Paediatric orthopaedic referral guidelines

Contact information 2 Mandatory referral content Ankle and feet Demographic • Flat feet 3 • Child’s name • Intoeing 3 • Date of birth • Out-toeing 4 • Parent/guardian contact • Toe walking 4 details (incl. mobile) • Referring GP details Knee • Interpreter requirements • Bow legs 5 Clinical • Knock knees 5 • Reason for referral • Osgood-Schlatter disease 6 • Clinical urgency Hip • Duration of symptoms • Management to date and • Developmental dyspalasia of the hip (DDH) 7 response to treatment • Perthes disease 7 • Relevant pathology and • Slipped upper femoral epiphysis (SUFE) 8 imaging reports (please refer to specific guidelines) Other • Past medical history • Current medications • Infection – bone 9 • Functional status • Infection – joint 9 • Family history • Limping child 10 • Tumour – bone and soft tissue 10

Priority Priority will be determined on the basis of the information provided in the referral and according to the clinic’s referral triage process

Emergency Proceed to emergency department

Urgent Phone orthopaedic registrar or paediatric orthopaedic coordinator via the hospital switch For DDH referrals: Contact senior orthopaedic physiotherapist or paediatric orthopaedic coordinator/case manager

Routine Next available appointment. All referrals will be triaged by the paediatric orthopaedic service and appointments booked accordingly ERC 102295

Paediatric orthopaedic referral guidelines January 2011 1 Contact information

Specialist paediatric Address Contact details orthopaedic service

Barwon Health – Bellerine St (main entrance) Outpatient referrals: The Geelong Hospital Geelong Vic 3220 Enquiries: (03) 5260 3163 (GP Hotline) Fax: (03) 5226 7054

Paediatric orthopaedic coordinator: Mobile: 0409 334 744

Hospital switch: (03) 5226 7111 Senior orthopaedic physiotherapist – pager 310

Monash Children’s 246 Clayton Road Outpatient referrals: at Southern Health Clayton Vic 3168 Enquiries: 1300 3 iCARE (1300 342 273) Fax: (03) 959 iCARE (9594 2273)

Paediatric orthopaedic case manager: Phone: (03) 9594 4073

Hospital switch: (03) 9594 6666 Senior orthopaedic physiotherapist – pager 921 or 4516

The Royal Flemington Road Outpatient referrals: Children’s Hospital Parkville Vic 3052 Enquiries: (03) 9345 7060, #2 (GP Quick Access line) Fax: (03) 9345 5034

Hospital switch: (03) 9345 5522 Senior orthopaedic physiotherapist – pager 5465 or 5453

Western Health – Furlong Rd Outpatient referrals: Sunshine Hospital St Albans Vic 3021 Enquiries: (03) 8345 1616 Fax: (03) 8345 1079

Hospital switch: (03) 8345 1333 Senior orthopaedic physiotherapist – pager 766

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Paediatric orthopaedic referral guidelines January 2011 2 Ankle and feet

Flat feet

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Reassure parents. Most children Routine develop an arch by age six • Most children under age three have • Rigid flatfoot (arch does not reform flat feet • The vast majority of patients with on tip toe test or in non-weight-bearing) flexible flatfoot do not require • Ask if the child has pain in their feet • Painful flatfoot orthopaedic referral • Asymmetry Physical examination • Painless flexible flat feet require no treatment. Orthotics do not help form • Localised tenderness • Ask the child to stand on tip toes. an arch and are not recommended If the arch corrects, the foot is flexible • Difficulty in functional activities e.g. (requires no treatment) • Flat feet in children (fact sheet) running, jumping • Alternatively, if an arch can be seen in a non-weight-bearing position (e.g. sitting), the foot is flexible (requires no treatment)

Investigations • For rigid flatfoot only: weight-bearing X-ray (AP, lateral and oblique)

Intoeing

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Reassure the parents. Intoeing in most Routine children will improve as they grow and no Common causes: • Intoeing exceeds normal limits for age treatment is required. • Infant • Asymmetrical deformity • Intoeing can persist into adult life but – Metatarsus adductus rarely does this seem to cause major • Tripping in a school-age child that affects problems participation in activities • Toddler • Intoeing in children (fact sheet) • Progressive intoeing – Internal tibial torsion • Associated patella pain • School-age child • Hypertonicity – Increased femoral anteversion (excessive range of internal rotation and small range of external rotation)

