Thank you for your comments on our article [BCMJ 2021;63:211-216]. We agree that a primary care provider should see and examine all adolescents with an acute knee injury. In today’s health care climate, a screening virtual visit can be offered as an initial evaluation; however, this should be promptly followed by a physical examination if there is any history of concerning symptoms such as swelling, loss of motion, or instability. As is outlined by the College of Physicians and Surgeons of BC practice standard on virtual care, it is unacceptable to defer a physical examination because the virtual care medium does not allow for one. Virtual care is most appropriately used when access to in-person care is provided as needed to follow the virtual consultation. Adolescent patients with an acute knee injury, or history of one, should be promptly examined by a primary or urgent care provider and referred to an orthopaedic specialist when indicated.
An MRI should be requested urgently in all adolescent knee injuries presenting with an acute hemarthrosis but should never postpone referral. Often, a conversation with the radiologist is needed to advocate for a timely MRI in this patient population so that they are appropriately triaged for this investigation. This is our opportunity to advocate for patients who cannot advocate for themselves, and who should be triaged to receive their MRI prior to an adult waiting for an MRI that will not guide clinical management.
It is unfortunate to hear about your recent clinical experience with delayed presentation of adolescent patients with locked knees. Thank you for clarifying the cause of their delayed presentation. We hope that our article will not only bring attention to the problems associated with a delayed presentation in this patient population, but also empower orthopaedic surgeons locally to advocate and provide urgent access clinics for adolescent knee injuries. The solution to this problem is education for our primary care colleagues and accessibility to specialist consultation.
—Lise Leveille, MD, MHSc
—Tessa Ladner, BSc
—Christopher Reilly, MD
This letter was submitted in response to “Delay in diagnosis and management of adolescent ACL injuries.”
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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
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