Orthopaedic
referral guidelines- Total hip and knee joint replacement including NICE referral guidelines
- Hallux valgus and bunions
- Flat foot
- Plantar fasciitis
- Carpal tunnel syndrome
- Dupuytren's disease
- Flexor sheath ganglion
- Wrist ganglia
- Trigger finger and thumb
- Back ache and sciatica
Total hip and knee joint replacement
The most common condition requiring hip and knee joint replacement is osteoarthritis but arthroplasty is also used in rheumatoid arthritis, other inflammatory conditions, avascular necrosis, CDH and post-traumatic arthritis. The indications for joint replacement in the hip and knee are persistent pain, limited ambulation and night pain, despite full conservative therapy.
Joint replacement is a very successful operation and 90 to 95% of joint replacements will still be in place and functioning well at ten to fifteen years. A small number of patients experience complications which can be devastating and for this reason patients should not be considered for joint replacement until their condition has become chronic and conservative methods have failed.
Primary treatment:
- Weight reduction.
- NSAIDs and Paracetamol-based analgesics (COX-2 Inhibitor if intolerant of NSAIDs).
- Activity modification.
- Walking aid (contralateral hand).
Refer when:
- Pre-existing medical problems have been optimised.
- Conservative measures have failed.
NICE referral guidelines
| OA Hip
OA knee
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Hallux valgus and bunions
Hallux valgus is defined as an angle of greater than 15 degrees at the first metatarsophalangeal joint in the AP plain. A bunion is the formation of dorsomedial osteophyte at the first metatarso-phalangeal joint. There are many surgical options which achieve mixed clinical results and have a multitude of complications. Conservative measures should be tried before referral for surgical treatment.
Primary treatment:
- Advice on low heeled, wide forefoot shoes with soft leather uppers.
- Referral to chiropodist.
- Referral to orthotics (eg comfort shoes).
Refer when:
- There is severe deformity (overriding toes).
- There is severe pain from the metatarsophalangeal joint or bunion.
- Conservative methods have failed.
Flat foot
Flat foot can either be flexible or fixed. A flexible flat foot is flat when weight-bearing but forms a normal arch when non-weight-bearing or when standing on tip toe. Flexible flat foot is non-pathologic and requires no treatment. Rigid flat foot may be caused by tarsal coalition or neuromuscular conditions and is pathological.
Primary treatment:
- Flexible flat foot requires no treatment.
Refer when:
- Flat foot is rigid.
- Other pathology is suspected.
Plantar fasciitis
Plantar fasciltis is a benign, usually self-limiting, condition which ultimately responds to conservative treatment and even in the presence of a calcaneal spur on an x-ray is not usually treated surgically. A calcaneal spur is not indicative of any disorder.
Primary treatment:
- NSAIDs.
- Silicone heel pad.
- Steroid injection under the trigger point.
- Physiotherapy for stretch exercises of plantar fascia and tendo-achilles
Refer when:
- There is doubt about the diagnosis.
Carpal tunnel syndrome
Carpal tunnel syndrome is a common disorder which in its early phases can be successfully treated with a combination of conservative measures. If the duration of the symptoms is less than six months, these measures are worth trying, and there is good evidence that they may be efficacious in eradicating the disease.
Primary treatment:
- Splinting with a Futuro splint, especially at night for six weeks.
- NSAIDs.
- Injection into the carnal tunnel.
Refer when:
- Symptoms persist despite the above conservative measures.
- Symptoms have been present for longer than six to nine months.
Dupuytren's disease
Dupuytren's disease is a common digital affliction affecting predominantly men, but occasionally women, characterised by the formation of palmar and digital nodules, pits and contractures which commonly occur at the metacarpophalangeal and proximal interphalangeal joints.
The aim of surgical treatment is the relief of contractures and surgery is not indicated until a contracture of some magnitude is present. Surgery is not indicated in the early phases of the disease when there are simply pits and nodules, or even bands that are not associated with deformity.
Primary treatment:
- None.
Refer when:
- There is a 30 degrees fixed flexion deformity at either the MCPJ or PIPJ.
- The patient cannot flatten their fingers or palm on a table.
Flexor sheath ganglion
These small ganglia arising from the flexor sheath can cause pain during grip.
Primary treatment:
- Puncture or aspiration with a 21 gauge needle may disperse the lesion (50% will recur).
Refer when:
- The lesion cannot be emptied.
- The lesion appeared to be solid.
- There is doubt about the diagnosis.
- The lesion recurs and is symptomatic
- The lesion is eccentric, ie not in the midline of the digit.
Wrist ganglia
Most outpatient consultations for ganglia culminate in explanation and reassurance that ganglia are harmless and many resolve spontaneously. 40% disappear for at least twelve months after aspiration. Surgical scars on the dorsum of the wrist can be more painful than the ganglion. The recurrence rate after surgery is about 10% for dorsal wrist ganglia and 30% for ganglia adjacent to the radial artery.
Primary treatment:
- Reassurance as above.
- Aspiration under local anaesthesia using a wide bore needle (16 gauge).
- Apply a firm bandage for one week to prevent recurrence.
Refer when:
- The lesion cannot be emptied.
- The lesion seems to be solid.
- There is doubt about the diagnosis.
- The ganglion recurs after aspiration and is symptomatic.
Trigger finger and thumb
Between 50% and 70% of cases are free of triggering at least twelve months after a single steroid injection into the tendon sheath.
Primary treatment:
- Injection into the tendon sheath using a 21 or 23 gauge needle exactly at the midline of the ray at the level of the metacarpophalangeal joint.
- The effect of the injection may not be seen for three to four weeks.
Refer when:
- Triggering persists.
- Triggering recurs.
Back ache and sciatica
Simple back ache is a benign condition which does not usually require surgical intervention. The onset is generally in patients between the ages of 20 and 55 years. Pain originates in the lumbosacral region and may radiate to the buttocks and thighs but not below the knee. The pain is mechanical in nature, i.e. it varies with physical activity and varies with time. Patients with simple back ache are not unwell and the prognosis is good with 90% recovering from the acute attack in six weeks.
Sciatica is defined as unilateral leg pain (i.e. pain which radiates below the knee) which is greater in severity than the associated back pain and is most commonly the result of a prolapsed intervertebral disc. Pain generally radiates down the whole of the leg below the knee into the foot or toes and is associated with numbness and paraesthesia in a dermatomal distribution. There are signs of nerve root irritation which include reduced straight leg raise, which reproduces the distribution of the leg pain. Motor sensory and reflex changes are limited to one nerve root. Prognosis is reasonable and more than 50% of patients will recover from an acute attack within six weeks.
Primary treatment:
- Analgesia, anti-inflammatories, muscle relaxant.
- Bed rest for a maximum of 48 hours.
Referral:
- Should be made to the physiotherapy department, not to the orthopaedic department.
- If possible, referral should be made within 6 weeks of onset.
Beware red flags:
- There is difficulty with micturition.
- There is loss of anal sphincter tone and faecal incontinence.
- Saddle anaesthesia by the anus perineum or genitals.
- Widespread or progressive motor weakness in the legs or gait disturbance.
- Pain is constant, progressive and non-mechanical in nature.
- Sciatic symptoms are not resolving after four to six weeks of conservative treatment.
- The patient is systemically unwell.
- There is widespread neurology.
- There is structural deformity.
- ESR is abnormal.
Evidence for management of back pain
Source: Wansbeck orthopaedic guidelines