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Upper Limb Glos Care Pathway Overview

MSK Specialist Triage commenced in July 2018. All upper limb triage referrals for Orthopaedic review across Gloucestershire are divided between Gloucester Care Services (GCS) and Gloucestershire NHS Foundation Trust (GHNHSFT). GHNHSFT triage patients within the Gloucester and Cheltenham localities, and GCS triage the five other localities. The two organisations work closely together to ensure consistency and standardisation of approach.

Please strongly consider Supported Self-Management

Please click the relevant flowchart box to be taken directly to textual information

            

Red Flags

Screen to exclude traumatic injury/ fracture, infection, neurovascular, inflammatory arthropathy, cancer. 

Key clinical observations of concern:
  • Hot / red / swollen joint with raised body temperature
  • Rapidly worsening deformity
  • Neuro-vascular compromise
If the patient is still under consultant care post-operatively any issues relating to post-operative recovery should be referred back to the consultant.
If suspected tumour - refer via 2ww
If suspected acute infection - refer to A&E
If suspected fracture, dislocation, acute traumatic rotator cuff tear or significant acute soft tissue injury - Refer to A&E or the Trauma Triage Service
Clinical evidence of recent denervation with persistent altered sensation, sudden progression of symptoms and risk of permanent irreversible nerve damage - Refer for urgent specialist opinion via MSK Triage MSK Referral form
Suspected new diagnosis of inflammatory arthritis - refer to Rheumatology
Significant likelihood of peripheral vascular disease or occlusion - refer to Vascular surgery
Differential Diagnosis

Please do not refer to the MSK Specialist Triage (APS and Orthopaedics) Service for the following:

Exclude

Action to take

Suspected fracture or acute traumatic injury

Refer to A&E or the Trauma Triage Service

Suspected new diagnosis of inflammatory arthritis

Refer to Rheumatology

Supported Self-Management

Many patients with upper limb problems can, with advice and guidance, manage their problems without additional support. Please see the Individual Conditions for specific guidance.

See the Core Physiotherapy Services section below for patient self-referral information, printable posters and business cards.

When to do Investigations

  • X-ray if suspicious of trauma, infection or tumour.
  • If osteoarthritis suspected: AP & Lateral X-ray to confirm diagnosis especially if history is suggestive of loose bodies causing internal derangement.
  • For undiagnosed lump / sarcoma: x-ray required.

  • X-ray if suspicious of trauma, infection, tumour or Arthritis with radial sided wrist pain.
  • For ganglion: imaging not usually required.
  • For undiagnosed lump / sarcoma: x-ray required.
  • Nerve conduction studies rarely required as often clinical diagnosis can be made without. However may be useful for unconfirmed symptoms.

  • X-ray if suspicious of trauma, infection, tumour or OA.
  • Nerve conduction studies rarely required as often clinical diagnosis can be made without. However may be useful for unconfirmed symptoms.
  • For ganglion: imaging not usually required.
  • For undiagnosed lump / sarcoma: x-ray required.

  • X-ray if suspicious of:
    • Trauma
    • Arthritis
    • Tumour
    • calcific tendinitis
    • infection
    • Avascular necrosis (AVN)
  • Ultrasound for traumatic rotator cuff suspected tears in patients under 40 years
  • U/S and MRI not routinely indicated.
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