Physical examination • Observe child’s gait • Place in prone and check range for internal and external rotation of the hip, thigh-foot angle and foot posture

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Paediatric orthopaedic referral guidelines January 2011 3 Out-toeing

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Reassure the parents. The majority of Routine out-toeing will resolve as the child grows • Commonly seen in early walkers due to • If progressive out-toeing and no treatment is required restricted internal rotation of the hip • Functional difficulties • Exclude other causes such as slipped • May be associated with knock knees upper femoral epiphysis • Asymmetrical deformity (genu valgum) and flatfoot • Thigh-foot angle > 30 – 40 degrees • Be aware of serious causes e.g. slipped upper femoral epiphysis

Physical examination • Observe child’s gait • Place in prone and check for internal and external hip range of motion, thigh-foot angle and foot posture

Toe walking

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Consider referral to paediatric Routine physiotherapist for assessment • Usually idiopathic; family history • Inability to dorsiflex foot beyond neutral, and management of toe walking stand with heels down or walk on heels • Although rare, need to rule out • Signs of cerebral palsy with hypertonia, significant conditions such as spinal hyperreflexia or ataxia dysraphism, muscular dystrophy and • Calf hypertrophy cerebral palsy • Asymmetry Physical examination • Abnormal spine examination • Gait assessment • Inspect spine • Functional tests: check if able to stand with heels down with trunk straight and able to walk on heels • Calf length • Calf size • Neurological assessment

Investigations If suspicious: • spinal X-ray • CPK

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Paediatric orthopaedic referral guidelines January 2011 4 Knees

Bow legs (genu varum)

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Reassure the parents. Physiological bow Routine legs will resolve by age three with normal • Physiologic bowing is the most common • Persistence of bow legs after three years development. No specific treatment is cause of bow legs and is seen from of age required birth until two or three years of age • Intercondylar separation > 6 cm • If concerned, serial measurement of • Be aware of pathological causes e.g. intercondylar distance every six months • Asymmetrical deformity rickets, Blount’s disease to document progression or resolution • Excessive deformity may be useful Physical examination • Progressive deformity or lack • Bow legs and knock knees in children • Determine the patient’s height of resolution (fact sheet) and weight percentiles • P a i n • Assess intoeing • After a traumatic event • Measure intercondylar distance • Other associated skeletal deformity such in standing with feet together as height below 5th centile for age Investigations X-ray of knees if: • unilateral deformity • progressive deformity • lack of spontaneous resolution • aged over three years old

Knock knees (genu valgum)

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Reassure. The majority of physiological Routine knock knees will resolve with normal • Physiological knock knees is seen from • Persistence of significant knock knees development by age eight; no specific three to five years of age; it resolves with beyond age eight treatment is required growth by age eight • Intermalleollar separation > 8 cm • If concerned, serial measurement of • May be familial intermalleolar distance every six months • Asymmetrical deformity to document progression or resolution Physical examination • Progressive deformity or lack may be useful of spontaneous resolution • Determine the patient’s height • Bow legs and knock knees in children and weight percentiles • P a i n (fact sheet) • Measure intermalleolar distance • After a traumatic event in standing with knees together • Other associated skeletal deformity such as height below 5th centile for age Investigations X-ray of knees if: • unilateral deformity • progressive deformity • lack of spontaneous resolution

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Paediatric orthopaedic referral guidelines January 2011 5 Osgood-Schlatter disease

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Reassurance. This is a self-limiting Routine condition and symptoms will resolve with • Most frequent cause of knee pain • Symptoms not resolving with skeletal maturity (i.e. when the bones in children aged 10 – 15 years conservative treatment finish growing) • Symptoms persisting > 18 months Physical examination • Modify activities to manage the pain. Jumping or kicking activities should • Pain and swelling over the tibial tubercle be avoided • Prominent and tender tibial tubercle • Local measure such as ice, anti-inflammatories and quadriceps Investigations stretching are recommended • Plain radiographs are used to rule out serious pathology e.g. neoplasm, acute tibial apophyseal fracture and infection

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Paediatric orthopaedic referral guidelines January 2011 6 Hip

Developmental dysplasia of the hip (DDH)

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Screening ultrasound if risk Urgent factors present Risk factors: • Abnormal clinical examination • Developmental dysplasia of the hip • Female sex – Positive Ortolani’s or Barlow’s test (fact sheet) • Breech delivery – Limited hip abduction • Intrauterine packaging deformities e.g. – Leg length discrepancy plagiocephaly, foot deformities or • Abnormal ultrasound or X-ray torticollis • If risk factors and any clinical concerns • Family history of DDH

