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1 1971 Title: Protocol for the management of Upper Leg and Knee injuries Document Owner: Deirdre Molloy Document Author: Deirdre Molloy Presented to: Care & Clinical Policies Date: August 2015 Ratified by: Care & Clinical Policies Date: August 2015 Review date: August 2017 Links to other policies: 1. Purpose of this document - This clinical protocol provides a clear framework for nurses employed by Torbay & Southern Devon Health & Care Trust when providing care to patients over 2 years of age presenting at Minor injury Units with upper leg and knee injuries 2. Scope of the Policy: This protocol is for the use by Minor Injury Unit staff employed by Torbay and Southern Devon Health Care Trust who have achieved the agreed Trust clinical competencies to work under this protocol. 2.1 Exclusions All patients presented with upper leg and knee injury will be triaged/assessed. Those patients outside clinical protocols including x-ray protocol will be referred to the appropriated clinical setting. Refer all patients (prior to discharge) on anticoagulants i.e. Warfarin, Dabigatram etexilate (Pradaxa ), Apixiban (eliquis ) and Rivaroxaban (Xarelto ) for further medical review. NB Be aware of serious limb conditions such as mid shaft Femur fracture and refer to Emergency department via 999 ambulance immediately. 3. Assessment 3.1. Presenting signs and symptoms; may include some of the following; Pain, swelling, bruising/redness, wounds, inflammation/heat, inability or difficulty to weight bear, reduced or loss of function, deformity/dislocation 3.2. History; refer to protocol for History taking and Clinical Documentation and the Protocol for the Management of soft tissue limb injuries; Specific: Establish when, where and how the injury occurred. Establish the exact mechanism e.g. Valgus stress of knee may result in Medial collateral ligament injury Varus stress of knee may result in Lateral collateral ligament injury Twisting to flexed knee may result in Meniscus injury Forced flexion or hyperextension may result in Anterior cruciate ligament injury (isolated or Version 2.1 Page 1 of 10

2 with medial collateral or medial meniscus) Dashboard impact - may result in Posterior cruciate ligament injury (often with medial or collateral ligament) Did the patient fall from a height. What type of surface did they fall onto? Ask whether the patient could weight bear immediately after the injury A crack felt or heard does not necessarily indicate a fracture Was there immediate swelling to the injured limb. Pain score at time of injury and on presentation First aid treatment received. The amount of swelling may depend on whether ice and elevation have been applied Swelling of immediate onset indicates an acute haemarthrosis. Swelling developing over several hours indicates a reactive effusion Ask about any history of clicking, locking (inability to fully extend), and giving way including previous knee problems and surgery Past medical history including previous injuries to effected limb REFER ALL PATIENTS ON ANTICOAGULANT (heparin)therapy TO A+E 4. Clinical Examination Observe where possible patients gait, balance, mobility, ability to weight bear prior to examination. During examination always examine both legs, exposed to the upper thighs, while the patient is lying supine Look Symmetry Suspicion of a hip fracture observe for shortening and rotation of lower leg Swelling, Bruising/discoloration, Wounds/grazing Deformity/dislocations Feel: (palpate from hip down) Note any tenderness over: Pelvis, hip Proximal midshaft and distal Femur Femur condyles and joint line Patella, patellar tendon Distal tibia, tibial plateau, tibial tuberosity Fibula head Feel for warmth and crepitation. Test for effusion of the knee by inspection, the patellar tap test and, for small effusions, the fluid displacement test Assess muscle tone and bulk. Confirm wasting by comparing measurement with the other limb. Palpate collateral ligaments of knee. Palpate joint line of knee for meniscal injury. Version 2.1 Page 2 of 10

