ORTHOPAEDIC CHOICE Pathways
OA Wrist
Ganglion/Cysts
Dupuytrens contracture
Carpal Tunnel Syndrome Carpal Tunnel pathway For advice on management of CTS please follow link to Map of Medicine
Trigger Finger Trigger finger pathway For advice on management of trigger finger please follow link to Map of Medicine
Shoulder Shoulder pathway For advice on management of shoulder pain please follow link to Map of Medicine There are also further local guidelines
Is it Neck or Shoulder? Ask the patient to first move the neck and the move the shoulder. Which reproduces the pain? Red Flags = Urgent to Secondary Care Any mass or swelling -? Tumour Red skin, fever or systemically unwell -? Infection? Unreduced dislocation? Fracture Urgent Referral to Orthopaedic Choice History of trauma with loss of active abduction in younger patient -? Acute Cuff Tear Primary Care Refer If assistance is required with diagnosis Orthopaedic Choice Confirm Diagnosis Neck Follow Spinal Guidelines Shoulder History of Instability? Does the shoulder ever come out of joint? Is the patient worried that shoulder may dislocate? N o Y Instability Physio if Atraumatic Instability Traumatic dislocation Ongoing Symptoms Atraumatic with failed physio Instability X-ray Refer for extensive physio with specialist guidance Atraumatic if above fails for MRA Traumatic if 2 or more dislocations - consider surgical referal Is the pain localised to the AC joint and associated with tenderness? Is there high arc pain? Is there positive cross arm test? N o Y ACJ Disease Rest/NSAIDS/ analgesics ACJ Injection Physio Xray if no improvement ACJ Disease Refer if transient or no response to injection or physio ACJ Disease X-ray ACJ injection Guided injection if failed Persistent symptoms refer for ACJ resection Surgical referral for Gr 4,5,6 instability
Is there reduces passive external rotation? N o Y Glenohumeral joint Frozen shoulder or Arthritis X-ray to differentiate Analgesics Patient information Steroid injection Physio Glenohumeral joint Frozen shoulder with normal x-ray refer only if atypical and/or severe functional limitation Arthritis refer if poor response to analgesics and injection Glenohumeral joint Frozen Shoulder Confirm Diagnosis Intra-articular injection Patient information and analgesics Physio in stage 2 and 3 Refer for MUA/capsular release severe pain and functionally not coping Is there a painful arc on abduction? Is the pain on abduction worse with the thumb down, worse against resistance? History of trauma with loss of abduction in younger patient See Urgent N o Y Subacromial Pain Rest/Analgesics Subacromial injection Physiotherapy Subacromial Pain Transient or no response to injection and physiotherapy Glenohumeral joint Arthritis Confirm Diagnosis Advice and analgesics Intra-articulas injection Refer for joint replacement for pain relief Subacromial Pain X-ray Differentiate calsific tendinitis/ cuff pathology/ impingement USS if suspected cuff tear or prior to ASAD Repeat subacromial injection Refer for Barbotage for calsific tendinits Refer for Decompression of cuff repair. Other causes of Neck or Arm Pain Unexplained wasting, significant sensory or motor deficits, neurovascular compromise Y Neurological lesion Depending on severity refer to Orthopaedic Choice or Secondary Care A&E if suspected stroke Neurological lesion MRI - cervical spine or brachial plexus as appropriate Nerve conduction studies Onwards referral as appropriate
HIP/KNEE Hip/Knee pathway For advice on management of Hip and Knee pain please follow link to Map of Medicine There are also further local guidelines
Map of medicine knee pain pathway Referred to Orthopaedic Choice Knee slow to resolve after injury despite conservative management, or lack of confidence in return to sport Suspected anterior cruciate ligament tear history of significant twisting or hyperextension knee injury associated with rapid effusion ongoing painless instability associated with twisting activities positive Lachman s test +/- anterior drawer May have associated mensical tear, other ligamentous injuries including posteroloateral corner Follow ACL pathway Suspected posterior cruciate ligament tear history of blow to anterior proximal tibia, or hyperflexion or hyperextension injury may experience rapid knee effusion positive posterior sag and drawer of tibia positive dial at 90 may have concurrent injuries including posterolateral corner (with positive dial test at 30 and/or positive Hughston s test) or meniscal tear may experience instability sensation on descending slopes and stairs, and pushing heavy loads Suspected medial collateral ligament tear history of forceful valgus injury may develop effusion can be associated with mensical tear or other ligamentous injury depending on severity localised tenderness Follow MCL pathway Suspected lateral collateral ligament tear history of forceful varus injury usually develops localised swelling can be associated with meniscal or other ligamentous injury depending on severity localised tenderness Follow LCL pathway Follow PCL pathway
