Knee Dislocation in Emergency Medicine Follow-up

  • Author: H Brendan Kelleher, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Jan 11, 2011
 

Further Inpatient Care

Historically, conventional arteriography was recommended for all cases of knee dislocation and, though it remains the criterion standard for popliteal artery evaluation, there is growing debate over its universal application.

Vascular assessment with the ankle-brachial index, duplex sonography, and/or CT angiography is changing this paradigm while an increasing number of popliteal injuries are being managed nonsurgically (generally those that show no significant thrombosis at 48-72 h). Many surgeons thus argue that arteriography should not be routine and that case-by-case utilization of other imaging modalities combined with vigilant observation is sufficient.

For the EM physician, it is important to recognize that vascular examination findings may be normal in the presence of significant popliteal artery injury[2, 3] and that some combination of further investigation/observation is warranted in all knee dislocations. This may be different for each institution and/or each surgeon and should be decided on in a case-by-case basis in conjunction with the vascular consult.

Time is of utmost concern, as vascular repair delayed more than 8 hours after injury carries an amputation rate of greater than 80%. In contrast, operative vascular repair within 8 hours of injury yields a limb-salvage rate of 80%.

The repair of coexistent popliteal vein injury is controversial. Fasciotomy is recommended after vascular repair, as severe swelling and development of compartment syndrome are common in the postoperative phase.

Operative repair of nerve injury remains controversial, as a poor prognosis is common with both operative and nonoperative care.

Operative ligamentous repair is recommended by most authors, as functional results are better than those of nonoperative care, but determining the ideal timing of this intervention is complex and is a decision best left to the orthopedist.

Next

Transfer

  • Patients considered for transfer should have undergone emergency reduction of the knee dislocation. Since time is crucial in salvaging the limb after a vascular injury, transfer should be initiated only if vascular consultation and/or evaluation are not available at the transferring institution or if an arteriogram has been performed and results are normal.
Previous
Next

Complications

  • Popliteal artery injury
  • Popliteal vein injury
  • Peroneal nerve injury
  • Ligamentous injury
  • Compartment syndrome
Previous
Next

Prognosis

  • When treated expeditiously and appropriately, 60-70% of patients will have a painless, stable knee. Of the remaining patients, one half will eventually have reasonable function, while the other half will have a chronically unstable and painful knee.
Previous
Next

Patient Education

Previous
 
Contributor Information and Disclosures
Author

H Brendan Kelleher, MD  Assistant Professor of Clinical Emergency Medicine, University of Southern California Keck School of Medicine; Assistant Residency Director, Department of Emergency Medicine, University of Southern California Los Angeles County Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Diku Mandavia, MD, FACEP, FRCPC  Attending Staff Physician, Department of Emergency Medicine, Cedars-Sinai Medical Center; Clinical Associate Professor of Emergency Medicine, Los Angeles County-USC Medical Center; Co-Editor, Color Atlas of Emergency Trauma

Disclosure: Nothing to disclose.

Specialty Editor Board

James E Keany, MD, FACEP  Medical Director, TravelMDAssist; Staff Physician, Department of Emergency Services, Mission Hospital Regional Medical Center

James E Keany, MD, FACEP, is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and California Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Tom Scaletta, MD  Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Seroyer ST, Musahl V, Harner CD. Management of the acute knee dislocation: the Pittsburgh experience. Injury. Jul 2008;39(7):710-8. [Medline].

  2. Snyder WH III, Thal ER, Bridges RA, et al. The validity of normal arteriography in penetrating trauma. Archives of Surgery. 1978;113:424-426.

  3. Rose SC, Moore EE. Trauma angiography: the use of clinical findings to improve patient selection and case preparation. J Trauma. Feb 1988;28(2):240-5. [Medline].

  4. Lynch K, Johansen K. Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma?. Ann Surg. Dec 1991;214(6):737-41. [Medline].

  5. Johansen K, Lynch K, Paun M, Copass M. Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma. Apr 1991;31(4):515-9; discussion 519-22. [Medline].

  6. Fry WR, Smith RS, Sayers DV, Henderson VJ, Morabito DJ, Tsoi EK, et al. The success of duplex ultrasonographic scanning in diagnosis of extremity vascular proximity trauma. Arch Surg. Dec 1993;128(12):1368-72. [Medline].

  7. Inaba K, Potzman J, Munera F, McKenney M, Munoz R, Rivas L, et al. Multi-slice CT angiography for arterial evaluation in the injured lower extremity. J Trauma. Mar 2006;60(3):502-6; discussion 506-7. [Medline].

