Referral guidelines for the Paediatric Orthopaedic Physiotherapy ...

To book a hip ultrasound send a written referral to the Orthopaedic bookingoffice, St Michaels Hospital Hayle,: extn 8892 or 8830 and specify Carol Scottsbaby hip ultrasound clinic.2.1.3. Fixed/Congenital Talipes Equinovarus (CTEV)Any child with fixed talipes equinovarus should be referred urgently to thePaediatric Orthopaedic Physiotherapy team. Contact paediatric orthopaedicphysiotherapy admin, St Michaels Hospital extn 8846 Mon-Fri. A writtenreferral will also be required.The child will not always be seen by a physiotherapist on the ward but theywill be offered an outpatient appointment within 1 week. If CTEV isdiagnosed antenatally through a scan, the parents may already be known tothe Paediatric Orthopaedic Physiotherapy team. Please notify the teamwhen the child is born.Mr Parsons does not need to routinely be informed of babies with fixedtalipes or other congenital foot problems as the paediatric orthopaedicphysiotherapy team will refer on as necessary.2.1.4. Obstetric Brachial Plexus PalsyA child presenting with a brachial plexus palsy should be referred urgently tothe Paediatric Orthopaedic Physiotherapy team. Contact orthopaedicpaediatric physiotherapy admin, St Michaels Hospital extn 8846. A writtenreferral will also be required. The child will not always be seen by aphysiotherapist on the ward but they will be offered an outpatientappointment within 1 week. An X-ray of clavicles is required to excludefractures.Upper limb Consultant Orthopaedic Surgeon RCHT does not need toroutinely be informed of new babies with Obstetric Brachial Plexus Palsy asthe Paediatric Orthopaedic Physiotherapy team will refer on as necessary.2.1.5. Upper Limb AbnormalitiesReferral to Consultant Orthopaedic Surgeon via referral managementservice2.1.6. Lower Limb DeficienciesRefer directly to Dr Rachel Bottell, Disablement Services Centre, DerrifordHospital, Tel 0845 155 80732.1.7. Positional Deformities of the feetFor a child who presents with positional deformities e.g. Positional talipesequinovarus, calcaneovalgus, metatarsus adductus, Make a written referralto the Paediatric Orthopaedic Physiotherapy team via Referral ManagementService2.1.8. PlagiocephalyRefer as soon as identified to the Paediatric Orthopaedic PhysiotherapyTeam via Referral Management Service2.1.9. TorticollisRefer as soon as identified to the Paediatric Orthopaedic PhysiotherapyTeam via Referral Management Service.Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 2 of 14

2.2.1. Curly Toes /Overlapping Toes“Curly toes” are common in infancy and characterised by flexion andexternal rotation of the lesser toes. Most will resolve spontaneously and areasymptomatic 2 . There is no evidence that physiotherapy can be used totreat curly toes.Asymptomatic curly toesPain, redness, callous formation,difficulty finding footwear.5 th toe overriding 4 th toes and difficultywith footwearNo treatment requiredDiscuss referral with PCH-CICPodiatry departmentRefer to Ben Holroyd or JamesMetcalfe Consultant OrthopaedicSurgeons via Referral ManagementService2.2.2. Genu varum / Genu valgumBefore the age of two, most children will have slight symmetrical bowing ofthe knees and ankles when they stand. Between the ages of two and four,children may develop genu valgum and a standing inter-malleolar distanceof approximately 6 centimeters is considered normal. Genu valgum normallycorrects itself and approximately the age of 6 3 .Asymmetrical genu varum / genuvalgumConcerns regarding excessive genuvarum / genu valgumRefer to Paediatric OrthopaedicConsultant via ReferralManagement ServiceRefer to Paediatric OrthopaedicConsultant Team via ReferralManagement Service2.2.3. OuttoeingAssess the child once walking is well established eg .walkingindependently for 6 monthsAsymptomatic symmetrical outtoeing can be a normal variant caused byeither external tibial torsion, proximal femoral retroversion or a combinationof the two. Outtoeing may be symptomatic or asymptomatic. There are anumber of differential diagnoses that may present with an outtoeing gait (egPerthes, DDH, Slipped upper femoral epiphysis).Sudden onset out toeing followingtrauma (sometimes low level)Asymmetrical out toeingSymmetrical out toeing associatedwith pain in hips, knees or feetSymmetrical out toeingAsymptomaticRefer to A/ERefer to Orthopaedic Consultant viaReferral Management ServiceRefer to paediatric Orthopaedicphysiotherapy team RCHT viaReferral Management ServiceReferral not required.Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 4 of 14

