- within 16 weeks. Semi-urgent - within 8 weeks

Transcription

1 National Access Criteria for First Specialist Assessment Category Definitions: These are recommended guidelines for HHS specialists prioritizing referrals from primary care Immediate - within 1 week Urgent - within 4 weeks Semi-urgent - within 8 weeks Routine - within 16 weeks Low Priority - within 24 weeks Immediate and Urgent cases must be discussed with the Specialist or Registrar in order to get appropriate prioritisation and then a referral letter sent with the patient or faxed. NATIONAL REFERRAL GUDIELINES FOR ORTHOAPEDICS Category Immediate Urgent Semi-Urgent Routine Low Priority Criteria Suspected malignancy Disc prolapse with significant neurological deficit Extreme functional impairment community at risk Trauma not requiring immediate intervention Major risk of permanent disability through delay Severe functional impairment requiring considerable assistance with ADL. Severe pain sleep regularly disturbed, poor analgesic control. Serious congenital condition in infants Significant risk of permanent disability through delay Moderate functional impairment restriction of leisure activity, no assistance for ADL. Moderate pain some sleep disturbance, modest analgesic control. Moderate risk of permanent disability through delay. Employment seriously restricted. Rapidly progressive deformities. Mild-moderate functional impairment restriction of leisure activity, no assistance for ADL. Mild moderate /episodic pain satisfactory analgesic control. Low risk of permanent disability through delay. Employment being maintained. Slowly progressive deformities. No/minimal functional impairment no restriction of leisure activity, no assistance for ADL. No/minimal/episodic pain analgesics seldom required. Employment not threatened. No/very slow progressive deformities. Patient seeking second opinion/reassurance.

2 National Referral Guidelines - Orthopaedic Diagnosis Evaluation Management Options Problems are categorised by the following anatomical heading: Neck Shoulder Elbow Wrist & hand Back Hip Knee Ankle & foot Paediatric Miscellaneous A thorough history and 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 notes below. Referral Guidelines These guidelines are provided (below) to give greater clarity in situations of the primary/secondary interface of care.

3 Diagnosis Evaluation Management Options Referral Guidelines NECK Mechanical neck pain without arm pain Neck pain associated with referred pain to the upper arm without neurological deficit. Activity modifications Analgesics NSAIDs Maybe physiotherapy If symptoms and signs persist despite adequate care. Key points: Duration of symptoms. Presence of neurological symptoms and signs including evidence of lower limb spasticity. Work status. Weight loss, appetite loss and lethargy. Fever and sweats. Treatment to date Previous malignant disease. General medical condition. Investigations ( only if indicated): X-ray FBC & ESR Biochemistry (consider calcium and phosphate, protein electrophoresis, PSA. Rheumatoid serology in specific cases). Maybe trial of soft collar if severe spasm Neck pain associated with neurological deficit Cervical myelopathy Neck pain secondary to malignant disease Neck pain secondary to infection SHOULDER Rotator Cuff Tendonitis/Tear s, Pain /stiffness in the shoulder including frozen shoulder Routine history and noting the key points above. particularly neurological X-rays ( standard views) Consider FBC & ESR Anti inflammatory drugs Consider 1 cortisone injection. Refer semiurgent. Refer urgent. patient fails to respond to treatment. Evidence of weakness suggestive of a rotator cuff

4 AC joint problems tear is more urgent. Recurrent dislocation shoulder Shoulder instability ELBOW Tennis/golfer s elbow Painful /stiffness in elbow locking WRIST AND HAND Carpal Tunnel Syndrome Dupuytrens particularly neurological X-rays ( standard views).. Consider FBC & ESR.. Key points: Duration and speed of progression Functional impairment. Family history of Dupuytrens. Smoking. Previous surgery. General medical condition (especially Advice to avoid dislocation Shoulder rehabilitation programme with physiotherapist. Bands Modify activity ( e.g. patient with tennis elbow to use wrist in supination as much as possible) Consider cortisone injection Consider one cortisone injection Splintage Refer for neurophysiological studies. recurrent functional instability and /or pain and has not responded to the rehab programme. fails to respond to treatment. not responding to treatment Refer urgently if muscle wasting or associated with pregnancy. Please ensure copy of EMG studies is attached with referral. Finger contractures more urgent i.e. IP joint contracture more urgent than the MPC joint involvement. Refer semiurgent if PIP

5 Stenosing tenovaginitis (eg. Trigger finger, de Quervain). Rheumatoid conditions (refer to rheumatology recommendations). Basal Thumb Ganglia Painful/stiffness of the wrists. Congenital upper limb abnormalities BACK Mechanical low back pain without leg pain. Back pain and sciatica without neurology Spinal stenosis with limitation of walking distance diabetes, epilepsy, liver disease). Medications (especially for epilepsy)... X-ray.. X-ray. 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. Consider injection with steroids. Usually refer to specialist rheumatologist/physi cian Activity modification. Consider steroid injection. Consider aspiration (18g needle) and multiple punctures. Trial of wrist splint Physio Activity modification Analgesics and NSAIDs. Refer ACC guidelines Booklet. joint > 60º (Please supply photo of contracture if possible) functional impairment or if unresponsive to treatment after injection. Refer to Rheumatology recommendati ons fails to respond. Refer routine symptomatic ganglia. Cosmesis alone is not a reason for referral. x-ray abnormal or if does not respond to adequate conservative treatment Refer to local service with full history and assessment included. significant symptoms persist after 6 weeks of treatment.

