REFREC016
ORTHOPAEDICS REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
Problems are categorised by the
following anatomical headings:
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Ankles and feet
Back
Elbows
Hands and wrists
Hips
Knees
Miscellaneous
Neck
Shoulders
Last updated February 2006
Evaluation
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.
Management Options
Referral Guidelines
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.
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REFREC016
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Ankles and feet
Arthritis
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Analgesics/anti inflammatories.
Physiotherapy.
Activity modification.
Walking aids.
Consider steroid injection.
Refer if functional impairment despite
conservative treatment after six
months. Routine Category 4.
Standard history and examination.
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Modification footwear.
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X-rays standing.
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Orthoses.
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Weight-bearing AP.
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Consider steroid injections for
intermetatarsal bursal/neuroma.
Refer for routine assessment Category
4 if severity of symptoms warrants after
three months conservative treatment.
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Modification footwear.
Orthoses.
Physiotherapy.
Consider steroid injection.
Refer for routine assessment Category
4 if severity of symptoms warrants after
three months’ conservative treatment.
Standard history and examination.
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Physiotherapy.
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AVOID steroid injections.
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Heel cups/raise.
Refer for routine assessment Category
4 in three months if conservative
treatment fails or if patient has tender
nodule.
Standard history and examination.
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Physiotherapy.
 X-rays.
X-rays allow exclusion of some
diagnoses.
NB: Plantar spurs on an x-ray does not
infer plantar fascitis.
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Steroid injections for plantar
fascitis.
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Heel cups/raise.
Standard history and examination.
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Pain and deformity in forefoot
(including bunions)
Pain and instability in hind foot.
Standard history and examination.
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Achilles tendon pathology.
Heel Pain.
X-rays.
X-rays.
X-rays.
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.
Calcaneo Valgus Foot
Almost always correctable to neutral,
but check the hips for stability.
Flat Feet
Under the age of three years, flat feet
Last updated February 2006
Refer immediately Category 1.
Reassurance.
If not flexible or not looking normal by
three weeks, should be referred
Category 2.
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REFREC016
are normal.
Ask the child to stand on tip toes. If
the arch corrects, the foot is normal.
In Toeing
Standard history and examination.
Diagnosis / Symptomatology
Reassurance.
Evaluation
Management Options
Only for a second opinion beyond
walking age – Category 4.
Referral Guidelines
Back
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Mechanical low back pain without
leg pain.
Key points:
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Activity modification.
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Analgesics and NSAIDs.
Duration of symptoms.
Functional impairment.
Time off work.
Treatment to date.
Previous spinal surgery.
General medical condition and
medication.
Persistent severe symptoms refer as
category 4
(See ACC Guidelines Booklet).
Investigations:
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 X-rays.
 FBC ESR Biochemistry.
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(Consider calcium and phosphate,
electrophoresis, immunoglobulins,
PSA, Rheumatoid serology in specific
cases.)
Mechanical low back pain with leg
pain but without neurological deficit
Key points:
 Note key points above
 Weight loss
 Loss of appetite
 Lethargy
 Fevers and sweats
Last updated February 2006
If these symptoms present, refer as
category 2
If these symptoms absent, refer as
category 4
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REFREC016
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Back pain and sciatica with
neurological deficit.
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Spinal stenosis with limitation of
walking distance.
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Back pain secondary to neoplastic
disease or infection.
Previous malignant disease
Urinary difficulties
As above.
Diagnosis / Symptomatology
Refer as Category 2.
Evaluation
Management Options
Referral Guidelines
Elbows
Tendonitis.
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Standard history and examination.
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Consider Cortisone injection.
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Anti inflammatories.
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Bands.
Refer as routine Category 4 if fails to
respond to treatment after four weeks
or recurrence.
Locking.
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Standard history and examination.
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None.
Routine Category 4 referral with x-ray,
but consider occupation and functional
disability.
Painful/stiffness in elbow.
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Standard history and examination.
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Anti inflammatories.
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Consider FBC & ESR.
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Physiotherapy.
Refer routinely Category 4 if not
responding to treatment after three
months.
Last updated February 2006
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REFREC016
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Hands and wrists
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Contractures.
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Dupuytrens.
Refer progressive contractures
(especially PIP contractures) with
functional impairment as routine.
Referral Category 4.
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).
Stenosing tenovaginitis (eg Trigger
fingers, de Quervains).
Standard history and examination.
Rheumatoid conditions (cf
Rheumatology Recommendations).
Standard history and examination.
Basal Thumb Arthritis.
Standard history and examination xray.
Consider injection with steroids.
Refer as routine referral Category 4 if
functional impairment or if
unresponsive to treatment after one
injection.
Referral to Orthopaedic Surgeon is via
Rheumatologist/General Physician.
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Anti inflammatories.
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Activity modification.
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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.
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Standard history and examination.
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Anti inflammatories.
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X-rays to include scaphoid views.
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Trial of wrist splint.
Refer as routine Category 4 after six
months.
