Specialty: Children's Orthopaedic
Age group: Children
Direct to an emergency department
- Suspected bone or joint infection (e.g. red-hot swollen joint, or child is unwell or febrile)
- Limping child with any of the following
- acute onset, severe localised joint pain
- concern for non-accidental injury
- nocturnal symptoms
- persistent limp (longer than 7 days) that is not improving
- petechiae or purpura
- suspicious for malignancy
- systemic symptoms (e.g. fever, weight loss).
Criteria for referral to public hospital service
- Assessment of
- cavovarus foot
- clawing of the toes
- clubfoot
- congenital absence of toes
- congenital vertical talus or rocker bottom foot
- rigid or painful flat foot deformity in a child older than 3 years that is limiting functional activities (e.g. running, jumping)
- hallux varus
- painful hallux valgus (bunion) that is limiting functional activities (e.g. running, jumping) and unable to be managed in primary care
- polydactyly of the foot
- tarsal coalition that is painful or with deformity
- In-toeing
- that is unilateral
- with hypertonicity or patellofemoral symptoms
- in a child older than 8 years that is limiting functional activities or causing tripping
- Out-toeing that is
- unilateral
- progressive
- in a child older than 4 with knee pain or that is limiting functional activities
- Toe walking with either
- abnormal spine examination
- an inability to dorsiflex the foot beyond neutral, stand with heels down or walk on heels
- asymmetry
- calf hypertrophy
- signs of cerebral palsy with hypertonia, hyperreflexia, or ataxia
- Recurrent ankle instability unable to be managed in primary care
- Osteochondritis dissecans (OCD) of the talus.
Information to be included in the referral
Information that must be provided
- Reason for referral and expectation or outcome, anticipated by the child, or their carer, and the referring clinician from referral to the health service
- Findings on physical examination including point tenderness, range of motion and neurological exam
- Height percentile
- Weight percentile
- The functional or psychological impact on quality of life or activities of daily living including impact on work, study, social activities or carer role
- Pain history: onset, location, nature of pain and duration
- Details of previous management and pain management including the course of treatment(s) and outcome of treatment(s)
- Child’s age
- Relevant medical history and comorbidities including neurodiversity, muscular dystrophy, cerebral palsy, spinal conditions, rheumatological conditions or neurological conditions
- Weight bearing x-ray of affected bone or joint (including details of the diagnostic imaging practice).
Provide if available
- Details of any previous physiotherapy or paediatric assessments or opinions
- For toe walking
- x-ray of the spine (including details of the diagnostic imaging practice)
- details of any previous neurology assessments or opinions
- creatine phosphatase level
- Statement about the parent(s) or guardian’s interest in having surgical treatment if that is a possible intervention
- If the child is neurodiverse, gender diverse or has a disability
- If the child identifies as an Aboriginal and/or Torres Strait Islander
- If the child has a preferred language other than English and if they rely on cultural or linguistic support (e.g. Aboriginal cultural support, an interpreter)
- If the child lives in out-of-home care (foster care, kinship care, permanent care or residential care)
- If the child is aged 14 to 18 years, do they consent that their health information is shared with their parent, guardian or carer.
Additional comments
The Minimum information for referrals to non-admitted specialist services lists the information that should be included in a referral request.
The referral should note if the request is for a second or subsequent opinion as requests for a second opinion will usually not be accepted.
Where appropriate and available the referral may be directed to an alternative specialist clinic or service. Referrals for toe walking will usually be directed for physiotherapist assessment and management.
Referral to a public hospital is not appropriate for
- Cosmetic concerns about the foot or toes without pain, progression or functional impairment (e.g. incidental finding of accessory bones or cartilage, hallux valgus without pain or functional limitation, tarsal coalition that is manageable or without pain)
- Congenital curly toes
- Flexible flat feet with no pain, or pain that is manageable with orthotics
- Intermittent toe walking
- Sever’s disease
- Symmetrical in-toeing in a child less than 4 years or without functional impairment or patellofemoral symptoms.
Reviewed 02 October 2025