Direct Referral (ED to Ortho) Instructions

The patient-problems listed below may be referred directly by ED physicians for orthopaedic follow-up in University Orthopedics private offices, or the Rhode Island Hospital Orthopaedic Clinic. The ED attending physician’s judgment is important – if you think immediate consultation is in the patient’s best interest, please request orthopaedic resident evaluation. The orthopaedic resident on first call for the ED can be reached through beeper 350-1326. Work with our resident. Tell him or her your specific concerns. If you think that the attending should be involved, please let our residents know.

It is essential that information about a referred patient’s ED visit be available when he/she is seen in the orthopaedic office or clinic. It is impractical to convey this material through a phone call to the orthopaedic surgeon. It is essential that you fax the pertinent information directly to the involved office or clinic, using the attached Fax Cover Sheet for Referred Patients. Unless you do this immediately, you have not made an effective referral. X-rays and ED record will not be available for follow-up care. Not knowing the referring physician’s name or concerns, we’ll only be able to provide negative comments to the ED QA program.

We are concerned about x-ray interpretation. Quite frankly, we see too many examples of misinterpreted trauma x-rays. Therefore we urge that you validate as “undisplaced” any fracture x-ray that you believe is that. This can be done by reviewing the films with either an attending radiologist, or an orthopaedic resident or attending orthopaedic surgeon.

We expect that appropriate ED musculoskeletal care will be provided by the ED staff. Patients who cannot walk without support will be taught to use, and furnished with, crutches or walker. This will be documented in the ED record. If indicated, home PT may be prescribed to ensure safe and functional mobility. Slings, splints, knee immobilizers, walking shoes, etc. will be provided. Patients will be instructed in donning and doffing as needed. Appropriate analgesia will be prescribed as needed. (Note that oral narcotics are typically necessary to provide adequate relief of acute musculoskeletal injuries (with NSAIDs as well, if appropriate.) Patients who are unable to work should be given written documentation of this, as an excuse not to work until they have had follow-up evaluation.

While our policy has been to discourage “curb-side consults”, and to encourage orthopaedic resident involvement with the majority of ED patients with significant musculoskeletal problems, we recognize that this new approach, involving direct referral may suggest some changes. Consider discussing a case with our on-call residents or attendings.

If you decide to refer a patient directly to Orthopaedic Surgery, this should be done to the private office of the on-call orthopaedist for insured patients, or to the RIH Orthopaedic Clinic for uninsured patients.

A patient with severe, unremitting pain, impaired sensation or muscle strength, inability to move a body part, stand or walk, or with significant swelling, or with wound associated with significant local tissue injury usually deserves ED orthopaedic consultation. Please feel free to request consultation liberally for any of the following conditions if you think it is wise to do so.

Some Conditions Appropriate for Direct Orthopaedic Referral

CONDITION	Suggested Follow-up	Treatment	Caution
Neck Pain, negative x-rays, cooperative, alert, low-energy or no injury	1-2 weeks (Sooner if pain severe, any sign of neurologic abnormality)	Soft Collar; Neck Instructions	x-ray interpretation, occult instability, (? Flexion - Extension films), r/o neurologic abnormality?
Clavicle fracture	3-7 days	Sling; swath ? figure-8	Skin; N-V
Undisplaced proximal humerus fracture	1-3 days if severe pain; 4-7 if moderate	Sling & Swath	Gleno-humeral dislocation; Other Injury
Satisfactorily reduced shoulder dislocation	1-3 days if first; 4-7 if recurrent	Sling & swath	Satis reduction? Motor & Sensation
Painful elbow after injury, x-rays negative	1-3 days if severe pain; 4-7 if moderate	Sling; Consider LA Splint	Localized tenderness. ? Hemarthrosis
Olecranon bursitis, skin intact, no suspected infection	1-3; unless chronic, then 7-14	Long arm splint if significant	Aspiration, gram stain & C&S if infection concern
Wrist pain, negative x-rays	3-7; sooner if pain severe	Volar wrist splint	? snuff-box tender – if scaphoid fx is considered: thumb spica splint.
Undisplaced 2^nd – 5^th metacarpal fracture(s)	3-7 days	Intrinsic plus splint (MP’s @ 90°) involved and adjacent digits.	Skin intact?; Rotational alignment
Undisplaced finger proximal phalanx fracture	3 – 5 days	Intrinsic plus splint – forearm to finger tips	? really undisplaced
Undisplaced thumb MC or phalanx fracture, or thumb sprain	3-5 days	Thumb spica splint	? really undisplaced
Finger or thumb sprain, x-rays negative	3 – 5 days	Same as for undisplaced fractures, as above.	? really undisplaced
Finger fracture, middle or distal phalanx	3-5 days	Intrinsic plus splint (MP’s @ 90°) involved and adjacent digits.	? really undisplaced
Upper Back Pain	1-2 weeks (Sooner if pain severe, any sign of neurologic abnormality)	Analgesia, gentle stretching, rest as needed.	? Neck ? Shoulders
Lower Back Pain	1-2 weeks (Sooner if pain severe, any sign of neurologic abnormality)	Analgesia, gentle stretching, rest as needed.	? Work excuse
Suspected or proven coccygeal fracture (Or contusion)	1-2 weeks	Reassurance, cushion, analgesia, limit activity if needed	? Work excuse
Hip pain; no injury, no fracture on x-ray	1 week, or sooner if severe pain	Crutches or walker, limit activity, analgesia, ?NSAIDs	? Referred pain ? Work excuse
Thigh contusion	1 week	Stretching exercises; “RICE” crutches, analgesia
Knee injury – X-rays negative, knee stable; able to “straight-leg-raise” With or w/o effusion	1 week	Crutches, limit activity, Knee Immobilizer analgesia, “RICE” ?NSAIDs	? Aspiration if tense effusion, or if injury not convincing (for stat gram stain, C&S, cell count / diff)
Pre-patellar, or infrapatellar bursitis, without suspicion of infection	1 week	Knee Immobilizer, crutches, prn. Rest	Aspiration, gram stain & C&S if infection concern
Undisplaced fibula fracture, knee and ankle stable, NV intact,	1 week	Crutches, prn; “RICE” Analgesia	R/o compartment synd; peroneal palsy, knee or ankle ligament injury
Calf contusion; Calf muscle strain	1 week	Crutches, prn; “RICE”	Palpate Achilles; Thompson Test to r/o rupture of AT
Ankle sprain (includes minimal avulsion fractures)	1 week	Crutches, prn; “RICE”, S.L. Splint if very swollen or sore. Stirrup splint and walk, WBAT, in sneaker, if minor.	Are you sure about Dx? Is lateral collateral (primarily anterior fibulo-talar) ligament tender? Is NV OK? X-rays per Ottawa Rules.
Undisplaced lateral malleolus fracture	1 week	Short Leg Splint, crutches	R/o subtle displacement of talus laterally
Contusion of foot or ankle	1 week	Short Leg Splint; crutches	Sensation and passive toe mvt / strength ok?
Undisplaced metatarsal fractures	1 week	Short Leg Splint; crutches	Sensation and passive toe mvt / strength ok?
Toe Phalangeal Fractures	1 week	Buddy tape loosely, prn; shoe with adequate toe room (?” post-op” or cast shoe)	Confirm skin ok. Subungual hematoma to drain? Crutches, prn
Broken or wet cast	Next available office or clinic	Remove; check skin; apply equivalent splint	If Fx is fresh or possible unstable, consult ortho resident Crutches if LE.