Mr Gavin M Holt 

MB. ChB. F.R.C.S. (Ortho)

Consultant Hip & Knee Surgeon

NHS Clinics

Cheltenham General Hospital

Tel. 08454 226952 Fax.08454 223404

Cirencester Hospital

Tel. 01285 884571 Fax.

Tetbury Hospital

Tel. 01666 502336 Fax.

Private Appointments


Tel. 07989896473


Acute Knee Referral Form


Patient Details (Please include telephone number):





History:


Side: Left / Right                                                        Date of Injury:


Is this a high energy injury?

Examples: -

    • RTA
    • Equine injury
    • Team sport (football, rugby etc)
    • Fall from a height
    • Industrial injury
    • Skiing Injury

Yes / No

Was there an audible pop or crack in the knee?

When something finally fails there is often a loud crack.

Yes / No

Did the knee swell immediately ?

Within 30 min of the injury indicates haemarthrosis. (Later swelling is usually inflammatory)

Yes / No

Is there any past history of symptoms in the knee?

Chronic conditions should be referred in to routine clinic slots:-

    • Evolving meniscal wear
    • Evolving arthritis
    • Gout / Pseudogout

Yes / No


Notes: -









Examination:


Please annotate this diagram with the site(s) of swelling or tenderness.


Right Knee


Notes: -




Left Knee


Notes:-




Is there detectable instability: Yes / No


This is notoriously difficult to assess immediately after injury as pain inhibition limits the passive envelope of movement of the knee.                                                


Notes:-




Exclude limb threatening conditions:


Is there a fracture?

If yes arrange emergency assessment by the on call orthopaedic team. Some patients can be seen in the knee clinic, many will require admission.

Yes / No

Is the knee fully or partially dislocated?

If yes arrange emergency admission to Cheltenham General Hospital and inform the on call orthopaedic team.

Yes / No

Are the two pulses in both feet present and equal.

If not arrange emergency admission to Cheltenham General Hospital and inform the on call orthopaedic team.

No / Yes

Is the contraction of tibialis anterior and extensor hallucis longus grade 5 in both sides.

If not arrange emergency admission to Cheltenham General Hospital and inform the on call orthopaedic team.

No / Yes

Is there any suspicion of infection in the knee joint?

If yes arrange emergency admission to Cheltenham General Hospital and inform the on call orthopaedic team.

Yes / No


Working Diagnosis:................................................................................................


It is important to state a working diagnosis in order to prioritize patients in the knee clinic.


Notes: -





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