Acute Knee Pain with History of Recent Trauma
Red flags
Send to Emergency Department or discuss via Orthopaedic SpR on call
- High impact trauma
- First time traumatic patellar dislocation suspected
- Significant haemarthrosis, known bleeding disorder or taking anticoagulants
- Quadriceps / patella tendon rupture
- Unable to weight bear
- Sepsis with NEW or SUDDEN CHANGE in knee pain
- Systemically unwell with NEW or SUDDEN CHANGE in knee pain
- Unremitting pain
- Rapid onset of a large, tense effusion within 6 hours
- Evidence of neurovascular damage or compartment syndrome
- Acutely locked knee
- Suspected complete posterior cruciate ligament injury
- New and significant knee instability after trauma, especially significant joint opening with medial stress in extension
-
If concern regarding suspected new malignancy please refer via 2 Week Wait Criteria.
- Suspected or confirmed malignancy
- Localised hard mass adjacent to knee/unexplained weight loss/severe night pain not controlled by analgesia
Rheumatology
New symptoms of inflammation suggesting systemic inflammatory joint disease, workup and refer to Rheumatology
If no red flags try conservative measures:
Immediate Measures
PRICER Protection Rest Ice Compression Elevation Rehabilitation
- Analgesia
- Physiotherapy for physical therapy and bracing if needed
Musculoskeletal Interface Service Referral
- Conservative measures have failed including a course of tailored physiotherapy
- Diagnostic uncertainty (including if not sure whether surgery is indicated)
- Patient is medically unfit or declining surgery
Urgent Orthopaedic Referral
- Suspected injury to the anterior cruciate ligament
- Suspected meniscal injury with locking
- Recent history of trauma with knee instability and/or locking causing significant pain and functional impairment such as inability to work
Routine Orthopaedic Referral
- Meniscal injury interfering with the ability to work or persistent symptoms despite 8 weeks of rehabilitation by a physiotherapist.
- Isolated medial or lateral collateral ligament injury, (not fulfilling red flag criteria) interfering with the ability to work or persistent symptoms despite 8 weeks of rehabilitation by a physiotherapist.
Imaging
- Simple trauma suspected consider weight-bearing AP / lateral X-ray (MRI not indicated)
- Ligament or meniscus injury suspected AND patient under 50 then MRI (only prior to referral)
Knee MRI Guidelines
- GP requests for MRI scans of the knee in patients over 50 years of age are rarely indicated
- If osteoarthritis is a possible diagnosis (in a patient of any age) the patient should have a plain X-ray
- If the plain X-ray shows OA or the patient is over 50 years then the patient can be discussed with/referred to the MSK interface or Orthopaedic Surgeon without an MRI
- For informal advice please e-mail Dr Kim Farmer, Consultant Radiologist kim.farmer4@nhs.net
The guidelines above have been developed in conjunction with the RCHT Radiology Department. Should you feel that there is a need for clinical imaging outside of the criteria stated above then you may find it helpful to obtain advice from radiology email enquiries. They aim to respond within 24hrs and the email address is
rch-tr.GPRadiologyEnquiries@nhs.net
References
- Knee Pain – Assessment. Clinical Knowledge Summaries. National Institute Of Clinical Excellence March 2011
Date reviewed 22/02/2022
Next review due 22/02/2023
Sifter name Dr Rebecca Hopkins
Contributors
Dr Rebecca Hopkins, General Practitioner and Kernow RMS Orthopaedic Guidelines Lead
Jane Mitchell, Lead Professional Extended Scope Physiotherapist, MSK Interface, Cornwall Partnership Foundation NHS Trust
Dr Barrie Phypers, Consultant Anaesthetist, Royal Cornwall Hospitals NHS Trust
Lt Col Michael Butler, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust
Surg Cdr Jon Matthews, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust
Mr Robin Kincaid, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust
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