PenHealthOrthRefGuidelines
PENINSULA HEALTH ORTHOPAEDICS REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
Problems are categorised by the
following anatomical headings:
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Ankles and feet
Elbows
Wrists
Hips
Knees
Miscellaneous
Shoulders
Last updatedJanuary 2008
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 worded, quality referrals
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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PenHealthOrthRefGuidelines
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.
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 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 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 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.
Last updatedJanuary 2008
X-rays.
X-rays.
X-rays.
Refer as routine after failure to respond
to three months of conservative
treatment.
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PenHealthOrthRefGuidelines
Diagnosis / Symptomatology
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 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 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 as routine if not responding to
treatment after three months.
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Wrists
Painful/Stiff Wrists
Instability
Hand conditions: refer to Plastics
Last updatedJanuary 2008
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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.
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Physiotherapy.
Refer as routine after six months.
Hand conditions: refer to Plastics
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PenHealthOrthRefGuidelines
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.
Activity modification including the use
of a walking stick.
Home modification.
Investigations:
 X-ray (AP pelvis, AP affected hip
showing proximal 2/3 femur, and
lateral affected hip).
Last updatedJanuary 2008
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PenHealthOrthRefGuidelines
Previous THR infection,
loosening/wear, pain
History & examination
Key Points:
New pain
Affected gait pattern
Translucency on XR
Investigations:
XR lat hip, AP, pelvis
Diagnosis / Symptomatology
Pain in previous arthroplasty should be
referred fairly urgently.
If suspect infection, make acute
referral (don’t start Antibiotics).
Evaluation
Management Options
Referral Guidelines
Knees
Knee Arthritis:
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Osteoarthritis.
Standard history and investigation.
Key points:
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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.
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Avascular Neurosis.
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Use of walking aids.
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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.
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Anti inflammatories/analgesics.
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Physiotherapy.
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Activity modification including the
use of a walking stick.
Refer if significant pain, problems
relating to mobility, sleep disturbance
and unresponsive to therapy over
several weeks.
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History of recurring infections and
prostatism.
Investigations:
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Last updatedJanuary 2008
X-rays – four standard views plus
standing AP total knees.
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PenHealthOrthRefGuidelines
Previous TKR infection,
loosening/wear, pain
History & examination
Key Points:
New pain
Affected gait pattern
Translucency on XR
Investigations:
XR – routine knee series including AP
both knees in standing and lateral
view affected side
Potential arthroscopy
Meniscal tear / locked knee
History & examination
Key Points:
Check ROM, confirm true ‘lock’.
Investigations:
XR – routine knee series.
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Anti-inflammatories/analgesia
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Gait aids.
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Physiotherapy (particularly if
not a true lock).
History & examination
Key Points:
Frequency of recurrence
Patient age
Investigations:
XR – routine knee with ‘skyline view’.
Check for loose bodies.
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Anti-inflammatories/analgesia
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Gait aids – immobilisation
(particularly if primary
occurance).
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Physiotherapy
Recurrent patella dislocation
Last updatedJanuary 2008
Pain in previous arthroplasty should be
referred fairly urgently.
If suspect infection, make acute
referral (don’t start Antibiotics)
Refer if true locked knee – clearly
notate on referral.
Refer if significant pain, problems
relating to mobility, sleep disturbance
and unresponsive to therapy over
several weeks.
Refer if significant pain, problems
relating to mobility, sleep disturbance
and unresponsive to therapy over
several weeks.
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PenHealthOrthRefGuidelines
Ligamentous instability /
Acutely swollen knee
Last updatedJanuary 2008
History & examination
Key Points:
Assess and define varus/valgus and
anterior/posterior stability.
Investigations:
XR – routine knee series – check for
possible avulsion fractures.
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Anti-inflammatories/analgesia
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Gait aids – immobilisation
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Physiotherapy
Refer if significant pain, problems
relating to mobility, sleep disturbance
and unresponsive to therapy over
several weeks, particularly if anterior
or lateral instability.
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PenHealthOrthRefGuidelines
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Miscellaneous
Nerve Entrapment Syndromes
(EXCEPT CARPAL TUNNEL).
Standard history and examination.
Splintage.
Bone and/or Joint Infection.
Standard history and examination.
Acute referral to Orthopaedics.
Bone and Soft Tissue Tumours.
Standard history and examination.
Refer urgently if tumour or suspicion of
tumour.
Do not needle biopsy.
Refer semi urgently if muscle wasting,
otherwise, after three months refer
routinely. CARPAL TUNNEL – Refer
to Plastics
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.
Apophysitis, eg Osgood Schlatters,
Standard history and examination.
Consider x-ray.
Activity modification, reassurance.
If second opinion or confirmation
required only.
Standard history and examination.
Reassurance.
Refer for second opinion or severe
deformity outside the normal age
range.
JL Disease.
Gait.
Last updatedJanuary 2008
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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
Page 8 of 9
PenHealthOrthRefGuidelines
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Shoulders
Rotator Cuff Tendonitis/Tears.
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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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Anti inflammatories.
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Physiotherapy.
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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;
and / or
- confirmed subscapularis tear;
and / or
- <65 yrs of age
Pain/stiffness in shoulder.
AC joint problems.
Recurrent dislocated shoulder/shoulder
instability.
Last updatedJanuary 2008
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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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Cortisone injections.
Shoulder rehabilitation programme
(Physiotherapy)
Refer after three months if not
responding to treatment.
Refer after six months if persisting
symptoms.
Refer as routine referral if recurrent
functional instability and/or pain and
has not responded to the rehab
programme after three months.
Consider referral after recurrent
shoulder dislocation.
Acute rotator cuff tear following
shoulder dislocation – see above for
guidelines.
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