Serious shoulder and elbow conditions (Red Flags)

Who can refer:

• All primary care clinicians with relevant appropriate scope of practice i.e. GPs, Primary care MSK advanced practice physiotherapists, advanced nurse practitioners
• Patient self referral (resident of East Lothian HSCP, Edinburgh HSCP and West Lothian HSCP Where To Find Us – Musculoskeletal Physiotherapy)
• Secondary care consultants and associated teams
• MSK physiotherapists who identify patients with suspected serious conditions of the shoulder or elbow shoulder follow agreed pathways and processes NHS Lothian Integrated Shoulder & Elbow Service

Who and How to refer:

Condition	Presentation	Referral Type	Referral Process
Suspected septic arthritis/ septic bursitis	Red skin, painful joint, fever, systemically unwell	Same day	Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000
Suspected facture or dislocation	Trauma, electric shock, seizure, deformity, pain, loss of rotation, abnormal shape	Same day	Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000
Suspected acute distal biceps rupture	sudden and forceful eccentic load to a flexed elbow, weakness in flexion / supination, positive “hook” test.	Same day	Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000 Also consider urgent referral to MSK Physiotherapy to commence rehabilitation
Suspected acute traumatic rotator cuff tear in the younger patient	patient <65 years old, trauma, pain, significant weakness, sudden inability to raise arm	Urgent	Orthopaedics via SCI gateway > Lauriston Buildings > Orthopaedics- Elbow and shoulder
Suspected malignancy/ tumour	shoulder mass, swelling, unexplained deformity, history of cancer, signs or symptoms of lymphadenopathy	Urgent	Orthopaedics via SCI gateway > Lauriston Buildings > Orthopaedics- Elbow and shoulder

Who not to refer:

• Patients who have the presence of significant red flags/ suspicion of serious shoulder and elbow conditions or have suspected inflammatory condition – see serious shoulder & elbow conditions
• Age <16

How to refer:

Detail as per who to refer section,

For further information see associated sections

• Link to NHS Lothian patient internet site including patient information resources – https://services.nhslothian.scot/ISES/Pages/default.aspxopens a new window
• Link to NHS Inform page shoulder  problems https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/shoulder-problemsopens a new window
• Link to NHS Inform shoulder problems- Patient self help guide https://www.nhsinform.scot/self-help-guides/self-help-guide-shoulder-painopens a new window
• Link to NHS Inform page elbow problems https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/elbow-problemsopens a new window
• Link to intranet site NHS Lothian Integrated Shoulder and Elbow Service http://intranet.lothian.scot.nhs.uk/Directory/physiotherapy/NHSLIntegratedShoulderandElbowService/Pages/default.aspx