2.2.4. IntoeingAssess the child once walking is well established eg .walkingindependently for 6 monthsIntoeing may be due to metatarsus adductus, internal tibial torsion orfemoral anteversion. Children with metatarsus adductus should be referredto the paediatric Orthopaedic physiotherapy team (See table below)Internal tibial torsion is a normal variant up to 7 years of age 4 and may besymmetrical or asymmetrical. Femoral anteversion is a normal variant up to10 years of age 4 and is generally symmetrical.Physiotherapy is not indicated for asymptomatic normal variants and cannotprevent the tripping often associated with intoeing. However there is oftenparental concern therefore a leaflet titled “Intoeing Gait” is available via alink on the referral management system. The Plymouth PaediatricOrthopaedic Consultant team have also produced a section on their website(www.pposw.com or www.pposw.co.uk) - regarding normal variants and aleaflet on their links section.If as a health practitioner you remain concerned please telephone thePaediatric Orthopaedic Physiotherapy Team to discuss if referral isappropriate. Tel 01872 253824 or contact the Orthopaedic PhysiotherapyAdmin Team if no answer (01736 758846)Curved lateral border of the foot(Assess by holding a pen/pencil alongthe lateral border)Curved Lateral Border of the footindicates Metatarsus adductus.Refer to the paediatric Orthopaedicphysiotherapy Team RCHT viaReferral Management ServiceAsymptomatic intoeing with straightlateral border of the foot andsymmetrical hip range of movementAsymmetrical hip rotation orabductionIntoeing associated with foot ,knee orhip painNo treatment required.Parents can be issued with the adviceleaflet “Intoeing Gait” available via thelink on the referral managementsystemRefer to Consultant OrthopaedicSurgeon via Referral ManagementServiceRefer to paediatric OrthopaedicPhysiotherapy Team via RMSReferral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 5 of 14

2.2.5. Tip toe walkingMany children will tiptoe walk when first starting to weight bear and firststarting to walk. Persistent tiptoe walking, once walking is fully established,may be a symptom of a neurological disorder or may be associated withtight tendo achilles.Assess the child once walking is well established eg .walkingindependently for 6 monthsAbnormal lower limb neurologyTightness of Tendo Achilles / limitedankle dorsiflexion with normalneurologyNormal NeurologyRefer to Consultant PaediatricianRCHTRefer to Paediatric OrthopaedicPhysiotherapy Team via ReferralManagement ServiceRefer to the Paediatric OrthopaedicPhysiotherapy Team via ReferralManagement Service2.2.6. Back PainThere is an increased likelihood of serious pathology in the under-20 yearage group.There are a number of red flags specific to paediatric back pain 5Specific Red Flags in Paediatric PopulationHistoryPre-pubertal children especially4 weeksRecurrent or worsening painEarly morning stiffness and/orgellingNight painFever, weight loss, malaisePostural changes: kyphosis orscoliosisExaminationFever, tachycardiaWeight loss, bruisinglymphadenopathy or abdominal massAltered spine shape or mobilityVertebral or intervertebral tendernessLimp or altered gaitNeurologic symptomsChildren presenting with these red flags should be referred to the AcutePaediatrician Team, Level 4, Tower Block, Treliske Hospital.(See RCHT Care Pathway for the Physiotherapy Management of PaediatricBack Pain)The Paediatric Orthopaedic Physiotherapy team accepts referrals forpaediatric back pain with the absence of red flags under the age of 10years. Children over 10 years of age with the absence of red flags should bereferred to the local musculoskeletal outpatient physiotherapy department.2.3. A summary of these referral guidelines is at Appendix 1Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 6 of 14

3. Monitoring compliance and effectivenessElement to bemonitoredLeadToolFrequencyReportingarrangementsActing onrecommendationsand Lead(s)Change inpractice andlessons to besharedAppropriateness of referrals received by the multi-disciplinarypaediatric orthopaedic teamClinical Leads, Paediatric Orthopaedic Physiotherapy ServiceCompare each referral received with this guidanceEach referral received will be monitoredProforma response to be sent to referrer detailing reasons forreturn of referralTherapy Manager (Outpatients) to address persistent nonconformance(if identified) with the appropriate line managersRequired changes to practice will be identified and actioned withinone month. A lead member of the team will be identified to takeeach change forward where appropriate. Lessons will be sharedwith all the relevant stakeholders4. Equality and Diversity4.2. This document complies with the Royal Cornwall Hospitals NHS Trustservice Equality and Diversity statement.4.3. Equality Impact AssessmentThe Initial Equality Impact Assessment Screening Form is at Appendix 1.Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 7 of 14