6 Previous malignant disease. Previous spinal surgery General medical condition and medications Investigations if symptoms persist: X-ray FBC & ESR Biochemistry (consider calcium and phosphate, protein electrophoresis, PSA. Rheumatoid serology in specific cases). Back pain and sciatica with neurological deficit Back pain secondary to neoplastic disease or infection. Back pain with neurological bladder involvement ( cauda equina syndrome) Scoliosis As above Routine history and physical. family history of scoliosis or congenital spinal conditions X-ray standing PA and lateral whole spine. Refer semi urgent Refer urgent. Refer immediately child/growth remaining/pain. HIPS Hip Osteoarthritis Inflammatory joint Key Points: Walking distance Rest pain and disturbance of sleep. Analgesics / hydrotherapy. significant pain, disability, sleep disturbance and

7 Post traumatic Avascular Necrosis Previous total hip replacement. Paediatric Hip Conditions (Perthes, Slipped Upper Femoral Epiphysis SUFE, Synovitis) Irritable hip KNEES Ability to put on shoes. Use of walking aids. Treatment including NSAIDs and analgesics. Previous joint surgery. General medical condition and medications. History if recurrent infections and prostatism. Examination for range of movement. Investigations: X-ray (AP pelvis, AP affected hip showing proximal 2/3 femur and lateral of affected hip). History, and x-ray. Beware of pain in the knee as a symptom of hip disease. Activity modification this may well include the housework. Consider walking aid. Green prescription. Weight loss programme and support. Bed rest and simple analgesia. unresponsive (including analgesic medication). Pain in a previous arthroplasty should be referred after x-ray. If infection suspected, make an acute referral (do not start antibiotics). Acute referral if systemically unwell, febrile, or on suspicion of SUFE. Semi urgent referral for Perthes. Otherwise reassess at 24 hours. Age ranges usually: 18mont hs -6 years irritable 4-10 years Perthes years - SUFE Knee : Osteoarthritis Key points: Walking distance Analgesics significant pain, disability,

8 Inflammatory Post traumatic Avascular Necrosis Previous total knee replacement. ANKLES & FEET Rest pain and disturbance of sleep. Use of walking aids. Treatment including NSAIDs and analgesics. Previous joint surgery. General medical condition and medications. History if recurrent infections and prostatism. Examination for tenderness, swelling, range of movement and deformity. Investigations: X-ray - routine knee x- rays including AP of both knees and lateral affected side view weight bearing. X-rays AP and Lat ankle weight bearing if an ankle problem Include an Oblique view non weight bearing for foot problems. / hydrotherapy. Activity modification this may well include the housework. Consider walking aid. Green prescription. Weight loss programme and support. Analgesics and anti inflammatories. Active modification Walking Aids. Consider steroid injection. sleep disturbance and unresponsive (including analgesic medication). Pain in a previous arthroplasty should be referred after x-ray. If infections suspected make an acute referral (do not start antibiotics). functional impairment despite conservative treatment. Pain and deformity in forefoot ( including bunions) Pain and instability in hind foot. X-rays weight bearing views. Check Tibialis Posterior X-rays weight bearing views. Modification of footwear. Orthoses Consider steroid injections for intermetatarsal bursa/neuroma. Check Tibialis Posterior Modification of footwear. Orthoses conservative treatment fails. conservative treatment fails..

9 Achilles tendon pathology Heel Pain X-rays weight bearing views. And lateral calcaneus. Avoid steroid injections Heel cup/ raise. conservative treatment fails. PAEDIATRIC DEFORMITIES Club Foot Calcaneo valgus foot Flat feet In toeing MISCELLANEOUS X-rays X-rays allows exclusion of some diagnoses. NB: plantar spurs on an x- ray does not imply plantar fasciitis Features to be looked for are fixed equinus and varus. Almost always correctable to neutral but check the hips for instability. Under the age of 3 years flat feet are normal. Ask the child to stand on their tip toes if the arch corrects, the foot is normal.. Steroid injections for plantar fasciitis. Heel cup/raise. Reassurance reassurance Reassurance Refer urgently. Refer of not flexible/correct able. painful or spasm. Refer for a second opinion if asymmetrical or significant deformity. Bone and/or joint infection Bone and soft tissue tumours Bursitis ( pre-patella, trochanteric, olecranon) Do not needle biopsy.. Acute/inflammatory consider aspirating for diagnosis. Will either be traumatic, gouty or infected. Don t start antibiotics If acute consider aspirating for relief of symptoms. If chronic consider steroid injection. Acute referral. Refer urgently if tumour or suspicion of tumour. non responsive to treatment.

10 Apophysitis Eg Osgood Schlatters, Sever s Disease. Gait Sterno Mastoid Tumour (Congenital muscular torticollis). Removal plates, screws and pins.. Consider x-ray.. Up to 2 years bow leg is normal. Knock knees from age 2-5 years are normal.. Pain Ulceration Activity modification, reassurance. Reassurance. Passive stretching by parent or physiotherapist. does not settle. Refer for second opinion or severe deformity outside the normal age range. Normally refer to exclude other abnormality. Most metal implants are not removed. Consider referral if painful or risk of refracture. If is related to an injury then ensure patient s ACC number is included on the referral.