ACL injury pathway Suspected anterior cruciate ligament tear history of significant twisting or hyperextension knee injury associated with rapid effusion ongoing painless instability associated with twisting activities positive Lachman s test +/- anterior drawer May have associated mensical tear, other ligamentous injuries including posteroloateral corner MRI confirms isolated ACL rupture Recurrently unstable knee Patient young and wants to continue cutting activities Discuss with patient potential for ACL reconstructive surgery, including goals of surgery, expected postoperative timescales and rehabilitation requirements If patient keen to go ahead with surgery, refer for surgical opinion May 2013 Refer for MRI scan to confirm ACL tear and investigate other concurrent knee pathology MRI confirms isolated ACL rupture Recurrently unstable knee Discuss with patient potential for ACL reconstructive surgery, including goals of surgery, expected postoperative timescales and rehabilitation requirements If patient not keen to go ahead with surgery, refer for ACL brace and physiotherapy MRI confirms ACL rupture with meniscal tear Symptomatic meniscal tear Intermittently unstable knee Patient may require ACL reconstruction if young and wishes to participate in cutting sports and willing to comply with post-operative rehabilitation Patient may only require arthroscopic debridement of meniscal tear if knee remains stable on day-today activities, and does not participate in cutting activities Refer for surgical opinion MRI confirms ACL rupture with meniscal tear Asymptomatic meniscal tear Intermittently unstable knee Patient may require ACL reconstruction if young and wishes to participate in cutting sports and willing to comply with postoperative rehabilitation Refer for surgical opinion MRI confirms ACL rupture with PLC rupture Patient more likely to have functionally unstable knee Refer for surgical opinion
PCL injury pathway Suspected posterior cruciate ligament tear history of blow to anterior proximal tibia, or hyperflexion or hyperextension injury may experience rapid knee effusion positive posterior sag and drawer of tibia positive dial at 90 may have concurrent injuries including posterolateral corner (with positive dial test at 30 and/or positive Hughston s test) or meniscal tear may experience instability sensation on descending slopes and stairs, and pushing heavy loads Refer for MRI scan to confirm PCL tear and investigate other concurrent knee pathology Clinical findings and MRI confirm isolated PCL rupture Refer to physiotherapy for PCL injury rehabilitation program Patients do not usually require isolated PCL reconstruction Clinical findings and MRI confirm PCL rupture with symptomatic meniscal tear Refer for surgical opinion regarding meniscal tear May require physiotherapy referral for PCL injury rehabilitation program in meantime if able to tolerate Clinical findings and MRI confirm PCL rupture with PLC or other ligament involvement and instability Refer for surgical opinion May also require referral for combined instability brace in meantime if knee unstable If failed conservative management, refer for PCL brace or surgical opinion depending on level of disability and patient wishes
MCL injury pathway Suspected medial collateral ligament tear history of forceful valgus injury may develop effusion can be associated with medial mensical tear or ACL injury depending on severity localised tenderness If clinical findings suggest isolated Grade 1-2 MCL injury Refer to physiotherapy for MCL injury rehabilitation program (ROM and strengthening work) May need referral for x- ray to exclude bony injury If clinical findings suggest Grade 1-2 MCL injury + meniscal tear Refer MRI scan to investigate presence of meniscal tear If clinical findings and MRI scan confirms symptomatic meniscal tear, refer for surgical opinion May also require referral to physiotherapy if limited ROM and muscle strength If clinical findings suggest Grade 3 MCL injury, concurrent meniscal and other ligamentous involvement is likely Refer for x- ray and MRI scan to investigate any concurrent injuries Refer for surgical opinion If acute injury, brace locked at 30 for 3-6 weeks If non-acute, referral for brace if knee is unstable Referral for physiotherapy if limited ROM and reduced muscle strength