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Physiotherapy.
Congenital upper limb abnormalities (cf
Plastic Surgery Referral
Recommendation).
Last updated February 2006
Refer to local service as available.
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REFREC016
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Hips
Hip Arthritis
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Osteoarthritis.
Inflammatory Arthritis.
Post Traumatic Arthritis.
Avascular Necrosis.
Standard history and examination.
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Anti inflammatories.
Key points:
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Analgesics.
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Physiotherapy.
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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.
Refer if significant pain, problems
relating to mobility, sleep disturbance,
and unresponsive to therapy over
several weeks – Category 3.
Activity modification including the use
of a walking stick.
Home modification and use of ADC.
Investigations:
 X-ray (AP pelvis, AP affected hip
showing proximal 2/3 femur, and
lateral affected hip).
(Note: NHC Criteria for major joint
replacement.)
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.
Last updated February 2006
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REFREC016
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Knees
Anti inflammatories/analgesics.
Osteoarthritis.
Standard history and investigation.
Key points:
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Physiotherapy.
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Inflammatory Arthritis.
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Walking distance.
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Post Traumatic Arthritis.
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Rest pain and sleep disturbance.
Activity modification including the
use of a walking stick.
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Avascular Neurosis.
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Use of walking aids.
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Home ADC.
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Treatment including NSAIDs and
analgesics.
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Previous joint surgery.
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General medical condition and
medication.
Knee Arthritis:
Refer if significant pain, problems
relating to mobility, sleep disturbance
and unresponsive to therapy over
several weeks – Category 3.
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History of recurring infections and
prostatism.
Investigations:
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X-rays – four standard views plus
standing AP total knees.
(Note: NHC criteria for major joint
replacement.)
Last updated February 2006
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REFREC016
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Miscellaneous
Consider one steroid injection for
carpal tunnel.
Splintage.
Refer semi urgently – Category 3 – if
muscle wasting, otherwise, after three
months refer routinely – Category 4.
Nerve Entrapment Syndromes.
Standard history and examination.
Bone and/or Joint Infection.
Standard history and examination.
Acute referral to Orthopaedics –
Category 1.
Bone and Soft Tissue Tumours.
Standard history and examination.
Refer urgently if tumour or suspicion of
tumour – Category 2.
Do not needle biopsy.
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,
Standard history and examination.
Consider x-ray.
Activity modification, reassurance.
If second opinion or confirmation
required only – Category 4.
Standard history and examination.
Reassurance.
Refer for second opinion or severe
deformity outside the normal age range
– Category 4.
Passive stretching by parent or
physiotherapist.
If failure to respond after one year of
age, routine assessment – Category 4.
JL Disease.
Gait.
Sterno Mastoid Tumour (congenital
Muscular Torticollis).
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Symmetrical bow legs up to two
years are usually physiological
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Knock knees from age 2 – 4 are
also usually normal
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Angular deformities are usually
pathological
Standard history and examination.
cf Paediatric Surgery Referral
Recommendations.
Last updated February 2006
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REFREC016
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Neck
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Mechanical neck pain without arm
pain.
Key points:
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Neck pain associated with referred
pain to the upper arm without
neurological deficit.
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.
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Trial of soft collar.
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Activity modification.
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Analgesics and non steroidal antiinflammatories.
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.
Investigations:
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X-ray.
FBC & ESR.
Biochemistry.
(Consider calcium and phosphate,
protein electrophoresis,
immunoglobulins, PSA, Rheumatoid
serology in specific cases.)
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Neck pain associated with
radicular symptoms and
neurological deficit.
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Cervical myelopathy.
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Neck pain secondary to malignant
disease.
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Neck pain secondary to infection.
Last updated February 2006
Routine history and examination noting
the key points as above.
Refer for an immediate opinion –
Category 1.
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REFREC016
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Shoulders
Rotator Cuff Tendonitis/Tears.
Pain/stiffness in shoulder.
AC joint problems.
Recurrent dislocated shoulder/shoulder
instability.
Last updated February 2006
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Standard history and examination
particularly neurological
examination.
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X-rays (standard views).
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Consider FBC & ESR.
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Ultrasound examination.
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Standard history and examination
particularly neurological
examination.
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X-rays (standard views).
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Consider FBC & ESR.
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Standard history and examination
particularly neurological
examination.
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X-rays (standard views).
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Consider FBC & ESR.
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Standard history and examination
particularly neurological
examination.
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In older patients difficulty elevating
the arm following a dislocation.
Consider ultrasound examination.
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X-rays (standard views).
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Consider FBC & ESR.
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Anti inflammatories.
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Physiotherapy.
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Consider Cortisone injections.
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Anti inflammatories.
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Physiotherapy.
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Consider Cortisone injections.
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Anti inflammatories.
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Physiotherapy.
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Cortisone injections.
Shoulder rehabilitation programme
(Physiotherapy)
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.
Refer after three months – Category 3.
Refer after six months if persisting
symptoms as Category 4.
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
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