Orthopaedic Referral Guide

Hip

Total hip replacement is only considered only considered for advanced degenerative changes of the hip joint confirmed by x-ray evidence, if the patient is fit enough and wishes to consider surgical intervention having tried conservative management strategies. If the patient is experiencing rest and night pain, sleep disturbance, considerable reduction of walking distances and becoming housebound due to hip pain and not due to other pathologies. Peripheral pulses need to be good.

Risk factors: BMI of over 40, vascular insufficiencies, varicose veins. Risk of dislocation with epilepsy and Parkinson’s disease. House bound for any other reason, THR not usually indicated.

Please refer to the specialist musculoskeletal service for early to moderate disease management and for those with advanced changes not wishing or unable to consider surgical intervention.

Lateral hip pain – please refer to the specialist musculoskeletal service as this requires conservative management often with a biomechanical component.

Knee OA

Unicompartmental recovering or replacement only considered if there is no sign of degeneration in the other compartment and a low BMI only.

Total knee replacement only considered for advanced degenerative changes of the knee joint confirmed by x-ray evidence, when the patient wishes to consider surgical intervention having tried conservative management strategies. Patient preferably over 50 years of age with walking distances of less than 1/2 mile, constant pain, rest and night pain and if independence is threatened. Peripheral circulation must be good.

Risk factors: BMI of over 40, vascular insufficiencies

Please refer to the specialist musculoskeletal service for early to moderate disease management and for those with advanced changes not wishing or unable to consider surgical intervention.

Mechanical knee problems

Meniscal injuries

Under 40 years of age with a definite history of injury and inability to continue play or activity, and symptoms of mechanical derangement -effusion, locking, giving way, clunking supported by clinical and MRI findings and not settling with conservative measures.

Over 40 years of age -refer only for sudden onset/ traumatic knee pain, tears breaking the surface or meniscal cysts. Do not refer degenerative intra substance tears as this is early stage OA and will not be changed by surgery. Refer only if persisting mechanical problems with locking or giving way, confirmed by clinical and MRI findings. Meniscal extrusion and eburnation are terms meaning degenerative changes not necessarily requiring referral Usually degenerative meniscal changes with or without tears will settle with time and conservative measures.

Please refer to the specialist musculoskeletal service  for degenerative meniscal management and advice

Instability

Ligament ruptures—collateral or cruciate with a definite history of injury with swelling and inability to continue play or activity with continuing instability.   Ligament ruptures should be confirmed by clinical and MRI findings.

Please refer to the specialist musculoskeletal service for old injuries or for patients over 50 years of age.

Patellofemoral pain

Only refer to orthopaedics if chondral defects or advanced degenerative changes proven by x-ray or MRI, or for recurrent dislocation problems.   Patella tendinopathy requires conservative management, not generally requiring referral to orthopaedics.

Most patello femoral pain and/or patella tendon pain should be managed conservatively please consider referral to the specialist musculoskeletal service or physiotherapy.

Lateral hip pain / Greater Trochanteric Pain Syndrome

Lateral hip pain/gluteal tendinopathy/ greater trochanteric pain syndrome generally requires conservative management and does not usually require surgery, please consider referral to the specialist musculoskeletal service.

Patella/infra patella bursitis

Please refer to the specialist musculoskeletal service even if recurrent, these respond to conservative management and rarely require surgical intervention.

Ankle

Sprain

Refer to secondary care if continuing to be symptomatic after severe ankle sprain involving inability to weight bear following injury and failing to respond to conservative management including physiotherapy and orthotics if required.

OA ankle

Please refer to the specialist musculoskeletal service for mild/moderate degenerative changes for advice, treatment and management.

Refer to secondary care for advanced degenerative changes confirmed by x-ray failing to respond to conservative management and fit and willing to consider surgery.

For help with diagnosis and/or for conservative management please consider referral to specialist musculoskeletal service.

Foot

OA 1st metatarsal phalangeal joint

Please refer to the specialist musculoskeletal service for mild/moderate degenerative changes for advice, treatment and management.

Refer to secondary care for advanced degenerative changes first metatarsal phalangeal joint, not responding to conservative management including foot orthoses, shoe wear advice and/or injection and fit and willing to consider surgery.

Morton’s neuroma

Please refer to the specialist musculoskeletal service for early/mild disease for advice, treatment and management.

Refer to secondary care if failing to respond to conservative management including foot orthoses, shoe wear and /or injection and willing to consider surgery.

Tibialis posterior dysfunction

Please refer to the specialist musculoskeletal service for mild/moderate degenerative changes for advice, treatment and management.

Refer to secondary care if failing to respond to conservative management, fit enough and willing to consider surgery.

For help with diagnosis and/or conservative management please consider referral to specialist musculoskeletal service.