LCL injury pathway Suspected lateral collateral ligament tear history of forceful varus injury usually develops localised swelling can be associated with meniscal or other ligamentous injury depending on severity localised tenderness If clinical findings suggest isolated Grade 1-2 LCL injury Refer to physiotherapy for MCL injury rehabilitation program (ROM and strengthening work) If clinical findings suggest Grade 1-2 LCL injury + meniscal tear Refer MRI scan to investigate presence of meniscal tear If clinical findings suggest Grade 3 MCL injury, concurrent meniscal and other ligamentous involvement is likely May need referral for x- ray to exclude bony injury If clinical findings and MRI scan confirms symptomatic meniscal tear, refer for surgical opinion May also require referral to physiotherapy if limited ROM and muscle strength Refer for x- ray and MRI scan to investigate any concurrent injuries Refer for surgical opinion Referral for brace if knee is unstable Referral for physiotherapy if limited ROM and reduced muscle strength
Map of medicine suspected meniscal tear primary care management Degenerate-type meniscal tears Meniscal tears following acute injury Over 50yrs, x-ray (WB AP and lateral) In presence of mild to moderate OA changes, refer for surgical opinion if patient experiencing true locking and symptomatic In absence of true locking, see OA knee pathway In absence of OA changes refer for MRI scan Refer for MRI scan to confirm presence of meniscal tear and evaluate chondral changes Physiotherapy may be indicated if loss of muscle power and decreased ROM. If locked knee, or strong clinical suspicion of meniscal tear and symptomatic, refer directly on for surgical opinion Patient will require either x- ray or MRI prior to surgery If MRI scan confirms meniscal tear, and remains symptomatic, refer for surgical opinion Suspected symptomatic meniscal tear from history and examination, refer for MRI scan to confirm meniscal tear
Map of medicine patellofemoral OA primary care management Referred to Orthopaedic Choice X-rays within last 6/12 Weightbearing AP, lateral Early stage OA Physiotherapy to increase ROM, increase quadriceps power and help with pain management Advice re non-weight bearing activities Advice re pain control medication incl. NSAID s and analgesia Advice re weight-loss if appropriate Provision of OA knee information to patient Mid stage OA As for early stage if not already attempted Steroid injection if appropriate see appendix 1 Advanced OA As above if not already attempted Refer for surgical opinion if significant pain levels, affecting ADL and/or disturbed sleep. This is only following discussion with patient regarding pros and cons of surgery, surgical goals, expected recovery timescales. Patient should have completed shared decision making tool prior to referral X-rays skyline views if not already done Appendix 1 Steroid injection indications include acute flare-up of symptoms Cautions include Diabetes Contra-indications include Known hypersensitivity to local anaesthetic Local/systemic infection Tendon bodies and other classic avascular areas Unstable joints Tuberculosis Pregnancy and breast feeding Children under 18 Peripheral vascular disease Poor diabetic control HbA1/C > 8.5/9.0 Peptic ulcers active or history of peptic ulcer Prosthetic joint Recent trauma how recent? When? Spinal conditions Anticoagulant therapy Psychogenic disorders
Map of medicine tibiofemoral OA primary care management Referred to Orthopaedic Choice X-rays within last 6/12 Weightbearing AP, lateral Early stage OA Physiotherapy to increase ROM, increase quadriceps power and help with pain management Advice re non-weight bearing activities Advice re pain control medication incl. NSAID s and analgesia Advice re weight-loss if appropriate Possible offloading OA knee brace if appropriate Provision of OA knee information to patient Mid stage OA As for early stage if not already attempted Steroid injection if appropriate see appendix 1 Advanced OA As above if not already attempted Refer for surgical opinion if significant pain levels, affecting ADL and/or disturbed sleep. This is only following discussion with patient regarding pros and cons of surgery, surgical goals, expected recovery timescales. Patient should have completed shared decision making tool prior to referral X-rays skyline views if not already done Appendix 1 Steroid injection indications include acute flare-up of symptoms Cautions include Diabetes Contra-indications include Known hypersensitivity to local anaesthetic Local/systemic infection Tendon bodies and other classic avascular areas Unstable joints Tuberculosis Pregnancy and breast feeding Children under 18 Peripheral vascular disease Poor diabetic control HbA1/C > 8.5/9.0 Peptic ulcers active or history of peptic ulcer Prosthetic joint Recent trauma how recent? When? Spinal conditions Anticoagulant therapy Psychogenic disorders
