not start antibiotics)

Refer to same ortho surgeon if known from your records

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Knees

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

KNEE CONDITION or COMPLAINT (WITHOUT ARTHRITIS)

***Pre Teen or Early Adolescent with knee pain of unknown mechanism and no radiographical knee findings should have a  Hip X-ray on the affected side to rule out SUFE***

Standard history and examination
Key Points:

  • Severity of injury
  • Haemarthrosis/effusion
  • Pain
  • Locking
  • Instability
  • Response to conservative Rx
  • Recurrence
  • X-Ray - routine knee\
  • Consider FBC/ESR Serum Urate
  • Possible Ligament physical tests -McMurry Test, Lachman's Test, Anterior Drawer/Pivot Shift Test
Analgesics
Anti inflammatories
Splint
Physiotherapy
Maintain quads
Maintain ROM

Refer if persisting symptoms
>6 weeks  -
especially with

  • Pain
  • Instability
  • Locking
  • Recurrent effusion

Minimum Data Required

  • X-ray
  • Acute or Chronic
  • Mechanism of injury if applicable
  • If locking note intermittent or constant

*CT arthrogram and U/S are not reliable for diagnosis of Meniscal or  Ligament injury*

Knee Arthritis
Osteoarthritis
Inflammatory Arthritis
Post Traumatic Arthritis
Avascular Necrosis
Key Points:
Walking distance
Rest pain & disturbance of sleep
Use of walking aids
Treatment including NSAID's and analgesics
General medical conditions and medication,
Examination for tenderness, swelling, range of movement and deformity
Investigations:
X-ray routine knee X-rays including AP of both knees standing and lateral affected knee

Anti inflammatories/
Analgesics/physiotherapy
Activity modification including the use of a walking stick
Weight reduction
Glucosamine?

Further Resources for Conservative Management:

Refer if significant pain, disability, sleep disturbance and unresponsive to therapy.

Minimum Data Required

Previous total knee replacement (TKR)
Infection
Loosening
Wear
Key Points:
New pain
Limp
Grating
Peri Prosthetic radiolucency on X-Rays including AP of both knees standing and lateral affected side
 

Pain in a previous arthroplasty should be referred.
If infection suspected make acute referral (do not start antibiotics)

Refer to same ortho surgeon if known from your records

Minimum Data Required

  • X-ray  report

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Miscellaneous

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Bone and/or Joint Infection Standard history and examination
FBC, ESR, CRP
Blood Cultures
X-ray of the affected area
***Do not start antibiotics*** Urgent referral
Contact registrar on call
Bone and Soft Tissue Tumours

Standard history and examination
X-ray of the affected area

Chest X-ray
FBC, U&E's, LFT's, ESR, CRP
Do not needle biopsy

  Refer urgently to hospital

Bursitis
(Pre-Patellar,
Trochanteric,
Olecranon)

Standard history and examination
Consider aspirating for diagnosis if swollen.   Will either be traumatic, gouty or infected

If acute inflammation consider aspirating for relief of symptoms
If chronic non-infective consider steroid injection

Refer if non responsive to treatment

Minimum Data required

  • Acute or Chronic
APOPHYSITIS  eg Osgood Schlatters- Severs Disease Standard history and examination
Consider X-rays
Activity modification,
Reassurance
Splints
Heel Raise
Refer if does not settle
Removal - plates,
Screws & pins
Pain
Ulceration
X-ray of the affected area
 

Most metal implants are not removed.  Consider referral if painful or risk of refracture. Consider removal if under 16 years.
Exception - wrist plates - Consider removal at 1 year

If infection, refer same day.  Swab prior to commencing antibiotics

Minimum Data Required

  • X-ray

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Paediatric Conditions

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

DDH / Perthes Disease/ SCFE Standard history and examination
X-rays of Pelvis & upper femur
 

Refer immediately if suspicions

Minimum Data Required

  • X-ray

 

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Shoulders

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Rotator Cuff
Tendinitis/Tears
Pain/stiffness in shoulder including
Frozen shoulder
A/C joint problems
Standard history and examination
X-rays (standard views) & U/S scan
Consider FBC & ESR
Anti inflammatory
Physiotherapy
Consider Cortisone injections -
? Ultrasound or CT guided (via Radiology Services)

Age & expectations.
Refer if patient fails to
Respond to treatment.
Evidence of weakness
Suggestive of Acute rotator cuff tear in young patient is more urgent

Minimum Data Required

  • X-ray
  • Ultrasound would ensure accurate triage
  • Acute or Chronic
  • Mechanism of Injury if applicable
Arthritis Standard history and examination
X-rays (standard views)
Physiotherapy
Consider Cortisone injections -
? Ultrasound or CT guided (via Radiology Services)

Minimum Data Required

  • X-ray
Recurrent dislocation of shoulder
Shoulder instability
Standard history and examination
X-rays (standard views)
Advise to avoid dislocation through activity modification
Shoulder rehabilitation
programme (physiotherapy)

Refer if recurrent functional instability and/or pain and has not responded to the rehab programme

Minimum Data Required

  • X-ray
  • Acute or Chronic

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Ulna Neuritis

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

 Ulna Neuritis History & Examination
Elbow X-ray
Consider nerve conduction studies.
Analgesic
Activity Modification
Refer if established permanent paraesthesia & motor loss in ulnar nerve distribution greater than a few weeks

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Wrist and Hand

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Carpal Tunnel Syndrome History  Examination
Consider EMG Studies
Tinnels Sign
Phalens Test
Splint
Steroid Injection
Activity Modification

Refer especially if established permanent paraesthesia and motor loss

Minimum Data Required

  • Permanent, Persistent or Intermittent Parasthesia localised to Median Nerve territory
  • Acute or Chronic
  • Dominant or non dominant hand
  • Any evidence of Muscle Wasting
Stenosing
Tenovaginitis
DeQuervains
Standard history and examination Consider injection with steroids
Splint
Refer if functional
Impairment or if
Unresponsive to treatment after injection
Basal thumb arthritis
Or small joint arthritis
Standard history and examination
X-ray
Anti inflammatories
Activity modification
Consider steroid injections
Splinting/Physio

Refer if fails to respond

Minimum Data Required

  • X-ray
Ganglia Standard history and examination
Wrist X-ray +/- ultrasound
Consider aspiration (18g needle)
And multiple puncture
Refer if ganglia symptomatic
Cosmesis will receive low categorisation if sole condition
Painful/Stiff Wrists Standard history and examination
X-ray
Anti inflammatories
Trial of wrist splint
Physiotherapy

Refer if X-ray abnormal or if does not respond to adequate conservative treatment

Minimum Data Required

  • X-ray
  • Acute or Chronic

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Last updated: 1 August 2013