We studied a teleconsulting service for second opinions in orthopaedics. Three units of the national insurance organization for accidents at work were connected to a large orthopaedic hospital in Bologna. During a 20-month study, 65 consultations were provided: 51 (78%) by asynchronous (store-and-forward) consulting and 14 (22%) by realtime videoconferencing. All the consultations made use of radiology images (radiographs, computerized tomography scans, magnetic resonance imaging scans and ultrasound scans). Video-messages and still images were commonly used to support the asynchronous consultations. More data were transmitted on average for an asynchronous teleconsultation (8 MByte) than in a videoconference (5 MByte). The average time spent by orthopaedic specialists was slightly longer in videoconferences (21 min, SD 8) than in asynchronous teleconsultations (19 min, SD 8). The clinicians confidence in their diagnosis was generally good but was lower in asynchronous consultations. The main problem affecting the telemedicine service was the lack or the low quality of the information received from the referring sites. The clinical complexity of the case and the organizational requirements were declared to be the main factors affecting the choice of consulting procedure. The study showed that the asynchronous method was preferred in the majority of cases and could be easily integrated into clinical practice, although there were some concerns about the diagnostic quality of the information transmitted.