Acute knee injury (SOP)

GGC Paediatric Guidelines
NHS GGC

Objectives

SOP for acute knee injuries including 1st and subsequent patellofemoral dislocations.

Scope

Inclusion:

  • Soft tissue knee injuries
  • Patellofemoral dislocation (1st and subsequent)

Exclusion:

  • Suspected/proven extensor mechanism disruption
  • Fractures
  • Tibiofemoral dislocations or suspected multi-ligament knee injuries

Emergency Department management

The patient should have history, examination* and XR. Findings should be documented in the ED notes.

The XR should be reviewed for osteochondral fracture and/or lipohaemarthrosis, Segond or tibial spine fractures.

*Following a significant knee injury it may not be possible to test ligamentous integrity. It is important to assess ability to SLR and presence/absence of effusion/haemarthrosis

Who to refer?:

  • Fracture/lipohaemarthrosis on XR – refer to orthopaedics who will review and order MRI. Admit/discharge according to clinical review findings.
  • Tibiofemoral dislocations or suspected multi-ligament knee injuries. Examine NV status. Keep NBM. refer to orthopaedics who will review
  • No fracture on XR –all patients should be referred to physiotherapy (TrakCare referral – note this is not an opt-in referral).

No fracture clinic appointment should be made. Ortho review not required at this stage.

The patient should be discharged with adequate analgesia. They should be instructed to weight bear as tolerated. A knee extension brace (e.g Buchannan splint) and/or crutches may be required for comfort in some cases.

Referring to Physiotherapy:

  • Patellofemoral dislocation, haemarthrosis – refer on Trakcare.
  • Soft tissue injury – provide with RHC knee soft tissue injury advice booklet and opt in letter for physiotherapy. Make opt-in physio referral on Trakcare.

Action by Physiotherapy

Patients referred with first time patellofemoral dislocation will ideally be seen Tues/Wed/Thur/Fri mornings.**

Patients with significant haemarthrosis, lipohaemarthrosis or clinical concern of intraarticular derangement will require same/next day ortho review with a view to further imaging.

In this case, the physiotherapist will contact the trauma liaison nurse (TLN) to arrange the review.  

Trauma Liaison Nurses:

** Physiotherapy will try to see these referrals in the morning when fracture clinics are running. However some patients may need to be appointed in the afternoons due to staffing availability.

Action by Trauma Liaison

The TLN will take details and organise for the patient to be added on to the same day fracture clinic (urgent manual process by reception staff).

The TLN or physiotherapist will escort the patient around to clinic 2 to wait for review.

The TLN will add the patient to the ‘soft tissue knee pathway’ shared portal worklist.

The TLN will give parents written contact details for the trauma liaison service.

If the fracture clinic has already finished it may be possible for the patient to be reviewed by the on call middle grade. If this is not achievable in a reasonable timeframe, the patient should be booked into the next fracture clinic (force book if required).

Action by orthopaedic surgeon in fracture clinic

At present, MRI scans can only be requested by medical staff. The patient will be reviewed, knee examined and an MRI scan requested as appropriate. In the case of 1st time patellofemoral dislocation with haemarthrosis or lipohaemarthrosis the referral should state ‘urgent patellofemoral pathway’ which will guide vetting and booking by radiology.

Other indications for urgent scan would be suspected acute traumatic OCD, acute lateral meniscal tear and locked knee.

The reviewing doctor should document a brief general history relevant to the possibility of GA procedure.

The parents should be instructed to phone the trauma liaison team when the scan has been

Action by Radiology

Urgent referrals aim to be within 2 weeks based on radiology waiting times at the time of referral.

Reporting will ideally be urgent but will be in line with radiology reporting timeframes at time of exam.

Orthopaedics and radiology have an understanding that orthopaedics may review the image as needed before formal reporting.

If an urgent report is required then an orthopaedic consultant should have a direct discussion with the radiology consultant.

Action by Trauma Liaison

The shared portal worklist will be checked/updated daily.

If report is not available 3-4 days after the scan TLN should contact the referrer who can chase according to clinical priority

Once the report is available, it should be discussed with the on call team who can seek specialist advice if required.

Possible outcomes –

  • Theatre required - admission for theatre arranged by TLN, TLN will liaise with knee surgeon(s) for elective slots the TLN will liaise with the relevant secretaries, for trauma list slots the TLN will ask the on call middle grade to make the appropriate booking.
  • Fracture clinic appointment required to discuss surgical options – arranged by TLN
  • No surgery required – can be referred back to physiotherapy on trakcare (TLN to action) and family informed by TLN.

The portal worklist will be updated (TLN) and the patient transferred to the ‘scanned and sorted’ worklist for the purpose of prospective audit of pathway.

Editorial Information

Last reviewed: 15/09/2025

Next review date: 30/09/2028

Author(s): Ms Alexandra Smith, Consultant Paediatric Orthopaedic Surgeon, RHCG., Ms Heather Farish, Team Lead Physiotherapy, Paediatric MSK, RHCG. .

Author email(s): Steven.Foster@nhs.scot.

Co-Author(s): Stakeholders: Mr Innes Smith, Consultant Paediatric Orthopaedic Surgeon, RHCG, , Dr Gillian Campbell, Consultant in Paediatric Emergency Medicine, RHCG, Dr Thomas Savage, Clinical Lead for Paediatric Radiology, RHCG., Paediatric Trauma Liaison Service, RHCG..

Approved By: RHC Acute/ED Clinical Governance Group