Knock knees

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  Emergency

  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

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  Other useful information for referring practitioners Not and exhaustive list

  • 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