Please refer to the specialist musculoskeletal service for management of non surgical conditions such as:

  • Plantar fasciitis
  • Achilles tendinopathy/enthesiopathy
  • Peroneal and early tibialis posterior tendinopathy
  • Rear and forefoot pain
  • Early to moderate OA foot and ankle
  • Diagnosis of foot and ankle and biomechanical problems

Shoulder

Instability/internal derangement

Refer to secondary care following first time of dislocation for patients under 25 years of age. Patients of up to 60 years with definite history of sudden onset/trauma and/or dislocation with persisting symptoms not responding to conservative management. Older patients to be managed conservatively where possible. Hypermobile patients with multidirectional subluxation/dislocations or habitual/party trick dislocators please manage conservatively where possible.

Please refer to the specialist musculoskeletal service or physiotherapy

Acromioclavicular joint

Refer to secondary care following trauma especially where deformation of the joint is causing- puckering, overstretching, discoloration or break down of the overlying tissues. Refer to secondary care for advanced degenerative changes of acromioclavicular joint confirmed by x-ray evidence when the patient wishes to consider surgical intervention having tried conservative management strategies and regularly experiencing persistent problems with rest and night pain, impingement and/or functional impairment.

Please refer to the specialist musculoskeletal service for mild/moderate disease advice, treatment and management

Impingement

Refer to secondary care for recurrent chronic impingement problems failing to respond to conservative management strategies of injecting and scapulothoracic rehabilitation.

Please refer to the specialist musculoskeletal service for mild/moderate disease advice, treatment and management

Glenohumeral capsulitis/OA shoulder

Capsulitis

Please refer to specialist musculoskeletal service as surgical intervention is rarely required.

Please note that diabetic patients are often resistant to treatment and require extra conservative management.

OA shoulder

Please refer to the specialist musculoskeletal service for mild/moderate degenerative changes for advice, treatment and management.

Please refer to secondary care to consider shoulder replacement for advanced degenerative changes of the glenohumeral joint confirmed by x-ray evidence, when the patient wishes and is fit enough to consider surgical intervention having tried and failed to respond to conservative management strategies.

Rotator cuff tears

Please refer to the specialist musculoskeletal service for help with diagnosis, treatment and conservative management of patients of over 50 years of age with degenerative rotator cuff tears.

Elbow

Degenerative changes

Refer to secondary care for advanced degenerative changes of the elbow joint confirmed by x-ray evidence, giving rest and night time pain and unacceptable limitation of function, when the patient wishes to consider surgical intervention having tried all conservative management strategies.

Please refer to the specialist musculoskeletal service for mild/moderate disease advice, treatment and management.

Radial or cubital tunnel pathology

Refer to secondary care for advanced radial or cubital tunnel problems causing weakness and loss of sensation and function.

Please refer to secondary care for subluxing ulnar nerve.

Please refer to the specialist musculoskeletal service for early cubital tunnel problems.

Epicondylosis

Please refer to the specialist musculoskeletal service for medial and lateral epicondylosis as most of these conditions resolve over a two to three year period with conservative management and do not require any surgical intervention

Olecranon bursitis

Please refer to specialist musculoskeletal service even if recurrent, surgical intervention is rarely required

Please refer to specialist musculoskeletal service for help with diagnosis and/or conservative management.

Hand and wrist

Carpal tunnel syndrome

Refer to secondary care for symptoms failing to respond to conservative strategies in under 3-6 months; long term problems, permanent parasthesiae or loss of sensation, wasting of the thenar eminence and weakness, problems with dexterity and willing to consider surgical intervention.

For help with diagnosis or for early stage symptom management please refer to specialist musculoskeletal service.

Degenerative changes of the first carpometacarpal joint of thumb

Refer to secondary care for advanced changes confirmed by x-ray evidence, failing conservative management strategies and wishing to consider surgical intervention.

Please refer to the specialist musculoskeletal service for early to moderate degenerative disease.

Degenerative changes of the wrist

Refer to secondary care for advanced changes confirmed by x-ray evidence and failing to respond to conservative management strategies and wishing to consider surgical intervention.

Please refer to the specialist musculoskeletal service for early to moderate degenerative disease.

De Quervain’s syndrome

Refer to secondary care chronic/ recurrent De Quervain’s syndrome failing to respond to injecting and conservative management strategies.

Please refer to the specialist musculoskeletal service for mild / moderate disease advice and treatment.

Trigger finger/thumb

Chronic / recurrent Trigger finger / thumb failing to respond to injecting and conservative management strategies.

Please refer to the specialist musculoskeletal service for mild / moderate disease advice and treatment.

Hand ganglions

Refer to orthopaedics ONLY if the ganglion is causing significant pain or problems with function, not for cosmetic reasons. The patient needs to be counselled that the ganglion is only a harmless sac of jelly like fluid which does not become worse but will usually resolve naturally over time; surgery will leave a scar and the ganglion may reappear even after surgical removal.

Dupytrens contractures

Surgical intervention is only required for more advanced disease where contracture of the metacarpophalangeal joint is of over approx 30 degrees and of the proximal interphalangeal joint is of approx 15 degrees interfering significantly with function and where the patient is willing to consider surgery understanding that results may be variable.

For help with diagnosis of wrist and hand pain and / or for injecting and conservative management please consider referral to the specialist musculoskeletal service.