​If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergency medical advice via phone to on-call consultant/registrar.

This emergency criteria are not an exhaustive list of orthopaedic emergencies. Health professionals should refer to HealthPathways for more information.

On this page

  1. Adult patients (aged 16 years or over)
    1. Ankle or foot injury (acute)
    2. Ankle or foot osteoarthritis
    3. Back pain
    4. Hip osteoarthritis
    5. Knee osteoarthritis
    6. Knee pain (acute)
    7. Scoliosis or kyphosis
    8. Shoulder instability
    9. Shoulder pain
    10. Wrist or hand osteoarthritis
    11. Wrist or hand pain
    12. Non-condition specific
  2. Paediatric patients (aged 0 to 15 years)
    1. Back pain
    2. Baker’s cyst
    3. Bow legs
    4. Club foot
    5. Curly toes
    6. Developmental hip dysplasia
    7. Flat feet
    8. In-toeing
    9. Knee injury
    10. Knock knees
    11. Limp
    12. Metatarsus adductus
    13. Out-toeing
    14. Perthes disease
    15. Scoliosis or kyphosis
    16. Slipped upper femoral epiphysis
    17. Toe walking
    18. Non-condition specific

Adult patients (aged 16 years or over)

Ankle or foot injury (acute)

  • Dislocations.
  • Displaced ankle, midfoot, Lisfranc or hindfoot fracture (particularly talar and calcaneal fractures).
  • Nail bed trauma (subungual haematoma associated with distal phalanx fractures).
  • Open injuries with exposed tendons or bones/joints.
  • Septic arthritis.
  • Suspected neurovascular compromise or compartment syndrome.
  • Syndesmosis injuries.
  • Tendon ruptures.

Ankle or foot osteoarthritis

  • Pain following trauma where fracture is suspected.
  • Suspected acute bone or joint infection.
    Note: do not commence antibiotics until reviewed by specialist medical officer – contact on-call registrar to discuss clinical concerns.
  • Suspected acute Charcot foot (where a High Risk Foot Service is not available) characterised by clinical signs of unilateral inflammation (redness, heat, swelling) present in the neuropathic foot, palpable pedal pulses, pain may be present despite neuropathy, no evidence of trauma, injury or ulcer to support infection.

Back pain

  • Atypical spinal pain with concern for vascular compromise or urgent non-musculoskeletal source of pain (for example ruptured or dissecting abdominal aortic aneurysm or other visceral pathology).
  • Spinal trauma or fracture.
  • Sudden, progressive neurological signs or symptoms, including any of the following:
    • suspected Cauda equina syndrome (for example acute loss of bladder or bowel function due to suspected disc prolapse)
    • myelopathy in upper or lower extremities (for example heavy or weak legs and sudden change in gait, spasticity legs, hyperreflexia including upper motor neurone signs, weakness or clumsiness of hands)
    • rapidly progressive spinal nerve root compression (for example foot drop).
  • Suspected spinal infection (for example osteomyelitis, discitis, epidural abscess).

Hip osteoarthritis

  • Fever (≥38°C), systemic symptoms and painful hip.
  • Pain following trauma where fracture is suspected.
  • Rapidly worsening symptoms.
  • Sudden onset acute pain that is not improved by rest and/or pain so severe that weight bearing is not possible.
    Note: consideration to be made to osteonecrosis, metastatic cancer, septic arthritis or fracture.

Knee osteoarthritis

  • Fever (≥38°C), systemic symptoms and painful swollen knee.
  • Pain following trauma where fracture is suspected.
  • Rapidly worsening symptoms.
  • Sudden onset acute pain that is not improved by rest and/or pain so severe that weight bearing is not possible.
    Note: consideration to be made to osteonecrosis, metastatic cancer, septic arthritis or fracture.
  • Unable to differentiate an acute swollen knee from infection with serious pain.

Knee pain (acute)

  • Acute, multiple ligament knee injury (Grade 3 – complete) with uncontrolled pain and compromised mobility.
  • Acute, post-surgical complications (for example bleeding, infection, wound breakdown).
  • Acute onset painful atraumatic knee effusion or haemarthrosis.
  • Ruptured or severed tendons.
  • Suspected acute bone or joint infection.
    Note: do not commence antibiotics until reviewed by specialist medical officer. Contact on-call registrar to discuss clinical concerns.
  • Suspected fracture or dislocation.

Scoliosis or kyphosis

  • Malignancy with signs of spinal cord compression.
  • New onset spinal pain or rapidly progressive neurological deficit (including bowel or bladder dysfunction).
  • Recent trauma with exacerbated symptoms of spinal pain or neurological change.
  • Signs of infection in the presence of scoliotic or kyphotic deformity (for example high C-reactive protein, fever, malaise, sepsis).

Shoulder instability

  • Acute traumatic shoulder dislocations, including unreduced or locked dislocations, and shoulder dislocations or pain following seizures or electrocution.
  • Atypical shoulder pain that may be associated with chest pain or shortness of breath or stridor that could indicate cardiac or respiratory cause.
  • Displaced or unstable fractures that cannot be managed in primary care.
  • Signs of septic arthritis (local inflammation, pain, fever, and systemically unwell).
  • Signs of vascular injury or compromise.
  • Unexplained mass or swelling.

Shoulder pain

  • Acute traumatic shoulder dislocations, including unreduced or locked dislocations, and shoulder dislocations or pain following seizures or electrocution.
  • Atypical shoulder pain that may be associated with chest pain or shortness of breath or stridor that could indicate cardiac or respiratory cause.
  • Fractures that cannot be managed in primary care.
  • Signs of septic arthritis (local inflammation, pain, fever, and systemically unwell).
  • Signs of vascular injury or compromise.
  • Sudden onset significant motor or sensory deficit in upper limb.
  • Unexplained mass or swelling.

