If a client has a brain injury, spinal cord injury or orthopaedic injury AND one or more of the following, an assessment from a specialist rehab dietitian is recommended:

1. Slow bone healing or non-union

• Slow bone healing or non-union without a surgical explanation
• Client is also obese or has unmanaged diabetes (which will contribute to the slow bone healing)
• Low or unknown vitamin D level

2. Pressure injury or slow wound healing

• Wounds that are large, severe and/or slow to heal despite district nursing or tissue viability input (e.g. a Grade 3 or Grade 4 pressure injury)
• Client has a significant wound and is losing or gaining weight
• Comprehensive blood tests have not been done

3. Major elective surgery being planned

• Malnutrition screening (using Perioperative Nutrition Screen, Malnutrition Universal Screening Tool or Mini Nutritional Assessment) indicates the client is at high risk of malnutrition
• Comprehensive blood tests have not been done
• Protein intake and micronutrient intake have not been optimised

4. Fatigue

• Fatigue that persists despite good sleep hygiene and pacing
• Vitamin D, vitamin B12, folate, haemoglobin, ferritin, kidney function and HbA1c have not been checked
• Client is skipping meals to manage their weight

5. Reduced smell or taste

• Client says their food has ‘no taste’
• Using excessive amounts of salt, sugar or hot sauce to compensate
• No awareness when something was burning (a safety risk)

Why these get missed: these clinical signs are often treated as isolated problems rather than potential indicators of (or contributors to) poor nutritional status. Identifying nutrition-related issues early (and involving a dietitian), can support healing, recovery, and overall rehabilitation.

CASE STUDY

Delayed Bone Healing & Smell Loss After Trauma

The unique approach of a specialist rehab dietitian

1. The Case

25-year-old male with multiple orthopaedic injuries to his arms and face following a road traffic accident. His weight was not a concern, but he had delayed bone healing, poor sleep, significant fatigue and complete loss of smell.

• Diet: predominantly crisps, chocolate, energy drinks, frozen pizza and sandwiches
• Home support: lives at home, but both parents work full-time so he is unsupported with meals for most of the day
• Weight: stable and within a healthy range — no concerns

2. The Approach

How specialist rehab dietetic input was able to help:

• Comprehensive blood tests identified deficiencies in folate, vitamin B12 and vitamin D — likely contributing to his fatigue and delayed bone healing; liaised with the GP to correct the nutrient deficiencies
• Diet analysis showed he wasn’t meeting most of his protein, vitamin and mineral requirements, explaining both the impaired bone healing and the deficiencies picked up on blood testing
• Supplement plan implemented for vitamins, minerals and protein to help him meet his requirements quickly, while working on the nutritional quality of his diet longer term
• Taste and smell testing confirmed his sense of taste was intact, but his sense of smell was completely absent due to his facial fractures
• Smell training and compensation strategies taught to help make mealtimes more enjoyable despite his total loss of smell
• ENT/Smell Clinic referral made for further investigation into his loss of smell
• Home safety review completed and liaised with the OT regarding the need for gas, smoke and carbon monoxide detectors in the property (given his total loss of smell)

3. The Outcome

Outcome at 12 months: all nutrient deficiencies were corrected and blood results were normal, all of his fractures had healed, and he was eating a more nutritious and varied diet while continuing to use his preferred smell compensation strategies for enjoyment.

Why this case matters: his deficiencies were only confirmed once dietetic input was already in place. There is currently no validated nutrition screening tool for this client group that is not based on weight or BMI, which is exactly why cases like his are so easily missed. What was visible beforehand — delayed bone healing, persistent fatigue and loss of taste or smell — didn’t need a blood test to spot, only recognition that they were nutrition-related. That awareness is why this guide was produced: outlining visible, non-weight-based red flags that case managers can use to justify requesting a dietetic assessment.