eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Dislocation, Knee: Treatment & Medication
Updated: Oct 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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.
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 Media files 3 and 5, respectively.
Lateral knee dislocation.
Lateral knee dislocation after reduction (same patient as in Image 2).
- 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.
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.
Medication
NSAIDs, analgesics, and anxiolytics are used to treat the pain associated with dislocations.
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with injuries.
Fentanyl citrate (Duragesic, Sublimaze)
Narcotic analgesic with greater potency and much shorter half-life than morphine sulfate. Excellent choice for pain management and sedation with its short duration time (30-60 min) and ease of titration. Easily and quickly reversed by naloxone. After initial dose, subsequent doses should not be titrated more frequently than q3h or q6h.
Adult
0.5-1 mcg/kg/dose IV/IM q30-60min
Pediatric
<2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg/dose IV/IM q60min
>12 years: Administer as in adults
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation
Meperidine (Demerol)
Narcotic analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Adult
50-150 mg PO/IV/IM/SC q3-4h prn
Pediatric
1-1.8 mg/kg (0.5-0.8 mg/lb) PO/IV/IM/SC q3-4h prn; not to exceed adult dose
Cimetidine may increase respiratory and CNS depression; hydantoins may decrease effects; avoid with protease inhibitors
Documented hypersensitivity; concurrent MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with head injuries, since meperidine may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex); substantially increased dose levels, due to tolerance, may aggravate or cause seizures even if no prior history of convulsive disorders; monitor closely for meperidine-induced seizure activity if prior seizure history
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for treatment of mild to moderately severe pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tabs/d
Pediatric
0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen or 5 mg of hydrocodone bitartrate/dose
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite which may cause hypersensitivity; caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and aspirin (Percodan)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity; may potentiate anticoagulant effects of warfarin
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association of aspirin with Reye syndrome, do not use in children (<16 y) who have flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Anxiolytics
Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.
Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent for patients who require sedation for longer than 24 h. Monitor BP after administering and adjust as necessary.
Adult
1-10 mg/d PO/IV/IM divided bid/tid; not to exceed 4 mg/dose
Pediatric
0.05-0.1 mg/kg IV slowly over 2-5 min; may repeat a dose of 0.05 mg/kg IV slowly; not to exceed 4 mg/dose
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Nonsteroidal anti-inflammatory agents (NSAIDs)
These agents are used most commonly for the relief of mild to moderately severe pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, inhibiting prostaglandin synthesis.
Adult
200-400 mg PO q4-6h prn; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT carefully and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (monitor PT carefully and instruct patients to watch for signs of bleeding)
Ketoprofen (Oruvail, Orudis, Actron)
Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with a small body size, the elderly, and those with renal or liver disease. Doses higher than 75 mg do not increase its therapeutic effects. Administer high doses with caution and closely observe the patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT carefully and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (monitor PT carefully and instruct patient to monitor for signs of bleeding)
Flurbiprofen (Ansaid, Ocufen)
Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT carefully and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.
Adult
500 mg PO initial dose, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
More on Dislocation, Knee |
| Overview: Dislocation, Knee |
| Differential Diagnoses & Workup: Dislocation, Knee |
 Treatment & Medication: Dislocation, Knee |
| Follow-up: Dislocation, Knee |
| Multimedia: Dislocation, Knee |
| References |
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References
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Further Reading
Keywords
knee dislocation, dislocated knee, dislocated knee symptoms, dislocated knee treatment, knee cap injury, knee injury, popliteal artery injury, knee hyperextension, trauma to the knee
