Knee Dislocation in Emergency Medicine Treatment & Management

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

Prehospital Care

  • Prehospital personnel should splint the extremity and provide rapid transport to a medical facility.
  • Perform field reduction for patients with evidence of vascular compromise.
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Emergency Department Care

  • Do not delay reduction in limbs with obvious vascular impairment. Only patients with good peripheral pulses should undergo prereduction radiographs.
  • Reduction is straightforward and often easily accomplished in the ED. After adequate sedation, longitudinal traction will relocate the majority of knee dislocations. Prereduction and postreduction photos of a lateral knee dislocation are shown in the images below. Lateral knee dislocation (before reduction). Lateral knee dislocation (before reduction). Lateral knee dislocation after reduction. Lateral knee dislocation after reduction.
  • Posterolateral dislocations are particularly difficult and often require operative reduction. This is especially true when the medial femoral condyle button-holes through the medial aspect of the joint capsule and/or MCL — an occurrence that is often accompanied by a "dimple sign" overlying the medial aspect of the knee.
  • After reduction, splint the lower extremity in approximately 20 degrees of flexion to avoid postreduction re-dislocation, apply ice, and keep the knee elevated.
  • Postreduction radiographs should be obtained, preferably before further ligamentous stressing/assessment.
  • Postreduction hard signs of arterial injury should prompt emergent vascular surgical intervention that should not be delayed for arteriography. In this setting, arteriograms may indeed be contributory to the surgical decision matrix but can be performed in the operating room by the vascular surgeon with less contrast administration than traditional arteriography tends to use.
  • All reduced knee dislocations without hard signs of arterial injury should be assessed with ABI/API measurements. Any reading of less than 0.90 should prompt further imaging (ie, arteriography vs CT angiography vs duplex sonography), which should be decided upon in conjunction with the vascular consult.
  • All knee dislocations, regardless of emergent revascularization needs, should be admitted for serial perfusion checks.
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Consultations

Always consult both orthopedic and vascular surgeons. Many patients have significant vascular injury requiring surgical revascularization, and all patients will at least require admission for serial vascular checks and further surgical stabilization consideration.

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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].

 
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Types of knee dislocation.
Posterior knee dislocation.
Lateral knee dislocation (before reduction).
Open knee dislocation.
Lateral knee dislocation after reduction.
 
 
 
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