3 Move hip (Passive. Active & resistance) Flexion/extension Abduction/adduction Internal/external rotation Move knee (Passive Active & resistance) Extension (normal = 0 ). Try to obtain full extension if not obviously present. Pain may be the cause, but a springy block to full extension suggests a meniscus tear Flexion (normal = over 135 ) Straight leg raise. Ask the patient to straight leg raise, which against resistance generally excludes rupture of the quadriceps or patellar tendon, a transverse patellar fracture or avulsion of the tibial tubercle Special tests With the knee at 90 (if possible): Assess the anterior cruciate ligament for anterior glide (anterior drawer test). Up to 5 mm movement is normal. Over 1.5 cm indicates anterior cruciate ligament rupture. Less displacement and asymmetrical movement of the tibial condyles may suggest isolated cruciate laxity or rotational instability. Always compare both legs. If unable to flex to 90, assess in about 15 flexion (Lachman test). Assess the collateral ligaments Medial collateral ligament Look for tenderness of the medial ligament at its femoral attachment and the joint line. With the leg straight, gently apply valgus stress and examine for pain and opening up of the joint line, suggesting injury of the medial collateral ligament. Severe laxity may indicate additional cruciate rupture. Compare the two sides. If no instability is demonstrated repeat the test with the knee flexed to 30 and the foot internally rotated. Some opening up of the joint in this position is normal. Abnormal opening suggests a partial medial ligament tear Lateral collateral ligament Similarly, look for lateral tenderness and apply varus stress in extension and 30. Laxity in both positions suggests additional posterior cruciate ligament rupture Assess the posterior cruciate ligament for posterior glide (posterior drawer test) Palpate the joint lines, the ligament insertions and bony landmarks for tenderness Check the peroneal nerve Examine for weakness of foot dorsiflexion and eversion, and loss of sensation over the lateral aspect of the fore foot) Version 2.1 Page 3 of 10

4 Assess the menisci : McMurray test Assess sensation and circulation distal to injury. 4.1 Investigations, X-ray and the Ottawa Knee rule : AP and lateral are the standard views: If a patella fracture is suspected clinically and the standard views are normal, request alternate views with Radiographer advice. In traumatic knee injury Less than a week old In patients over 17 years Without distracting injury or previous surgery A knee radiograph is only indicated if one or more of the following apply: Age 55 or over Inability to flex the knee to 90 Tenderness of the fibular head Inability to walk four steps both immediately and in the unit Isolated tenderness of the patella Skyline views may be required seek radiographer advice If a tibial plateau fracture is suspected clinically and the standard views are normal, request oblique views seek radiographer advice Sometimes a fat fluid level in the suprapatellar bursa (lipohaemarthrosis) is the only sign of an intra-articular fracture NB All patients with suspected Femur and hip fractures must be referred to the Emergency department for Investigations and further management. 5. Treatment 5.1 Suspected Hip Fractures Assess pain score and give analgesia as per patient group direction. Consider use of entonox as per protocol. Immobilise patient in supportive manner. Refer to emergency department for further review and management via ambulance. If competent cannulate patient and where prescribed or as per Patient Group Direction give 1 litre of Normal saline. 5.2 Suspected Mid-shaft Femur Fractures Assess pain score and give analgesia as per patient group direction. Consider use of entonox as per protocol. Immobilise patient in either full length back slab or await ambulance support with trauma splintage Refer to emergency department for further review and management via 999 ambulance Version 2.1 Page 4 of 10

