Knee Ligamentous and Meniscal Injury - Paediatric CPC

For clinical advice, please telephone the relevant specialty service.

Northern Adelaide Local Health Network

• Lyell McEwin Hospital (08) 8182 9000

Southern Adelaide Local Health Network

• Flinders Medical Centre (08) 8204 5511

Women's and Children's Health Network

• Women’s and Children’s Hospital (08) 8161 7000

Inclusions

• suspected or confirmed meniscal tear of any type
  
• suspected or confirmed injury to anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL)

Exclusions

• chronic recurrent multifocal osteomyelitis, also known as non-bacterial osteitis. Note: consider referral to Rheumatology.
• non-traumatic knee pain with no diagnosis in the presence of normal hip and knee imaging. Note: consider referral to sports medicine or physiotherapy. Consider referred pain from the hip and hip X-rays.
• non-traumatic monoarticular swelling with no structural damage on MRI. Note: consider referral to Rheumatology
• suspected inflammatory diagnosis (for example juvenile idiopathic arthritis).
  Note: consider referral to Rheumatology.
  

Triage categories

Category 1 (appointment clinically indicated within 30 days)

• locked knee – generally seen within 2 weeks via rapid access assessment due to urgency of clinical presentation
  
• any acute meniscal or ACL, PCL,MCL, LCL injury
  
• stiff knee
  
• significant instability or giving way

Category 2 (appointment clinically indicated within 90 days)

• chronic injury
  
• intermittent instability symptoms
  
• post-traumatic limb deformity
  
• intermittent locking episodes. Note: consider MRI prior to referral

Category 3 (appointment clinically indicated within 365 days)

• nil

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

• clinical history including:
  
  • date of injury
    
  • mechanism of injury, e.g. direct blow, pivoting, cutting, jumping
    
• symptoms including onset and duration, including:
  
  • if the knee catches, locks, gives way
    
  • if the patient can weight bear
    
• if the leg can fully straighten
  
• physical examination including:
  
  • swelling, if leg able to straighten, stiffness, anterior/posterior draw, pain on palpation
    
• investigations
  
  • plain x-rays: anterior posterior (AP), lateral, notch and skyline. Include date, provider and location of imaging

Additional information to assist triage categorisation

• magnetic resonance imaging (MRI), include date, provider and location of imaging
  
• any prior injury
  
• level of sports involvement
  

Clinical management advice

• Rule out acute fracture.
  
• If fracture is identified, the patient should be assessed at the nearest emergency department or urgent care clinic.
  
• If the patient has bucket-handle tear or locked knee, refer urgently for rapid access assessment.
  
• If the patient is unable to weight bear, refer to emergency for urgent assessment.
  
• If the patient has acute injury:
  
  • follow RICE protocol (Rest, Ice, Compression, Elevation)
    
  • knee splint
    
  • use crutches if unable to weight bear
    
  • use protected weight bearing with crutches for mobility
    
  • refer to community physiotherapy
    
• If the patient has a chronic injury, assess for instability symptoms, refer to physiotherapy and for semi-urgent Orthopaedic Surgery assessment.

Referral requirements for specific sites

• Physiotherapy at Women’s and Children’s Hospital (WCH) do not accept referrals from General Practitioners (GPs) – refer instead to community or private physiotherapy.
  
• Physiotherapy at Flinders Medical Centre (FMC) and Lyell McEwin Hospital (LMH) do accept referrals from GPs for paediatric orthopaedic conditions.
  

Clinical resources

• Royal Children’s Hospital Melbourne – Acute Knee Injuries: Emergency Department

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

• full name, including aliases
• date of birth
• residential and postal address
• telephone contact number/s – home, mobile and alternative
• Medicare number, where eligible
• name of the parent or caregiver, if appropriate
• preferred language and interpreter requirements
• identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

• impact on employment
• impact on education
• impact on home
• impact on activities of daily living
• impact on ability to care for others
• impact on personal frailty or safety
• identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery, where surgery is a likely intervention.
• Choice to be treated as a public or private patient.
• Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The role of the referring clinician (e.g. General Practitioner, Nurse Practitioner) in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the referring clinician once the transfer of care has occurred.