  8. Soto JA, Munera F, Cardoso N, Guarin O, Medina S. Diagnostic performance of helical CT angiography in trauma to large arteries of the extremities. J Comput Assist Tomogr. Mar-Apr 1999;23(2):188-96. [Medline].

  9. Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA. Detecting vascular injury in lower-extremity orthopedic trauma: the role of CT angiography. Orthopedics. Aug 2008;31(8):761-7. [Medline]. [Full Text].

  10. Knudson MM, Lewis FR, Atkinson K, Neuhaus A. The role of duplex ultrasound arterial imaging in patients with penetrating extremity trauma. Arch Surg. Sep 1993;128(9):1033-7; discussion 1037-8. [Medline].

  11. Zierler RE. Vascular surgery without arteriography: use of Duplex ultrasound. Cardiovasc Surg. Jan 1999;7(1):74-82. [Medline].

  12. Barnes CJ, Pietrobon R, Higgins LD. Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. J Trauma. Dec 2002;53(6):1109-14. [Medline].

  13. Browner BD, Jupiter JB, Levine AM. Dislocations and soft tissue injuries of the knee. In: Skeletal Trauma. Vol 2. WB Saunders Co; 1992:1717-1741.

  14. Chhabra A, Cha PS, Rihn JA, Cole B, Bennett CH, Waltrip RL. Surgical management of knee dislocations. Surgical technique. J Bone Joint Surg Am. Mar 2005;87 Suppl 1(Pt 1):1-21. [Medline].

  15. Cone JB. Vascular injury associated with fracture-dislocations of the lower extremity. Clin Orthop. Jun 1989;(243):30-5. [Medline].

  16. Dennis JW, Jagger C, Butcher JL, et al. Reassessing the role of arteriograms in the management of posterior knee dislocations. J Trauma. Nov 1993;35(5):692-5; discussion 695-7. [Medline].

  17. Giannoulias CS, Freedman KB. Knee dislocations: management of the multiligament-injured knee. Am J Orthop. Nov 2004;33(11):553-9. [Medline].

  18. Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations. J Bone Joint Surg Am. Feb 2004;86-A(2):262-73. [Medline].

  19. Henrichs A. A review of knee dislocations. J Athl Train. Oct-Dec 2004;39(4):365-9. [Medline].

  20. Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg Am. Jul 1963;45:889-904. [Medline].

  21. Klineberg EO, Crites BM, Flinn WR, et al. The role of arteriography in assessing popliteal artery injury in knee dislocations. J Trauma. Apr 2004;56(4):786-90. [Medline].

  22. Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy. Apr 2009;25(4):430-8. [Medline].

  23. McDonough EB Jr, Wojtys EM. Multiligamentous injuries of the knee and associated vascular injuries. Am J Sports Med. Jan 2009;37(1):156-9. [Medline].

  24. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. Jun 2004;56(6):1261-5. [Medline].

  25. Nicandri GT, Chamberlain AM, Wahl CJ. Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries. Clin J Sport Med. Mar 2009;19(2):125-9. [Medline].

  26. Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. Oct 2007;63(4):855-8. [Medline].

  27. Rihn JA, Groff YJ, Harner CD, Cha PS. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg. Sep-Oct 2004;12(5):334-46. [Medline].

  28. Robertson A, Nutton RW, Keating JF. Dislocation of the knee. J Bone Joint Surg Br. Jun 2006;88(6):706-11. [Medline].

  29. Rockwood CA, Green DP, Bucholz RW. Injuries of the knee. In: Fractures in Adults. Vol 2. Lippincott Williams & Wilkins Publishers; 1996:2112-2126.

  30. Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. May 2004;86-A(5):910-5. [Medline].

  31. Varnell RM, Coldwell DM, Sangeorzan BJ, Johansen KH. Arterial injury complicating knee disruption. Third place winner: Conrad Jobstaward. Am Surg. Dec 1989;55(12):699-704. [Medline].

  32. Welling RE, Kakkasseril J, Cranley JJ. Complete dislocations of the knee with popliteal vascular injury. J Trauma. Jun 1981;21(6):450-3. [Medline].

 
Previous
Next
 
Types of knee dislocation.
Posterior knee dislocation.
Lateral knee dislocation (before reduction).
Open knee dislocation.
Lateral knee dislocation after reduction.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.