ORTHOPAEDIC PROTOCOLS FOR THE GENERAL PRACTIONER

ORTHOPAEDIC GUIDELINES FOR THE GENERAL PRACTITIONER

These guidelines are very much an ‘aide memoire’ and are not to be comprehensive or replacing of experience, conservative judgement and treatment. They are aimed at being complimentary and supportive of the primary care practitioner, enabling the most efficient further management of the patient if referral is required.

Shoulder

CLINICAL CONDITION	INVESTIGATION	TREATMENT	REFERRAL
Rotator cuff impingement Chronic rotator cuff tear	plain x-ray ultrasound (both)	anti-inflammatory medication physiotherapy ( isometric internal and external rotation exercises) subacromial steroid injection ; max 3 modification of activities of daily living	when no response to at least 3 months of conservative treatment.
Frozen shoulder	plain x-ray ultrasound (both)	anti-inflamcation physiotherapymatory medi glenohumeral steroid injection ; max 3	when no response to at least 3 months of conservative treatment.
Acromio-clavicular joint pain	plain x-ray	anti-inflammatory medication physiotherapy	when no response to at least 3 months of conservative treatment.
Acute rotator cuff tear ( unable to abduct the arm after trauma)	plain x-ray ultrasound or arthrogram	surgical	immediate as early repair yields better results.
Acute calcific tendonitis	plain x-ray	anti-inflammatory medication surgical decompression ; arthroscopic	early surgical decompression of the calcific deposit can provide great pain relief
2 part fracture of the proximal humerus with minimal displacement	plain x-ray repeat x-ray to exclude displacement	immobilisation with collar and cuff and early pendulum exercises	when unstable or displaced
3 or 4 part fracture of the proximal humerus	plain x-ray	referred for specialist opinion	referral
Fracture of the clavicle	plain x-ray	immobilisation	complicated fracture ( open , brachial plexus injury)
Glenohumeral dislocation	plain x-ray	relocation and immobilisation broad arm sling	surgical reconstruction should be discussed given the high recurrence of dislocation
Acromio-clavicular dislocation	plain x-ray	collar and cuff when displacement less than the width of the clavicle	AC dislocation with displacement greater than the width of the clavicle should be considered for surgery
Humeral shaft fractures	plain x-ray	referred for specialist opinion	referral

Elbow

CLINICAL CONDITION	INVESTIGATION	TREATMENT	REFERRAL
Lateral or medial epicondylitis	none	anti-inflammatory medication physiotherapy forearm strap corticosteroid injection	patients who fail to improve after 6 months of conservative treatment
Degenerative arthritis	plain x-ray	anti-inflammatory medication physiotherapy	patients who fail to improve after 3 months of conservative treatment patients with mechanical symptoms due to loose bodies
Dislocation	plain x-ray	relocation and early mobilisation for stable relocations ( no tendency to redislocate in a full range of motion)	referral for unstable elbow dislocations
Childrenís elbow fractures	plain x-ray	depends on type of fracture	given the complex anatomy and treatment, referral is indicated
Pulled elbow	plain x-ray to exclude fracture	relocation	referral when no improvement after relocation
Radial head fracture	plain x-ray	early mobilisation if < 1 mm. displacement	referral if > 1 mm. displacement
Olecranon fracture Supracondylar fracture Fracture dislocations	plain x-ray	surgical	immediate referral
Distal biceps tendon rupture	plain x-ray, ultrasound	surgical	immediate referral

