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Orthopaedics


If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

The list below includes common traumatic injuries that require referral to emergency and should not be referred for elective / fracture clinic categorisation

Adult

 

Shoulder and elbow conditions

  • Clinically indicated e.g. suspected septic arthritis
    • Evidence of acute inflammation e.g: haemarthrosis, tense effusion

Wrist and hand

  • Uncontrolled sepsis including hand infections
  • Upper limb radiculopathy in the presence of suspected cervical spine infection
  • Acute development of peripheral nerve compression symptoms following trauma or acute event

Hip and knee

  • Suspected septic arthritis
  • Knee extensor mechanism rupture
  • Suspected fracture
  • Evidence of acute inflammation for example
    • haemarthrosis
    • tense effusion
  • Suspected infection or sudden pain in arthroplasty
    • if joint infection is suspected refer immediately to emergency or contact the orthopaedic registrar on call.  Do not commence antibiotics unless delay to specialist review is likely

Foot and ankle

  • Suspected septic arthritis
  • Acute achilles tendon rupture

Spine

  • Actual or threatened cauda equina syndrome 
    • Unilateral or bilateral radicular pain
      • And/or dermatomal reduced sensation
      • And/or myotomal weakness
      • Reduced saddle sensation (subjective or objective pin prick)
      • unexplained or unexpected loss or change of bladder or bowel function
      • Sexual disturbance
      • perineal anaesthesia
  • Presentations that increase the probability of acute threatened Cauda Equina: 
    • Back Pain with: 
      • Presence of new saddle anaesthesia, bladder or bowel disturbance. 
      • Age < 50 
      • Unilateral onset progressing to bilateral leg pain 
      • Alternating leg pain 
      • Presence of new motor weakness 
  • Spinal tumour with significant pain and/or neurological deficit 
  • Lumbar Spine Stenosis (LSS) presenting with clinical symptoms of the following:
    • Recurring and insidiously but increasing back pain with gradual onset of unilateral or bilateral lower limb sensory disturbance and/or motor weakness
    • Incomplete bladder emptying, urinary hesitancy, incontinence, nocturia or urinary tract infections.   Bladder and/or bowel dysfunction may progress gradually over time.
  • Clinical signs of spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs/symptoms 
  • Spinal fractures demonstrated on imaging 
  • Clinical suspicion spinal infections
  • High risk of irreversible deficit if not assessed urgently

Trauma and fractures

  • Acute cervical myelopathy
  • Acute back or neck pain secondary to neoplastic disease or infection
  • Spinal injuries
  • Suspected open fracture
  • Fracture requiring manipulation or operation
  • Suspected acute bone or joint infection
  • Acute high energy fracture with/without neurological abnormality
  • Injury associated with vascular compromise
  • Clavicle fracture
  • Osteoporotic / pathological fracture new abnormal neurology
  • Joint dislocations
  • Open injuries with possible tendon or joint involved
  • Nail bed injuries or retained foreign body
  • Knee extensor mechanism rupture
  • Acute peripheral nerve injury
  • Suspected acute compartment syndrome

Hand trauma

  • Acute ligament injury
  • Tendon rupture
  • Compound ‘tooth knuckle’ injury

Upper and lower limb trauma

  • Open, unstable or suspected fractures

Timing of first review appointments at orthopaedic outpatient’s/fracture clinic

  • if there is documentation indicating adequate alignment and satisfactory initial treatment of fracture – to be seen within 14 days of referral
  • all other fracture cases, delayed presentation of tendon and nerve injuries - to be seen within 7 days of referral

 

Paediatric

Limping child/reluctant to weight bear

  • Limping child with signs of:
    • Being unwell, flushed, lethargic, fever, flat, anorexic and/or
    • Irritable and stiff joint and/or
    • Not improving
  • Systemically unwell, febrile or suspicion of septic arthritis
  • Concern of infection or trauma
  • Suspicion or concern of non-accidental injury

NB See Slipped upper femoral epiphysis (SUFE) CPC

Slipped upper femoral epiphysis (SUFE)

  • All suspected or confirmed SUFE should be referred to the ED or local orthopaedic on call registrar service no matter the chronicity

 

Scoliosis / Kyphosis

  • Systemically unwell
  • Abnormal neurological reason

Back pain

  • Systemically unwell

Tumour – bone and soft tissue

  • Suspected malignancy

 

 

The following are not routinely provided in a public Orthopaedics service.

Adult Service

  • Aesthetic or cosmetic surgery
  • Disability assessment (refer to HealthPathways)
  • Referrals for assessment prior to application for the Australian Defence Force or Queensland Police Service

Spine

  • Fusion for back pain due to degenerative disease without correlating clinical symptoms or signs of neural compression
    • chronic pain is defined as any pain lasting more than 6 months. Back and neck chronic pain – degenerative changes nil acute neurology (please refer to Spinal CPC)
  • Non-specific headache without red flags concerning features or not requiring surgical intervention should be referred to neurology.

Paediatric Service

  • Nil noted