Appendix 1. Summary of Referral GuidelinesFlat FeetAble to easily (and bilaterally) go up ontotiptoes (age appropriate)Arch present on tip toeNo tightness on ankle dorsiflexionNormal neurologyNo painful symptomsNo poor function, eg tripping / fallingAbsence of associated syndromeseg.Downs, Marfans, Ehlos Danlos ,hypermobility syndromeAbnormal neurologyArch not present on tip toeAsymmetrical flat footSignificant pain affecting activities of dailylivingTightness on ankle dorsiflexionDifficulty rising onto tip toesMarked tripping / fallingPain in knees or hipsPainful feet in child under 5 years of ageIf child 6 years of age and older and any offollowing:Pain in feet / anklesSkin pressure lesions of feet / anklesExcessive medial shoe wear causing poorfunctionCurly ToesAsymptomatic curly toesPain, redness, callous formation, difficultyfinding footwear.5th toe overlapping 4th toes and difficultywith footwearIn-toeingCurved lateral border of the foot(Assess by holding a pen/pencil along thelateral border)Asymmetrical hip rotation or abduction withthe hip at 90 degrees flexionIntoeing associated with foot ,knee or hippainNo treatment required. Referral tophysiotherapy or podiatry is not appropriate.Consider issuing advice leaflet “flat feet inyoung children” available from the link onthe referral management website.Refer to Consultant Paediatricians RCHTRefer to Consultant Orthopaedic Surgeonvia Referral Management ServiceRefer to Paediatric OrthopaedicPhysiotherapist RCHT via ReferralManagement ServiceRefer to the Podiatry DepartmentPCH-CICNo treatment requiredDiscuss referral with PCH-CIC PodiatrydepartmentRefer to Consultant Orthopaedic Surgeonvia Referral Management ServiceCurved Lateral Border of the foot indicatesMetatarsus adductus.Refer to the paediatric Orthopaedicphysiotherapy Team RCHT via ReferralManagement ServiceRefer to Consultant Paediatric OrthopaedicSurgeon via Referral ManagementServiceRefer to Paediatric OrthopaedicPhysiotherapy Team via ReferralManagement ServiceReferral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 8 of 14

Out toeingAsymmetrical out toeingSymmetrical out toeing associated with painin hips, knees or feetNormal NeurologyTip-toe WalkingAbnormal lower limb neurologyTightness of Tendo Achilles / limited ankledorsiflexion with normal neurologyNormal NeurologyBack PainPaediatric Specific Red flags presentAbsence of red flags(Age under 10 years)Absence of red flags(Age over 10 years)Refer to Paediatric Orthopaedic Consultantvia Referral Management ServiceRefer to paediatric Orthopaedicphysiotherapy team via ReferralManagement ServiceRefer to the Paediatric OrthopaedicPhysiotherapy Team via ReferralManagement ServiceRefer to the Consultant PaediatriciansRCHTRefer to Paediatric OrthopaedicPhysiotherapy Team via ReferralManagement ServiceRefer to the Paediatric OrthopaedicPhysiotherapy Team via ReferralManagement ServiceRefer to Acute Consultant PaediatriciansRCHTRefer to Paediatric OrthopaedicPhysiotherapy Team via ReferralManagement ServiceRefer to Local Musculoskeletal OutpatientPhysiotherapy DepartmentSpecific Red Flags in Paediatric Population 5HistoryPre-pubertal children especially4 weeksRecurrent or worsening painEarly morning stiffness and/orgellingNight painFever, weight loss, malaisePostural changes: kyphosis orscoliosisExaminationFever, tachycardiaWeight loss, bruisinglymphadenopathy or abdominal massAltered spine shape or mobilityVertebral or intervertebral tendernessLimp or altered gaitNeurologic symptomsReferral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 9 of 14

Appendix 2. Governance InformationDocument TitleDate Issued/Approved: 8 August 2013Referral guidelines for the PaediatricOrthopaedic Physiotherapy ServiceDate Valid From: 8 August 2013Date Valid To: 1 August 2016Directorate / Department responsible(author/owner):Sarah Harvey and Rachel Hancock, ClinicalLead PhysiotherapistContact details: 01736 758846Brief summary of contentsGuidance for those wishing to refer to thePaediatric Orthopaedic PhysiotherapyServiceSuggested Keywords:Target AudienceExecutive Director responsible forPolicy:Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 10 of 14Paediatric orthopaedics, intoeing, outtoeing,flexible flat feet, normal variants, genuvarum, genu valgumRCHT PCH CFT KCCGMedical DirectorDate revised: 1 August 2013This document replaces (exact title ofprevious version):Approval route (names ofcommittees)/consultation:Divisional Manager confirmingapproval processesName and Post Title of additionalsignatoriesSignature of Executive Director givingapprovalPublication Location (refer to Policyon Policies – Approvals andRatification):Document Library Folder/Sub FolderReferral guidelines for the PaediatricOrthopaedic Physiotherapy ServiceAHP Therapies Clinical Governance ForumPaediatric Orthopaedics Consultants atRCHT and Plymouth Hospitals NHS Trust(Derriford)Consultant Paediatricians RCHTPodiatry Department PCH-CICBruce Daniel, Interim Divisional ManagerD&TSally Rowe, Divisional Director D&TNot Applicable{Original Copy Signed}Internet & IntranetClinical / Physiotherapy Intranet Only