Wrist and Hand

CLINICAL CONDITION	INVESTIGATION	TREATMENT	REFERRAL
Degenerative arthritis of the wrist	plain x-ray	anti-inflammatory medication wrist splint	patients who fail to improve after 3 months of conservative treatment
Rheumatoid arthritis of the wrist / fingers	plain x-ray	referred for specialist opinion	early as some surgical procedures are more successful in the early stage
de Quervainís tenosynovitis		anti-inflammatory medication wrist splint steroid injection in 1^stextensor compartment	patients who fail to improve after 3 months of conservative treatment
Carpal tunnel syndrome		wrist splint steroid injection in carpal tunnel	patients who fail to improve after 6 weeks of conservative treatment
Ganglions of the wrist		none if asymptomatic wrist splint aspiration and steroid injection	patients who fail to improve after 3 months of conservative treatment
Colles' fracture with less than 10 degrees dorsal angulation and less than 1 mm. intra-articular step.	plain x-ray follow up x-ray at 1 and 2 weeks	reduction if necessary and Collesíplaster cast	referral if greater displacement or displacement in cast referral if intra-articular
Smithís fracture	plain x-ray	surgical	referral
Children's distal radius / ulna fracture with minimal displacement	plain x-ray	above elbow cast	referral if greater displacement or angulation
Scaphoid fractures of the distal pole or undisplaced waist fractures	scaphoid x-rays repeat x-ray to exclude secondary displacement	below elbow cast 6 weeks for distal pole fracture 8 to 12 weeks for waist fracture	referral if displaced or not united at 10/52
Scaphoid fractures of the proximal pole and displaced waist fractures	scaphoid x-rays	surgical	referral
Trigger digits		anti-inflammatory medication steroid injection in the tendon sheath	patients who fail to improve after 6 weeks of conservative treatment
Displaced or intra-articular fractures of the fingers	plain x-rays	surgical	referral
Lacerations of the hand		surgical exploration	referral for any deep laceration or laceration with tendon or nerve injury

Hip and Knee

CLINICAL CONDITION	INVESTIGATION	TREATMENT	REFERRAL
Chronic hip pain in the elderly	plain x-ray exclude lumbar spine pathology	anti inflammatory medication modification of activities of daily living	patients who fail to improve after 6 months of conservative treatment
Acute knee injury	plain x-ray to exclude fractures horizontal lateral for lipo-haemarthrosis	anti inflammatory medication rest, ice reassessment to exclude instability	referral if evidence of instability or suspicion of meniscal lesion
Chronic knee pain in the elderly	plain x-ray	anti inflammatory medication modification of activities of daily living bracing	patients who fail to improve after 3 months of conservative treatment
Knee instability	plain x-ray	referred for specialist opinion	referral
Osteochondritis dissecans	plain x-ray	referred for specialist opinion	referral
Osgood-Schlatter's disease	plain x-ray	rest, limitation of sport activity analgesics	patients who fail to improve after 6 months of conservative treatment
Patellar disorders in the young	plain x-ray 20 degrees, 40 degrees, 60 degrees skyline patellar views.	anti inflammatory medication modification of sports physiotherapy ( reinforcement of quadriceps, particularly vartus medialis exercises and medial taping ) patellar strap	patients who fail to improve after 6 months of conservative treatment
Transient synovitis of the hip in the child " irritable hip "	plain x-ray, exclude septic arthritis; tƒ ? WBC, ESR, CRP ?	rest, aspirin	referral if no improvement after 48 hr. rest or if signs of septic arthritis
Painful hip in the child - septic arthritis - Legg CalvÈ Perthes disease - slipped femoral epiphysis	plain x-ray, exclude septic arthritis; tƒ ? WBC, ESR, CRP ? bone scan?	referred for specialist opinion	referral
Fractures around the knee and hip	plain x-ray	referred for specialist opinion	referral

Foot and Ankle

CLINICAL CONDITION	INVESTIGATION	TREATMENT	REFERRAL
Mortonís neuroma	standing x-ray	modification of shoewear metatarsal pad corticosteroid injection	patients who fail to improve after 3 months of conservative treatment
Hallux valgus	standing x-ray vascular assessment diabetes ?	modification of shoewear	significant hallux valgus in the young rapid progression of deformity hallux valgus with rheumatoid arthritis hallux valgus with ulceration or pain
Hallux rigidus	as hallux valgus	modification of shoewear	early as some surgical procedures are more successful in the early stage
Plantar fasciitis Heel pain	plain x-ray to exclude stress fractures and arthropaties	heel cord stretching anti inflammatory medication heel pads corticosteroid injection	patients who fail to improve after at least 6 months of conservative treatment
Idiopathic flexible flatfoot	none if flexible and asymptomatic	orthosis if symptomatic	stiff flatfoot failure to improve with orthosis
Acute ankle sprain	plain x-ray	rest, ice , elevation bandage or splint	marked swelling on both sides of the ankle joint
Subacute - chronic ankle pain	plain x-ray bone scan to exclude occult fracture	anti inflammatory medication physiotherapy splinting	referral if no improvement after 8 weeks of conservative treatment
Undisplaced unimalleolar ankle fractures	plain x-ray repeat x-ray to exclude secondary displacement	plaster cast for 6 weeks	all displaced fractures all bi- or trimalleolar fractures

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