Knee dislocation: Difference between revisions

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*Medial (4%)
*Medial (4%)


==Evaluation==
==Clinical Features==
===Signs===
*Suggested by severely injured knee that is unstable in multiple directions
*Suggestive by severely injured knee that is unstable in multiple directions
*Lateral collateral ligament injured with peroneal nerve palsy = knee dislocation
*lateral collateral ligament injured with peroneal nerve palsy = knee dislocation
 
==Differential Diagnosis==
{{Knee DDX}}


===Associated Injuries===
===Associated Injuries===
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**Tibial nerve injured less often
**Tibial nerve injured less often
*[[Fractures]]
*[[Fractures]]
**femur and tibia most common
**Femur and tibia most common
**check hip and ankle joints for associated fracture
**Check hip and ankle joints for associated fracture
**avulsion fractures common
**Avulsion fractures common
*[[Compartment syndrome]] risk high with vascular compromise
*[[Compartment syndrome]] risk high with vascular compromise
==Differential Diagnosis==
{{Knee DDX}}
==Evaluation==
*Knee x-ray (to rule-out fracture); consider CT
*Vascular assessment
**Assess popliteal and distal pulses
**Measure ABIs
***ABI >0.9 - serial exams
***ABI <0.9 - arterial duplexes or CT angio


==Management==
==Management==
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***As above, but reversed. Provider pulls gently counter traction on proximal tibia while assistant pulls distal femure proximally then anteriorly
***As above, but reversed. Provider pulls gently counter traction on proximal tibia while assistant pulls distal femure proximally then anteriorly
**Splint in 10-15 degrees of flexion <ref name="Procedures for orthopedic emergencies">Davenport M. Procedures for orthopedic emergencies. In: Bond M, ed. Orthopedic Emergencies: Expert Management for the Emergency Physician. Cambridge: Cambridge University Press; October 31, 2013.</ref>
**Splint in 10-15 degrees of flexion <ref name="Procedures for orthopedic emergencies">Davenport M. Procedures for orthopedic emergencies. In: Bond M, ed. Orthopedic Emergencies: Expert Management for the Emergency Physician. Cambridge: Cambridge University Press; October 31, 2013.</ref>
*Vascular assessment
**Assess popliteal and distal pulses
**Measure ABIs
***ABI >0.9 - serial exams
***ABI <0.9 - arterial duplexes or CT angio
*Monitor for compartment syndrome
*Monitor for compartment syndrome
**no pulses: reduce immediately
**no pulses: reduce immediately
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*Institution will dictation admission process
*Institution will dictation admission process
**Suggested algorithm
**Suggested algorithm
***If: Strong pulses + ABI >0.9 + normal ultrasound, admit for obs and serial vasc exams
***If: Strong pulses + ABI >0.9 + normal ultrasound, admit for obs and serial vascular exams
***If: Good perfusion + asymmetric pulses or ABI <0.9 or abn U/S, consult vascular surgery + obtain CTA
***If: Good perfusion + asymmetric pulses or ABI <0.9 or abnormal ultrasound, consult vascular surgery + obtain CTA
***If: Weak pulses or signs of ischemia = emergent vascular surgery consult and OR
***If: Weak pulses or signs of ischemia = emergent vascular surgery consult and OR
*Consider trauma consult depending on mechanism and additional injuries
*Consider trauma consult depending on mechanism and additional injuries

Revision as of 10:28, 27 April 2017

Background

  • Popliteal artery injury occurs in ~25% of cases
    • Neurologic injury/deficit may indicate vascular injury
  • Spontaneous reduction occurs in up to 50% of dislocations; often occurs prior to ED arrival

Types

  • Anterior (40%)
    • hyperextension mechanism
    • often involves PCL, ACL and either medial or lateral ligs are injured
  • Posterior (33%)
    • popliteal artery often injured
    • dash board injury
  • Lateral (18%)
  • Medial (4%)

Clinical Features

  • Suggested by severely injured knee that is unstable in multiple directions
  • Lateral collateral ligament injured with peroneal nerve palsy = knee dislocation

Associated Injuries

  • Nerve injury
    • Common peroneal nerve injury (25%)
      • Test for sensation in 1st dorsal web space, dorsiflexion of foot, extension of toes
    • Tibial nerve injured less often
  • Fractures
    • Femur and tibia most common
    • Check hip and ankle joints for associated fracture
    • Avulsion fractures common
  • Compartment syndrome risk high with vascular compromise

Differential Diagnosis

Knee diagnoses

Acute knee injury

Nontraumatic/Subacute

Evaluation

  • Knee x-ray (to rule-out fracture); consider CT
  • Vascular assessment
    • Assess popliteal and distal pulses
    • Measure ABIs
      • ABI >0.9 - serial exams
      • ABI <0.9 - arterial duplexes or CT angio

Management

  • Reduce immediately
    • Posterior dislocation
      • Assistant holds distal femur and gently pulls counter-traction
      • Provider pulls proximal tibia longitudinally then anteriorly
      • Prevent additional arterial injury by limiting excessive force
    • Anterior dislocation
      • As above, but reversed. Provider pulls gently counter traction on proximal tibia while assistant pulls distal femure proximally then anteriorly
    • Splint in 10-15 degrees of flexion [1]
  • Monitor for compartment syndrome
    • no pulses: reduce immediately
    • no pulses post reduction: surgical exploration
      • ischemic time >8 hours has amputation rates as high as 86%
  • Neurological assessment
    • Peroneal nerve most commonly injured
      • Test for sensation in 1st dorsal web space, dorsiflexion of foot, extension of toes

Disposition

  • Institution will dictation admission process
    • Suggested algorithm
      • If: Strong pulses + ABI >0.9 + normal ultrasound, admit for obs and serial vascular exams
      • If: Good perfusion + asymmetric pulses or ABI <0.9 or abnormal ultrasound, consult vascular surgery + obtain CTA
      • If: Weak pulses or signs of ischemia = emergent vascular surgery consult and OR
  • Consider trauma consult depending on mechanism and additional injuries

References

  1. ↑ Davenport M. Procedures for orthopedic emergencies. In: Bond M, ed. Orthopedic Emergencies: Expert Management for the Emergency Physician. Cambridge: Cambridge University Press; October 31, 2013.


  • Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
  • AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
  • Levy BA, Fanelli GC, Whelan DB, Stannard JP, MacDonald PA, Boyd JL, Marx RG, Stuart MJ. Knee Dislocation Study Group. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009 Apr;17(4):197-206. http://www.ncbi.nlm.nih.gov/pubmed/19307669

See Also

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