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 102295 ERC 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 Return to front page 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 Return to front page 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 Return to front page 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 Return to front page 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