Links to key external standardsRelated Documents:Training Need Identified?National Service Framework for Children,Young People & Maternity ServicesCare Quality Commission Outcome 4 – Care& Welfare of People who use serviceso Guidelines for the referral of PaediatricBack Pain to the Physiotherapy Serviceo Association of Paediatric CharteredPhysiotherapists (APCP) Guide toGood Practice for PhysiotherapistsWorking with Childreno APCP Advice Publications – “Flat Feetin Young Children” and “Intoeing Gait”(June 2011)o Department of Health publication - Birthto Five (2009) – Chapter 4 “How YourChild will Grow”o See also Reference List at Appendix 3NoVersion Control TableDateVersionNoSummary of ChangesChanges Made by(Name and Job Title)20 Oct 11 V1.0 Initial Issue14 Oct 12 V2.0Alteration of Consultant names to genericOrthopaedic consultant. Alteration of referralpathway to paediatric orthopaedicphysiotherapy (now via Referral ManagementService).Addition re routine hip scans.Alteration to curly toes 5th overlapping 4th.Addition to outoeing referral criteria re traumaInsertion of picture of lateral border of footUnder intoeing sectionSarah HarveyAll or part of this document can be released under the Freedom of InformationAct 2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 11 of 14

Appendix 3.Initial Equality Impact Assessment Screening FormName of service, strategy, guideline, policy or project (hereafter referred to as policy)to be assessed: Referral guidelines for the Paediatric Orthopaedic PhysiotherapyServiceDirectorate and service area: Diagnostics Is this a new or existing Procedure? New& Therapeutics Division, AHP Therapies,PhysiotherapyName of individual completingTelephone: 01872 253824assessment: Sarah Harvey1. Procedure Aim* Minimise inappropriate referrals to the PaediatricOrthopaedic Physiotherapy Service2. Procedure Objectives* Ensure patients are seen by the most appropriate clinicalservice3. Procedure – intended Reduced incidence of inappropriate referralsOutcomes*4. How will you measure Analysis of referrals receivedthe outcome?5. Who is intended to Paediatric orthopaedic patientsbenefit from theProcedure?6a. Is consultationrequired with theworkforce, equalitygroups etc. around thisprocedure?b. If yes, have thesegroups been consulted?c. Please list any groupswho have been consultedabout this procedure.No*Please see Glossary7. The ImpactPlease complete the following table using ticks. You should refer to the EA guidance notesfor areas of possible impact and also the Glossary if needed.Where you think that the policy could have a positive impact on any of the equalitygroup(s) like promoting equality and equal opportunities or improving relationswithin equality groups, tick the ‘Positive impact’ box.Where you think that the policy could have a negative impact on any of the equalitygroup(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.Where you think that the policy has no impact on any of the equality group(s) listedbelow i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 12 of 14

Equality Positive Negative No Reasons for decisionGroup Impact Impact ImpactAge Improved care for paediatricpatientsDisabilityReligion orbeliefGenderTransgenderPregnancy/MaternityRaceSexualOrientationMarriage / CivilPartnershipYou will need to continue to a full Equality Impact Assessment if the following havebeen highlighted:A negative impact andNo consultation (this excludes any policies which have been identified as notrequiring consultation).8. If there is no evidence that the policypromotes equality, equal opportunitiesor improved relations - could it beadapted so that it does? How?Full statement of commitment to policy ofequal opportunities is included in the policyPlease sign and date this form.Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, ChyveanHouse, Penventinnie Lane, Truro, Cornwall, TR1 3LJA summary of the results will be published on the Trust’s web site.Signed ________________________________________Date _________________________________________Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 13 of 14

Appendix 4. References1 Cappello T, Song KM (1998) ‘Determining treatment of flat feet in children’, CurrentOpinion in Pediatrics, vol 10, pp 77-812 Staheli L (1989) Fundamentals of Pediatric Orthopaedics, 3 rd Edition, London: LippincottWilliams & Wilkins3 Fabry G, Cheng LX, Molenaers G (1994) ‘Normal and Abnormal Torsional Developmentin Children’, Clinical Orthopaedics and Related Research, Number 302, pp 22-264 Staheli L (1983) ‘Intoeing and Outtoeing in Children’, The Journal of Family Practice, Vol16, no 5, pp 1005-10115 Davis PJC, Williams HJ (2008) ‘The investigation and management of back pain inchildren’, Arch Dis Child Educ Pract Ed, vol 93, pp 73-83Referral guidelines for the Paediatric Orthopaedic Physiotherapy ServicePage 14 of 14