Ankle Ankle injury pathway For advice on management of Ankle pain please follow link to Map of Medicine
Bursitis pathway Referred to Orthopaedic Choice DB July 2013 ITERMETATARSAL BURSITIS Advice re footwear - lower heel height, activity appropriate, good fit, appropriate fore sole Toe spring/ rocker sole footwear/ Thomas bar modification Assessment of foot and lower limb mechanics with provision of orthoses or offloading devices Advice re pain control medication incl. NSAIDs and analgesia If inflammatory arthropathy suspected, bloods and referral to rheumatology If not improving Ultrasound scan Ultrasound guided steroid injection if appropriate see appendix 1 If not improving RETRO-CALCANEAL BURSITIS Assessment of foot and lower limb mechanics, then provision of appropriate functional foot orthoses As above if not already undertaken Discussion with patient regarding risks/benefits of surgery and recovery timescales Refer for surgical opinion Appendix 1 Steroid injection indications include acute flare-up of symptoms Cautions include Diabetes Contra-indications include Known hypersensitivity to local anaesthetic Local/systemic infection Tendon bodies and other classic avascular areas Unstable joints Tuberculosis Pregnancy and breast feeding Children under 18 Peripheral vascular disease Poor diabetic control HbA1/C > 8.5/9.0 Peptic ulcers active or history of peptic ulcer Prosthetic joint Recent trauma how recent? When? Spinal conditions Anticoagulant therapy Psychogenic disorders
MTPJ capsulitis/ synovitis pathway Referred to Orthopaedic Choice DB July 2013 Advice re footwear - lower heel height, activity appropriate, good fit, appropriate fore sole Toe spring/ rocker sole footwear/ Thomas bar modification Assessment of foot and lower limb mechanics with provision of orthoses or offloading devices Advice re pain control medication incl. NSAIDs and analgesia Advice re appropriate stretches Advice re weight-loss if appropriate If not improving X-ray and/or ultrasound As above if not already undertaken Ultrasound guided steroid injection if appropriate see appendix 1 If not improving MRI scan As above if not already undertaken Discussion with patient regarding risks/benefits of surgery and recovery timescales Refer for surgical opinion if significant pain levels, affecting ADL and/or disturbed sleep Appendix 1 Steroid injection indications include acute flare-up of symptoms Cautions include Diabetes Contra-indications include Known hypersensitivity to local anaesthetic Local/systemic infection Tendon bodies and other classic avascular areas Unstable joints Tuberculosis Pregnancy and breast feeding Children under 18 Peripheral vascular disease Poor diabetic control HbA1/C > 8.5/9.0 Peptic ulcers active or history of peptic ulcer Prosthetic joint Recent trauma how recent? When? Spinal conditions Anticoagulant therapy Psychogenic disorders
Freiberg s/ avascular necrosis pathway Referred to Orthopaedic Choice Advice re footwear - lower heel height, activity appropriate, good fit, appropriate fore sole Toe spring/ rocker sole footwear/ Thomas bar modification Assessment of foot and lower limb mechanics with provision of orthoses or offloading devices Advice re pain control medication incl. NSAIDs and analgesia Advice re activity and pacing Advice re weight-loss if appropriate If not improving X-ray to exclude differential diagnoses and for classification (A to E, depending on severity) Short term immobilisation If not improving Discussion with patient regarding risks/benefits of surgery and recovery timescales Refer for surgical opinion re debridement/ removal of loose bodies / osteotomy if significant pain levels, affecting ADL and/or disturbed sleep DB July 2013
Sinus tarsi pathway Referred to Orthopaedic Choice Assessment of foot and lower limb mechanics and provision of appropriate functional foot orthoses Advice re footwear and activities (particularly running) Strengthening exercises / stretches Mobilisation DB July 2013 If not improving Ultrasound scan Ultrasound guided steroid injection if appropriate see appendix 1 If not improving MRI scan As above if not already undertaken Discussion with patient regarding risks/benefits of surgery and recovery timescales Refer for surgical opinion Appendix 1 Steroid injection indications include acute flare-up of symptoms Cautions include Diabetes Contra-indications include Known hypersensitivity to local anaesthetic Local/systemic infection Tendon bodies and other classic avascular areas Unstable joints Tuberculosis Pregnancy and breast feeding Children under 18 Peripheral vascular disease Poor diabetic control HbA1/C > 8.5/9.0 Peptic ulcers active or history of peptic ulcer Prosthetic joint Recent trauma how recent? When? Spinal conditions Anticoagulant therapy Psychogenic disorders
