Referral pathways

Referral pathways depend on local care arrangements.

Trauma or Limping patients will be referred to orthopaedics, day care units or accident and emergency. 

• Remember that trauma is common in young children and other pathology can be missed. It is important to consider if the clinical assessment is in keeping with the trauma. If in doubt, refer. 
• The child with suspected inflammatory disease should be referred asap to paediatric rheumatology - Do not wait for the results of investigations - they may be normal anyway. 
• The presence of red flags warrants referral asap - likely general paediatrics.
• Concern about normal variants warrants referral - likely paediatric orthopaedics. 
• Pain that is not explained, limp that is not resolving, systemic upset or regression of motor milestones - all warrant referral - either general paediatrics or paediatric rheumatology. 
• Delay in walking, gait abnormalities, any suggestion of weakness, ‘coca-cola’ like coloured urine – warrants an immediate blood test for creatine kinase (CK), followed by a referral - either general paediatrics or paediatric neurology. Do not delay a CK test; if unable to do in general practice then refer the child to the local paediatric day unit for the blood test.
• Blood tests can be done in the paediatric day unit - do not traumatise the child (or yourself !) if you are not experienced in taking blood from children. 

Same day referrals are important to consider 

• Bone or joint pain or back pain and presence of red flags (fever, systemic upset, night pain, weight loss, pallor, bruising).
• Non-weight bearing / acute limp. 
• Painful scoliosis.
• Concerns about non-accidental injury.

Referral to paediatric rheumatology is warranted in the context of:

• suspicion of inflammatory disease (joint or muscle) - swollen or stiff joints, muscle pain or weakness.
• suspicion of multisystem disease (e.g., rash suggestive of vasculitis, Raynaud's, uveitis, fever of no apparent cause).
• limp that is not resolving, clumsy child, back pain, limb pain, joint pain that is not resolving. 
• school avoidance due to musculoskeletal pain. 

Referral to paediatric orthopaedics or orthopaedics is warranted in the context of:

• Suspicion of bone or joint infection.
• Limb pain that is not resolving. 
• Mechanical knee problems , 'Sport' injuries that are not resolving.
• Scoliosis, Joint or limb deformities, Painful flat feet, Bow legs or Knock knees that are not normal variants.

Referral to physiotherapy is common in children with established musculoskeletal disease. For children with rheumatic disease such as inflammatory arthritis, the management is multidisciplinary and the physiotherapist will work to optimise joint range of movement, muscle strength and function alongside medical treatments. Referral to physiotherapy is also useful with concerns about normal variants, anterior knee pain, chronic pain or functional problems (e.g., clumsy).