Knock knees

PAEDIATRIC

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    The list below includes common traumatic injuries that require referral to emergency and should not be referred for elective / fracture clinic categorisation

    Adult

    Shoulder and elbow conditions

    • Clinically indicated e.g. suspected septic arthritis
      • Evidence of acute inflammation e.g: haemarthrosis, tense effusion

    Wrist and hand

    • Uncontrolled sepsis including hand infections
    • Upper limb radiculopathy in the presence of suspected cervical spine infection
    • Acute development of peripheral nerve compression symptoms following trauma or acute event

    Hip and knee

    • Suspected septic arthritis
    • Knee extensor mechanism rupture
    • Suspected fracture
    • Evidence of acute inflammation for example
      • haemarthrosis
      • tense effusion
    • Suspected infection or sudden pain in arthroplasty
      • if joint infection is suspected refer immediately to emergency or contact the orthopaedic registrar on call. Do not commence antibiotics unless delay to specialist review is likely

    Foot and ankle

    • Suspected septic arthritis
    • Acute achilles tendon rupture

    Spine

    • Actual or threatened cauda equina syndrome
      • Unilateral or bilateral radicular pain
        • And/or dermatomal reduced sensation
        • And/or myotomal weakness
        • Reduced saddle sensation (subjective or objective pin prick)
        • unexplained or unexpected loss or change of bladder or bowel function
        • Sexual disturbance
        • perineal anaesthesia
    • Presentations that increase the probability of acute threatened Cauda Equina:
      • Back Pain with:
        • Presence of new saddle anaesthesia, bladder or bowel disturbance.
        • Age < 50
        • Unilateral onset progressing to bilateral leg pain
        • Alternating leg pain
        • Presence of new motor weakness
    • Spinal tumour with significant pain and/or neurological deficit
    • Lumbar Spine Stenosis (LSS) presenting with clinical symptoms of the following:
      • Recurring and insidiously but increasing back pain with gradual onset of unilateral or bilateral lower limb sensory disturbance and/or motor weakness
      • Incomplete bladder emptying, urinary hesitancy, incontinence, nocturia or urinary tract infections. Bladder and/or bowel dysfunction may progress gradually over time.
    • Clinical signs of spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs/symptoms
    • Spinal fractures demonstrated on imaging
    • Clinical suspicion spinal infections
    • High risk of irreversible deficit if not assessed urgently

    Trauma and fractures

    • Acute cervical myelopathy
    • Acute back or neck pain secondary to neoplastic disease or infection
    • Spinal injuries
    • Suspected open fracture
    • Fracture requiring manipulation or operation
    • Suspected acute bone or joint infection
    • Acute high energy fracture with/without neurological abnormality
    • Injury associated with vascular compromise
    • Clavicle fracture
    • Osteoporotic / pathological fracture new abnormal neurology
    • Joint dislocations
    • Open injuries with possible tendon or joint involved
    • Nail bed injuries or retained foreign body
    • Knee extensor mechanism rupture
    • Acute peripheral nerve injury
    • Suspected acute compartment syndrome

    Hand trauma

    • Acute ligament injury
    • Tendon rupture
    • Compound 'tooth knuckle' injury

    Upper and lower limb trauma

    • Open, unstable or suspected fractures

    Timing of first review appointments at orthopaedic outpatient's/fracture clinic

    • if there is documentation indicating adequate alignment and satisfactory initial treatment of fracture – to be seen within 14 days of referral
    • all other fracture cases, delayed presentation of tendon and nerve injuries - to be seen within 7 days of referral

    Paediatric

    Limping child/reluctant to weight bear

    • Limping child with signs of:
      • Being unwell, flushed, lethargic, fever, flat, anorexic and/or
      • Irritable and stiff joint and/or
      • Not improving
    • Systemically unwell, febrile or suspicion of septic arthritis
    • Concern of infection or trauma
    • Suspicion or concern of non-accidental injury

    NB See Slipped upper femoral epiphysis (SUFE) CPC

    Slipped upper femoral epiphysis (SUFE)

    • All suspected or confirmed SUFE should be referred to the ED or local orthopaedic on call registrar service no matter the chronicity

    Scoliosis / Kyphosis

    • Systemically unwell
    • Abnormal neurological reason

    Back pain

    • Systemically unwell

    Tumour – bone and soft tissue

    • Suspected malignancy

    • Refer to local Healthpathways or local guidelines
    • An OPSC clinic may be present at your local Hospital and Health Service. These children maybe streamed for a first review.
    • Assure parents physiological knocked knees will self-resolve with normal development by the age of 8 years; no specific treatment is required
    • If concerned, serial measurement of intermalleolar distance to be done 6 monthly to document progression or resolution
Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)
  • No category 1 criteria
Category 2
(appointment within 90 calendar days)
  • Ongoing pain in lower limbs after a traumatic event
Category 3
(appointment within 365 calendar days)
  • Persistence of significant knock knees beyond age eight
  • Intermalleollar separation > 8 cm
  • Asymmetrical deformity
  • Progressive deformity or lack of spontaneous resolution
  • Other associated skeletal deformity such as height below 5th centile for age

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Clinical history and examination including key points: -
    • evolution and duration of symptoms
    • treatment prescribed (analgesics, physiotherapy)
    • current and past medical history and medications
    • relevant family history associated to this condition i.e. siblings/parents with same condition
  • Weight bearing long leg XR if:
    • unilateral deformity
    • progressive deformity
    • lack of spontaneous resolution
    • over 8 years of age

3. Additional referral information Useful for processing the referral

  • No additional information

4. Request

  • Patient's 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

    Referring Practitioner Details

    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of referral
    • Signature

    Relevant clinical information about the condition

    • Presenting symptoms (evolution and duration)
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco and other drugs use

    Reason for request

    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for GP/second opinion
    • For a specified test/investigation the GP can't order, or the patient can't afford or access
    • Reassurance for the patient/family
    • For other reason (e.g. rapidly accelerating disease progression)
    • Clinical judgement indicates a referral for specialist review is necessary

    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.)

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    • Please note that 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 becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

    • 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.

Last updated: 22 July 2019

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