Triaging children and adolescents with musculoskeletal symptoms by their clinical findings

Triaging children and adolescents with musculoskeletal conditions—a referral guide for general practitioners offers general practitioners a guide to triaging children and adolescents by conditions that:

are suitable for management in the primary care setting
may require referral to a specialist
warrant urgent management in hospital.

This assumes the general practitioner has performed an initial assessment and has a potential diagnosis (or some differential diagnoses) in mind.

Table 1. Triaging children and adolescents with musculoskeletal conditions—a referral guide for general practitioners
[NB1]
Conditions that warrant urgent management in hospital [NB2]	Conditions that require specialist referral [NB3]	Conditions suitable for management in primary care
mechanical and trauma-related conditions
nonaccidental injury fracture with associated complications (eg open fracture, associated neurovascular compromise)	complete ligament tear more complex fracture (eg with angulation or displacement, or involving the growth plate [ie physeal injuries])	ligament sprain muscle strain simple fracture, avulsion fracture nonspecific back pain
nocturnal limb pain with strong suspicion of malignancy (systemically unwell)	nocturnal limb pain with some suspicion of malignancy (not systemically unwell)	benign nocturnal limb pain [NB4]
		postactivity muscular pain
hip-joint pain [NB5]
osteonecrosis (eg Perthes disease) slipped upper femoral epiphysis	acute chondrolysis of the hip developmental dysplasia of the hip	irritable hip (transient synovitis of the hip)
overuse-related trauma
	osteochondritis dissecans femoroacetabular impingement syndrome bone and physeal stress injuries	knee overuse (eg patellofemoral pain syndrome, patellar tendinopathy, infrapatellar fat pad irritation) traction apophysitis, including Osgood-Schlatter disease (of the tibial tuberosity) or Sever disease (of the heel) hypermobility-associated pain [NB6]
amplified pain syndromes (AMPS)
	diffuse AMPS localised AMPS (complex regional pain syndrome)	diffuse AMPS localised AMPS (complex regional pain syndrome)
inflammatory musculoskeletal conditions [NB7]
septic arthritis acute rheumatic fever with heart failure any patient who is systemically unwell (eg fever, pallor, severe pain, abnormal vital signs, impaired organ function) and has clinical features suggesting a systemic inflammatory disease	acute rheumatic fever without heart failure osteomyelitis clinical features suggesting systemic inflammatory disease in someone who is not systemically unwell, including: all types of juvenile idiopathic arthritis (JIA) juvenile dermatomyositis systemic lupus erythematosus in children and adolescents immunoglobulin A vasculitis Kawasaki disease autoinflammatory periodic fever syndromes	viral arthritis reactive arthritis—postinfectious, including: postviral following a urinary tract infection, sexually transmitted infection or gastrointestinal tract infection
Note: NB1: This list is not exhaustive. NB2: See Serious musculoskeletal conditions to exclude and their alerting features (‘red flags’) in children and adolescents that offers general practitioners a guide to serious conditions to exclude and alerting features (‘red flags’) in children and adolescents who present with musculoskeletal conditions. NB3: Specialist referral will depend on the condition (eg rheumatology, orthopaedic surgery, physiotherapy); refer via local referral pathways. NB4: See Features to help differentiate benign pain of childhood (including nocturnal limb pain) from more serious pathology in children and adolescents that offers general practitioners a guide to differentiating benign pain of childhood (including benign nocturnal limb pain) from more serious pathology. NB5: Hip-joint pain is very common in children and adolescents and is included here to distinguish nonurgent, semiurgent and urgent aetiologies. NB6: Joint hypermobility is extremely common in children and adolescents and rarely an indicator of a serious heritable collagen disorder. Referral to a specialist is not usually required unless the child or adolescent has a typical syndromic body habitus (eg Marfanoid habitus). NB7: Inflammatory musculoskeletal conditions are much less common than noninflammatory conditions in children and adolescents. If a child or adolescent is suspected of having an inflammatory disease, discuss the case early with a specialist.