5 If competence cannulate patient and where prescribed or as per Patient Group Direction give 1 litre of Normal saline 5.3 Distal Femur or condylar fractures Assess pain score and give analgesia as per patient group direction. Consider use of entonox as per protocol. Immobilise patient in either full length back slab or await ambulance support with trauma splintage Refer to Orthopaedics for further review and management via ambulance. 5.4 Fractured Patella Signs and Symptoms; Usually from a direct blow. There is pain, swelling, difficulty in bending the knee and perhaps crepitus or haemoarthrosis Investigations: May be difficult to interpret. Beware the bipartite patella (upper, outer quadrant) mimicking a fracture. If a patellar fracture is suspected clinically and the standard views are normal, request a skyline view Treatment of undisplaced patellar Fractures Assess pain score and give analgesia as per patient group direction. Immobilise patient in full length back slab. Arrange fracture clinic appointment Treatment of displaced, transverse fractures and undisplaced patellar fractures with extensor mechanism involvement, refer to orthopaedics for further management. 5.5 Patellar Dislocations (with no correlating fractures) or self -reduced Patellar Dislocations. Signs and symptoms; usually dislocates laterally. May reduce spontaneously. May have reoccurring dislocations. Treatment of patellar dislocations: Reduce under entonox as per protocol by gently extending the knee. If this fails (with knee x-rayed ) where competent to do so repeat with pressure on the lateral margins of the patella using both thumbs. Check post reduction x-rays. Reassess pain score and give analgesia as per Patient Group Direction. Apply full leg cylinder plaster of Paris cast (bi-valved). Provide crutches. Arrange fracture clinic appointment 5.6 Proximal Tibial fractures (including Oestocondral and Tibial Plateau fractures) Most common is the depressed lateral plateau fracture caused by Version 2.1 Page 5 of 10

6 impact from a car bumper, and usually associated with medial collateral and/or cruciate ligament rupture. Look for swelling, haemarthrosis and instability. Assess pain score and give analgesia as per Patient Group Direction. Immobilise patient in full length back slab. Refer to Orthopaedics for further review and management. 5.7 PROXIMAL FIBULAR FRACTURES Commonly associated with ligament rupture or another knee fracture May be part of a Maisonneuve fracture of the medial ankle Check the peroneal nerve, examine the ankle and X-ray the whole tibia, fibula and ankle. Treatment If isolated and without nerve injury: Assess pain score and give analgesia as per Patient Group Direction Provide support bandage e.g. wool & crepe or tubigrib. Provide crutches for partial weight bearing support. Arrange fracture clinic follow up. Fracture Clinic Otherwise refer to the Orthopaedic team 5.8 Osgood-Schlatter s Disease Recurrent pain, tenderness and swelling over the tibial tubercle in children, especially boys aged years. Radiographs may show an enlarged or fragmented tibial epiphysis Treat symptomatically with rest, Advise non- steroidal anti inflammatory medication as per Patient Group Direction. Refer to General practitioner for orthopaedic outpatient follow up. 5.9 Collateral Ligament Injuries Minor Sprains without laxity Assess pain score and give analgesia as per Patient Group Direction Support bandage. Crutches (depending on mobility) Quadriceps exercises. Written, verbal advice regarding knee exercises. Refer for physiotherapy For Moderate/severe sprains with laxity, haemarthrosis or avulsion fracture refer to Orthopaedics for further management Bursitis Prepatellar and infrapatellar bursitis result from inflammation, often associated with kneeling. Treatment; Rest/ elevation, avoid repetitive injury. Consider knee support Advise Over the Counter Non-steroidal ant inflammatory medication. Advise General Practitioner follow up. Version 2.1 Page 6 of 10

7 5.10.1nfected Bursitis Sometimes associated with trivial skin lesions over the knee, especially in occupations requiring kneeling; otherwise assumed to be blood borne. There may be increasing pain, cellulites, pyrexia and malaise. To commence on flucloxacillin (antibiotic if not allergic to penicillin) treatment and arrange GP or Emergency Department follow up depending on severity Acute Haemarthrosis Rapid onset of a tense and painful swelling following knee injury, if indicates a serious injury e.g. cruciate ligament rupture, meniscal tear, tibial avulsion or tibial plateau fractures. Treatment: Refer to orthopaedics 5.12 Cruciate Ligament Rupture Anterior Cruciate: Frequently associated with tears of the medial ligament and the medial meniscus The anterior drawer test is positive and there may be haemarthrosis and avulsion of the anterior tibial spine Posterior Cruciate. There is often associated damage to the collateral ligaments The posterior drawer test is positive. Beware a false anterior drawer test as the posteriorly displaced tibia is pulled forward into a normal position. There may be a haemarthrosis and avulsion of the posterior tibial spine on radiographs Refer to the Orthopaedic team for further management. Treatment: If presenting immediately after injury, refer to the Orthopaedic team If delayed presentation, support bandage, crutches, quadriceps exercises and refer to Fracture Clinic Meniscus Injuries Acute tears in the young adult, usually male, are generally from a sports incident of weight-bearing stress. In the middle-aged there may be no history of trauma There is immediate pain and inability to continue playing, with or without a haemarthrosis Joint line tenderness is non-specific, but a springy block to full extension is almost diagnostic of a displaced bucket-handle tear Treatment of isolated meniscus tears If the Knee is locked Refer to Orthopaedic team. Version 2.1 Page 7 of 10

