Joint Pain

Emergency department referrals

If any of the following are present or suspected, refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

Acute joint pain with fever*
Acute joint pain unable to weight bear*.
Lower limb joint pain persistently unable to weight bear
Joint pain in a child from a population at high risk of acute rheumatic fever*

Does your patient wish to be referred?

Minimum referral criteria

Does your patient meet the minimum referral criteria?

Category 1

Appointment within 30 days is desirable

Suspected hip dysplasia in an infant <6 months
History of joint pain without current arthritis where ARF is considered as a possible diagnosis (if current see as emergency)
Evidence of synovitis, arthritis or joint erosion on imaging
Joint pain with elevated inflammatory markers that are otherwise unexplained
Joint pain accompanied by symptoms or history of other inflammatory disease, eg inflammatory bowel disease, uveitis, new rashes, etc
Joint deformity / loss of range of movement
A child currently in out of home care (OOHC) or at risk of entering or leaving OOHC, where they have previously been on a waiting list for this problem and were removed without receiving a service

Category 2

Appointment within 90 days is desirable

Undiagnosed cause of joint or musculoskeletal pain that is not listed in Category 1
Children with hip pain following orthopaedic consultation and excluding orthopaedic conditions

Category 3

Appointment within 365 days is desirable

Known chronic musculoskeletal condition that is unlikely to deteriorate

If your patient does not meet the minimum referral criteria

Consider other treatment pathways or an alternative diagnosis.

If you still need to refer your patient:

Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
Please note that your referral may not be accepted or may be redirected to another service

Other important information for referring practitioners

Not an exhaustive list

Refer to local Healthpathways or local guidelines
Children with hip pain and potential orthopaedic diagnosis (e.g. perthe’s disease, slipped epiphysis, hip dysplasia and others) should be referred directly to orthopaedics/local pathways
Focal bony lesions are unusual in rheumatology and referral to other specialities should be considered
In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment
Clinical urgency is the dominant consideration in the prioritisation of a referral for a child currently in out of home care (OOHC), or at risk of entering or leaving OOHC.

Referral requirements

A referral may be rejected without the following information.

Essential referral information

History of joint symptoms. Note duration, joints or regions involved
Report presence or absence of concerning features
- Persistent fevers
- Weight loss (how much?)
- Rash
- Diarrhoea or bloody stools
- Abdominal pain
- Focal neurological signs
- Muscle wasting
- Recent visual symptoms e.g. photophobia, erythema, blurring
Confirmation of OOHC (where appropriate)

Additional referral information (useful for processing the referral)

Highly desirable Information – may change triage category

Detailed history of joint pain – diurnal or day to day variation, exercise symptoms
Family history of joint problems or inflammatory bowel disease
Recent respiratory or skin infections or systemic viral illness
Physical examination including heart sounds if rheumatic fever or post streptococcal arthritis considered
Burden of disease; school missed, ability to participate in usual activities, dependency for activities of daily living/hygiene/dressing
Joint examination findings – swelling, range of motion, erythema, heat

Desirable information — will assist at consultation

Other past medical history
Immunisation history
Developmental history
Medication history
Significant psychosocial risk factors (especially parents mental health, family violence, housing and financial stress, Department of Children, Youth Justice and Multicultural Affairs involvement)
Height/weight/head circumference and growth charts with prior measurements if available.
Other physical examination findings inclusive of CNS, birth marks or dysmorphology
Investigations as appropriate to clinical presentation:
- consider XR of hips or knees if involved
- consider FBC ESR ELFT
- consider rheumatologic and serological investigations for autoimmune or post infectious causes if appropriate. These investigations are not required for categorisation

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

Clinical Modifiers (where relevant)

Impact on employment
Impact on education
Impact on home
Impact on activities of daily living
Impact on ability to care for others
Impact on personal frailty or safety
Identifies as Aboriginal and/or Torres Strait Islander

Reason for Referral (essential)

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can’t order, or the patient can’t afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Clinical Information (essential)

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use