Tarsal tunnel pathway Referred to Orthopaedic Choice DB July 2013 Assessment of foot and lower limb mechanics and provision of appropriate functional foot orthoses Rest /ice Advice re footwear and activities Advice re pain control medication incl. NSAIDs and analgesia Strengthening exercises / stretches If not improving MRI / Nerve conduction studies Period of immobilisation Ultrasound guided steroid injection if appropriate see appendix 1 If not improving MRI scan As above if not already undertaken Discussion with patient regarding risks/benefits of surgery and recovery timescales Refer for surgical opinion re decompression Appendix 1 Steroid injection indications include acute flare-up of symptoms Cautions include Diabetes Contra-indications include Known hypersensitivity to local anaesthetic Local/systemic infection Tendon bodies and other classic avascular areas Unstable joints Tuberculosis Pregnancy and breast feeding Children under 18 Peripheral vascular disease Poor diabetic control HbA1/C > 8.5/9.0 Peptic ulcers active or history of peptic ulcer Prosthetic joint Recent trauma how recent? When? Spinal conditions Anticoagulant therapy Psychogenic disorders
Charcot arthropathy pathway ACTIVE, WARM AND/OR SWOLLEN CHARCOT FOOT Limb threatening emergency; urgent referral to orthopaedics and diabetic foot team for immediate immobilisation, with possible admission and IV medication. Active phase resolved INACTIVE, COOL BURNT OUT CHARCOT FOOT If not already done, refer to diabetic foot team Referral to orthopaedic choice Foot protection measures including offloading orthoses and accommodative footwear, bespoke if required. Protection measures for contralateral foot. DB May 2013
Hallux Rigidus pathway Referred to Orthopaedic Choice STRUCTURAL HALLUX RIGIDUS If conservative option needed or chosen by patient: Orthoses with forefoot extension Footwear with toe spring feature Advice re activity FUNCTIONAL HALLUX RIGIDUS Assessment of foot and lower limb mechanics, then provision of appropriate functional foot orthoses DB July 2013 If not improving X-ray Intra-articular ultrasound guided steroid injection if appropriate see appendix 1 If not improving As above if not already undertaken Discussion with patient regarding risks/benefits of surgery and recovery timescales Refer for surgical opinion re cheilectomy/ arthrodesis if significant pain levels, affecting ADL and/or disturbed sleep Appendix 1 Steroid injection indications include acute flare-up of symptoms Cautions include Diabetes Contra-indications include Known hypersensitivity to local anaesthetic Local/systemic infection Tendon bodies and other classic avascular areas Unstable joints Tuberculosis Pregnancy and breast feeding Children under 18 Peripheral vascular disease Poor diabetic control HbA1/C > 8.5/9.0 Peptic ulcers active or history of peptic ulcer Prosthetic joint Recent trauma how recent? When? Spinal conditions Anticoagulant therapy Psychogenic disorders
Digital deformity/contracture pathway Referred to Orthopaedic Choice FLEXIBLE DEFORMITY Orthodigital splinting Orthoses to influence forefoot and digital alignment Advice re pain control medication incl. NSAIDs and analgesia RIGID DEFORMITY Pressure deflective /palliative devices Extra depth/ modified footwear Advice re pain control medication incl. NSAIDs and analgesia DB July 2013 If not improving X-ray As above if not already undertaken Intra-articular ultrasound guided steroid injection if appropriate see appendix 1 If not improving As above if not already undertaken Discussion with patient regarding risks/benefits of surgery and recovery timescales Refer for surgical opinion re tendon lengthening or release/ cheilectomy/ excisional arthroplasty/ arthrodesis if significant pain levels, affecting ADL and/or disturbed sleep Appendix 1 Steroid injection indications include acute flare-up of symptoms Cautions include Diabetes Contra-indications include Known hypersensitivity to local anaesthetic Local/systemic infection Tendon bodies and other classic avascular areas Unstable joints Tuberculosis Pregnancy and breast feeding Children under 18 Peripheral vascular disease Poor diabetic control HbA1/C > 8.5/9.0 Peptic ulcers active or history of peptic ulcer Prosthetic joint Recent trauma how recent? When? Spinal conditions Anticoagulant therapy Psychogenic disorders
Low Back pain & Sciatica Low Back pain and radicular pathway
Neck Pain Neck pain pathway This includes;
Spinal Stenosis
Osteoporosis Spinal fracture This is not appropriate for Orthopaedic Choice Please see Map of Medicine pathway. Osteoporosis pathway