8 Definite new meniscus tear Assess pain score and give analgesia as per Patient Group Direction, support bandage, crutches, refer to Emergency Department review clinic Possible meniscus tear Assess pain score and give analgesia as per patient group direction, support bandage, crutches, refer to Emergency Department review clinic 5.14 Ruptured Quadriceps Tendon Complete inability to straight-leg raise, often with a palpable defect in the muscle insertion Assess pain score and give analgesia as per Patient Group Directions. Refer to orthopaedics for further management 5.15 Ruptured Achilles Tendon Complete Inability to straight leg raise, a palpable defect in the patellar tendon and high riding patella. There may be an avulsion of the tibial tuberosity. Assess pain score and give analgesia as per Patient Group Direction. Refer to orthopaedics for further management. 6. Documentation 6.1. Clinical records must be written in accordance with Torbay and Southern Devon Health & Care Trust History Taking and Clinical Documentation protocol and the Nursing & Midwifery Council guidelines of records and record management (2009) A summary letter of the MIU attendance and the care delivered must be sent to the General practitioner and also health visitor if under the age of 5yrs and school nurse if 5yrs to 16yrs of age to ensure the central medical record of the patient is accurate For patients being transferred to the Emergency department, ensure records are completed in a timely manner on shared IT system. A summary letter will be sent to the General practitioner in the normal manner For patients seeing the General Practitioner or specialist within the next 24 hours ensure the patient has a copy of the treatment record to take with them. A copy will be sent to the General practitioner in the normal manner. 7. Discharge information 7.1 Ensure those patients who have been referred for further acute intervention have appropriate transport to meet their needs, all relevant treatment has been prescribed and/or administered and correct information & documentation is given to the patient. 7.2 The patient /carer understand that if the condition deteriorates or they Version 2.1 Page 8 of 10

9 have any further concerns to seek medical advice. 7.3 The patient and /or carer demonstrate understanding of advice given during consultation. 7.4 The patient/carer has been provided with written advice leaflet to reinforce advice given during consultation 7.5 The patient/carer demonstrates and understanding of how to manage subsequent problems 8. Training and implementation: MIU Network meeting Cascade. All staff adhering to protocols must have agreed training and proven competence to work within protocol. Each protocol must be agreed and signed by line manager. 9. Monitoring tool _ Regular review of clinical practice to ensure individuals are adhering to clinical protocol. 10. References 11. British National Formulary 2015 British National Formulary for Children 2015 Clinical orthopaedic Examination. McRae R. 5 th edition 2004 Differential Diagnosis. Rafley, A. Lim, E. 2 nd edition 2005 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S NHS Devon Protocol for the management of soft tissue injuries NHS Devon Protocol for the management of knee injuries. Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 Minor Injuries, A Clinical guide. Purcell D. 2 nd edition 2010 South and West Devon formulary and Referral Torbay Care trust Management of Limb simple fractures and soft tissue injuries. Amendment History Issue Status Date Reason for Change Authorised V1 Created Feb 2013 Merger of Torbay Care Trust and NHS Devon Protocols for upper leg and knee injuries V 2.1 Reviewed August 2015 Review of protocol. Documentation reflects IT changes references updated D Molloy D Molloy Version 2.1 Page 9 of 10

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