Physical examination • Hip examination to check for instability with Barlow’s or Ortolani’s test • Limitation of hip abduction • Deep uneven gluteal crease • Leg length discrepancy • Waddling gait after walking age

Investigations • Hip ultrasound if aged under six months (paediatric ultrasound service if possible) • Plain X-ray if aged over six months (paediatric radiology service if possible)

Perthes disease

Initial pre-referral workup GP management Indications for specialist referral

Clinical history Pain management: Urgent • Typically presents between the ages • paracetamol • All patients with confirmed Perthes of four and 10 years or possible Perthes • NSAIDS • Variable pain with activity – Thigh, groin or knee pain • Sometimes seen in hyperactive boys

Physical examination • Variable limp • Hip irritability • Loss of hip motion, especially internal rotation and abduction in flexion

Investigations • Plain X-ray (AP and frog leg views)

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Paediatric orthopaedic referral guidelines January 2011 7 Slipped upper femoral epiphysis (SUFE)

Initial pre-referral workup GP management Indications for specialist referral

Clinical history Send to ED immediately Emergency • Hip, thigh or referred knee pain in age • Non-weight-bearing with crutches until • All patients with confirmed SUFE should group 10 – 16 years arrival at hospital be sent to the ED immediately • Pain worse with activity and • Contact orthopaedic registrar on call stressing hip joint through switchboard • O b e s i t y • Family history of SUFE

Physical examination • Obligatory hip external rotation during hip flexion in supine • Acute loss of hip internal rotation • Short leg • Externally rotated leg • Trendelenburg gait

Investigations • Plain X-ray (AP pelvis and frog leg lateral of both hips) • In early slips, X –rays may be normal. If clinical suspicion is high, an MRI may be needed and this will be part of the paediatric orthopaedic work-up

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Paediatric orthopaedic referral guidelines January 2011 8 Other

Infection – bone e.g. osteomyelitis

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Send to ED immediately if unwell Emergency • Any bone can be affected but • Do not give antibiotics as will negate • If clinically suspected, send referral cancellous bone is more common such cultures to ED as the metaphyseal region of long bones • May be reasonable to arrange some • Child is unwell with a fever, anorexia, investigations if child not clearly unwell localised tenderness or spasm around the joint if the infection is close to the joint • Beware of subacute osteomyelitis, where there may be few constitutional signs

Investigations • FBE, ESR, CRP • X-ray (change may lag 10 days behind clinical presentation)

Infection – joint e.g. septic arthritis

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Send to ED immediately Emergency • Infection more common in infants • Do not give antibiotics as will negate • Immediate referral to ED due to high risk and toddlers cultures to joint cartilage and growth plates • Hip joint more common than knee • No need for investigations if clinically or ankle joint suspected • Child unwell, listless, flushed and fever • Child cannot be coaxed to move the joint

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Paediatric orthopaedic referral guidelines January 2011 9 Limping child

Initial pre-referral workup GP management Indications for specialist referral

Clinical history Emergency • Red flag signs: unwell, flushed, lethargic, Age Common causes fever, flat, anorexic not to be missed All ages • T r a u m a • Joint is irritable and stiff • Infection – septic • Not improving arthritis, osteomyelitis • T u m o u r • Referred pain 1 to 4 • Developmental dysplasia years of the hip • Irritable hip (transient synovitis) 4 to 10 • Perthes disease years • Irritable hip (transient synovitis) • Juvenile idiopathic arthritis 10 to 16 • Slipped upper years femoral epiphysis

Investigations Depending on clinical presentation, consider: • FBE, ESR,CRP • hip X-rays (AP and lateral) • hip ultrasound

Tumour – bone and soft tissue

Initial pre-referral workup GP management Indications for specialist referral

Clinical history • Nil Urgent • Standard history • All cases of tumours or suspected tumours should be referred to The Royal Physical examination Children’s Hospital’s musculoskeletal tumour service and the referral • Standard examination discussed verbally with the service (contact Orthopaedic department on Investigations 9345 5444) Consider: • Attention referral to Mr. Mark O’Sullivan, • X - r a y Musculoskeletal Tumour Service • FBE and U&E • ESR/CRP/LFT Do not administer needle biopsy/injection

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Paediatric orthopaedic referral guidelines January 2011 10