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Three Part Question

In a [patient with an acutely locked knee ] does [early manipulation] at presentation [improve functional outcome]?

Clinical Scenario

A young man presents to the Emergency Department having injured his knee playing football. He is unable to fully straighten his knee, which is locked at around 20 degrees flexion. Xrays are normal.
You suspect he has a locked knee secondary to meniscal injury. In the past you have had conflicting advice regarding the management of these injuries so discuss with the Orthopaedic SHO how he should be further managed. The Orthopaedic SHO advises acute manipulation of the knee as he has read this speeds recovery, you wonder if he is correct.

Search Strategy

Medline 1950 to week 1 April 2008 using the OVID interface.
{[knee.mp OR joint loose bodies OR Knee injury OR Knee joint OR locked knee.mp OR Menisci, Tibial OR bucket handle tear.mp OR meniscal tear.mp] AND [extend.mp OR straighten.mp OR manipul$.mp] Search limited to English Language and Humans.

Search Outcome

356 papers found of which 4 were thought relevant.
2 out of these 4 papers were unavailable.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
N.B.Eastwood 1978 Great Britan	6 patients who presented to the General Practioner over a 31 year period.	6 retrospective Case Studies.	Restoration of funcion.	Immediate in all 6 cases	Small study. Uncontrolled. No mention of ethical approval. Not all cases followed up, and those that were on an anicdotal basis. No consideration for underlying pathology.
			Need for recurrent manipulation / procedures	One case recurrent locking treated with manipulation only. One case requiring lateral meniscectomy
I.J.Critchley and D.J.Bracey 1985 Great Britian	85 patients presenting to the Emergency Department with an acutely locked knee, all treated with manipulation under anaesthesia.	Retrospective Case Report.	Medial Meniscectomy	44.9% - 96% bucket handle tears	Uncontrolled. Small study. Data missing in 16 patients (lost to follow-up). No comment made regarding speed of recovery. No long term follow up of functional ability or recurrence. Different pathologies not considered at acute treatment.
			Lateral Meniscectomy	15.9% - all bucket handle tears
			Loose body removed	4.3%
			Recovery without further intervention	33.4%
			Medial and Lateral Meniscectomy	1.5%

Comment(s)

Although urgent manipulation of a locked knee may provide good relief of pain it is unclear if the procedure itself actually causes further joint damage. Consideration must be given to the likely underlying pathology, as manipulation may not be curatitve and further investigations including arthroscopy may be required. Poor level of evidence from this searches, although it shows that the majority require further procedures and treatment to correct the underlying abnormality.

Clinical Bottom Line

There is no good evidence that acute manipulation of the locked knee improves functional outcome, and it is possible that further joint damage may result from this. In the absence of specific evidence, local advice should be followed.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. N.B.Eastwood Manipulation for Locked Knee. Journal of the Royal College of General Practioners April 1978 (219-220)
2. I.J.Critchley and D.J.Bracey The acutely locked knee - is a manipulation worthwhile? Injury 1985 16, 281-283