Wrist or hand osteoarthritis

Acute wrist trauma.

Wrist or hand pain

  • Acute wrist trauma.
  • Septic arthritis of wrist or hand joints (suspected or confirmed).

Non-condition specific

  • Acute back or neck pain secondary to neoplastic disease or infection.
  • Acute cervical myelopathy.
  • Acute development of peripheral nerve compression symptoms following trauma or acute event.
  • Acute ligament rupture.
  • Acute nerve injury.
  • Acute onset painful atraumatic knee effusion or haemarthrosis.
  • Compound ‘tooth knuckle’ injury.
  • Crush injuries and suspected compartment syndrome (extreme pain with neurovascular compromise).
  • Evidence of acute inflammation (for example haemarthrosis, tense effusion).
  • Nail bed injuries or trauma (subungual haematoma associated with distal phalanx fractures).
  • Open injuries with exposed tendons, bones or joints.
  • Retained foreign body.
  • Ruptured or severed tendons.
  • Significant lacerations.
  • Signs of vascular injury or compromise.
  • Sudden onset acute pain that is not improved by rest and/or pain so severe that weight bearing is not possible.
    Note:     consideration to be made to osteonecrosis, metastatic cancer, septic arthritis or fracture.
  • Suspected acute bone or joint infection.
    Note: do not commence antibiotics until reviewed by specialist medical officer, contact on-call registrar to discuss clinical concerns.
  • Suspected infection or sudden pain in arthroplasty.
    Note: if joint infection is suspected refer immediately to emergency or contact the orthopaedic registrar on call.  Do not commence antibiotics unless delay to specialist review is likely.
  • Suspected neurovascular compromise or compartment syndrome.
  • Suspected or known fractures with displacement or deformity requiring diagnosis, opinion or surgical treatment.
  • Suspected or known joint dislocations unreduced or with neurovascular compromise requiring diagnosis, opinion or surgical treatment.
  • Suspected or known septic arthritis or osteomyelitis.
  • Syndesmosis injuries.
  • Uncontrolled sepsis including hand infections.
  • Upper limb radiculopathy in the presence of suspected cervical spine infection.

Paediatric patients (aged 0 to 15 years)

Back pain

  • Back pain with any of the following red flags:
    • acute onset (< 6 weeks)
    • bowel or bladder dysfunction
    • fever
    • neurological deficit
    • severe pain
    • trauma.

Baker’s cyst

Febrile or systemically unwell.

Bow legs

  • Abnormal calcium levels.
  • Fracture.

Club foot

Nil emergency criteria.

Curly toes

Nil emergency criteria.

Developmental hip dysplasia

Suspected septic arthritis of the hip.

Flat feet

Nil emergency criteria.

In-toeing

  • Acute joint pain with restricted range of motion.
  • Acute onset limp with signs of being unwell, fever, joint irritability, not weight bearing and/or not improving.
  • Suspected fracture.
  • Suspected septic arthritis.

Knee injury

  • Acute patella dislocation or unreduced subluxation.
  • Fracture.
  • Haemarthrosis.
  • Lacerations or penetrating wound into the knee requiring acute management.
  • Locked knee.
  • Neurovascular injury.
  • Suspected patella or quadriceps tendon rupture.
  • Systemically unwell.

Knock knees

Suspected fracture.

Limp

  • Acute onset limp with signs of being unwell, fever, joint irritability, not weight bearing and/or not improving.
  • New diagnosis of Slipped Upper Femoral Epiphysis (SUFE).
  • Suspected bony or limb soft tissue malignancy.
  • Suspected fracture.
  • Suspected septic arthritis or osteomyelitis.
  • Suspected non-accidental injury.

Metatarsus adductus

Nil em​ergency criteria.

Out-toeing

  • New diagnosis of Slipped Upper Femoral Epiphysis (SUFE).
  • Suspected fracture.
    Note: Pelvic x-rays: anterior to posterior (AP) and frog leg lateral views) are required for all children aged > 10 years presenting with out-toeing.

Perthes disease

  • Acute hip joint pain with restricted range of motion.
  • Acute onset limp with signs of being unwell, fever, joint irritability, not weight bearing and/or not improving.
  • Suspected septic arthritis or osteomyelitis.

Scoliosis or kyphosis

  • Acute breathlessness in the context of bony thoracic trauma.
  • Back pain with any of the following red flags:
    • acute onset (< 6 weeks)
    • bowel or bladder dysfunction
    • fever
    • neurological deficit
    • severe pain
    • trauma.
  • Scoliosis or kyphosis associated with orthopaedic trauma.
  • Scoliosis or kyphosis with abnormal neurological exam.

Slipped upper femoral epiphysis

New diagnosis of Slipped Upper Femoral Epiphysis (SUFE).

Note: all patients with SUFE require referral to the emergency department or direct contact with the local orthopaedic service. Patient should be advised to be non-weight bearing – using crutches (where practical) or a wheelchair, even when mild or stable due to the risk of progression. If completely unable to weight bear, urgent transfer by ambulance is required.

Toe walking

Nil emergency criteria.

Non-condition specific

  • Abnormal neurological exam in the context of orthopaedic trauma, limb neurology or injury with neurovascular compromise.
  • Acute joint pain with restricted range of motion.
  • Lacerations or penetrating wound requiring acute management.
    Note: in children, a higher index of suspicion for underlying neurovascular and tendinous injury.
  • Suspected bony or limb soft tissue malignancy.
  • Suspected fractures or dislocations with displacement or deformity.
  • Suspected ligament or tendon rupture.
  • Suspected non-accidental injury.
  • Suspected septic arthritis or osteomyelitis.

Current as at: Monday 17 June 2024
Contact page owner: System Purchasing