Red flags and serious pathology

GGC - MSK Index
NHS GGC

The primary aim of the patient assessment and differential diagnosis is to exclude any serious pathology through screening for red flags.

It is important to bear in mind that red flags represent a list of clinical findings rather than a set of diagnostic labels. They raise an index of suspicion with regard to sinister pathology. It is only after clinically reasoning all assessment findings that a clinical diagnosis should be made. It is also important to retain a sense of perspective when examining patients as only 1% of examined patients are suspected of having a serious pathology. It is vital to look at the patient from a holistic perspective and consider the context of each finding in light of other findings.

NB: Index of suspicion only. Accumulation (cluster) of a number of red flags or increased frequency of main indicators increases that index of suspicion.

Red Flags: are essentially clinical prediction guides: they are not diagnostic tests and they are not necessarily predictors of diagnosis or prognosis. The main role of red flags is that when combined they help to raise the clinician’s index of suspicion. Red Flags II.

Age > 50 years + History of Cancer + Unexplained weight loss + Failure to improve after 1 month of conservative management. (SENSITIVITY 1.0 i.e. 100 %) Greenhalgh and Selfe (2006)

Where a patient is failing to respond to conservative management re-screening for red flags should be repeated.

If serious pathology is suspected discuss with senior colleague or clinical specialist for potential ONWARD REFERRAL referral as required.

Possible red flags that may indicate serious pathology are:

  • History of cancer
  • Weight loss
  • Thoracic pain
  • Trauma
  • Widespread neuro changes

The Red Flag indicators of serious pathology include:

  • A past history of cancer
  • Unexplained weight loss (>10kg body weight in 3 months)
  • Non-mechanical and/or night pain
  • Intractable or increasing pain
  • IV drug use/HIV/Osteoporosis/TB
  • Abnormal bladder and bowel symptoms
  • Violent trauma
  • Progressive widespread neurological signs.  Unilateral or bilateral Ul/LL weakness and/or weakness extending over several dermatomes
  • Systemically unwell, infection, fever, high pulse
  • Severe acquired structural deformity
  • Peripheral neuropathy with rapid structural changes – consider Charcot
  • Gait disturbance

For guidance on the identification and onward referral for patients with suspected Serious Pathology, see the relevant sections below.

Cauda Equina

Signs and symptoms

  • Dysfunction of bladder, bowel or sexual function
  • Sensory changes in saddle or peri-anal area
  • Gait disturbance

Pain may be wholly absent; the patient may complain only of lack of bladder control and of saddle anaesthesia.

Next stepsCauda Equina Pathway

CES Triage

CES Guidelines

CES Outcome form

CES question proforma

Guidance for CES phone call to ortho

CES Patient information leaflet

Malignant spinal cord compression

Signs and symptoms

  • History of cancer
  • Unexplained back or neck pain, mild initially but becomes severe
  • Band like, escalating trunk pain. Feeling of being squeezed.
  • Can be worse lying flat/ at night
  • Gait disturbance / vague non specific lower limb symptoms / reduced mobility
  • Vague numbness, weakness or difficulty using arms or legs
  • Dysfunction of the bladder and bowel and / or sexual dysfunction

Next steps

See West of Scotland guidelines for malignant spinal cord compression.

Myelopathy

Signs and symptoms

  • Insidious progression
  • Non dermatomal decreased sensation
  • Non myotomal weakness
  • Gait disturbance, ataxia
  • Clumsy or weak hands
  • Combination of neuro changes in upper and lower limbs
  • +ve Hyperreflexia
  • +ve Clonus
  • +ve Babinski sign
  • +ve L'hermitte's sign
  • +ve Hoffman's sign

Next steps

Onward referral for GP/Neuro.

Cancer or tumour

Signs and symptoms

  • Atypical mass / swelling with or without the presence of pain
  • Pain with no history of injury
  • Unremitting or increasing pain
  • Weight loss
  • Past medical history of Cancer
  • Systemically unwell
  • Night pain and disturbed sleep

Next steps

Urgent referral to orthopaedics or GP

Infection, inflammation

Signs and symptoms

  • Increased risk if post op, HIV, IVDA, TB, immunosuppressed
  • History of inflammatory arthritis
  • Red, hot, swollen, painful
  • Wound leakage
  • Systematically unwell, malaise
  • Fever
  • Gross restriction of movement
  • Sever pain with no history of trauma
  • Night pain
  • Discitis, sudden onset of acute spinal pain or change in pattern with combination of above

Next steps

Refer to GP/Ortho.

Inflammatory arthropathy

Signs and symptoms

  • Morning stiffness & backache, or multiple joint problems (pain / stiffness / swelling ).  No improvement with rest.
  • Generally unwell
  • Associated skin rash, inflammatory bowel disease, eye problems, (uveitis / conjunctivitis), urethritis
  • Sacroiliac pain / tenderness
  • Altered blood results.  Positive C-Reactive protein (CRP), ESR, Plasma viscosity (PV), +ve HLA B27 test

Next steps

Refer to Rheumatology.

Significant trauma of skeletal injury/dislocation

Signs and symptoms

  • Loss of movement + abnormal shape / deformity
  • Un-resolving pain over site
  • Reduced active and passive movement
  • Red, swollen, bruised
  • Minor trauma (history of osteoporosis)

Next steps

Refer to ortho/A&E

Aortic aneurysm

Signs and symptoms

  • Over 60
  • Acute, sudden onset of back pain
  • Low back pain that is severe - doubled over in pain
  • Severe abdominal pain
  • Continuous pain, no better with rest
  • Pain may radiate into the groin or leg
  • Pain may be accompanied by symptoms of internal bleeding, such as nausea, vomiting, rapid heart rate, cool or clammy skin, sweating, and / or shortness of breath

Next steps

Refer to surgical team/GP

Suspected deep vein thrombosis

Signs and symptoms

  • Oedema at calf
  • Red, hot limb
  • Painful -often behind the knee but not in all cases
  • Feet cyanosis deep red/purple

Next steps

Patient to contact NHS24 for advice.

Septic arthritis

Signs and symptoms

  • Severe joint pain, usually in just 1 joint, sudden onset.
  • Swelling around a joint.
  • The skin around a joint has changed colour.
  • Patient is generally unwell and may have a high temperature or feel hot and shivery.

Next steps

Patient to contact NHS24 for advice.

Sepsis

Signs and symptoms

  • known or suspected infection
  • acting confused
  • slurred speech or not making sense
  • blue, grey, pale or blotchy skin, lips or tongue – on brown or black skin, this may be easier to see on the palms of the hands or soles of the feet
  • a rash that does not fade when you roll a glass over it
  • difficulty breathing, breathlessness or breathing very fast

Next steps

Sign post to A&E or call 999.

Editorial Information

Last reviewed: 30/04/2024

Next review date: 30/04/2025

Reviewer name(s): Louise Ross , Alison Baird , Karen Glass.