eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Knee
Updated: Mar 31, 2008
Introduction
Background
Fractures of the knee include fractures of the patella, femoral condyles, tibial eminence, tibial tuberosity, and tibial plateau. Direct and indirect forces can cause these fractures.
Frequency
United States
Patellar and tibial plateau fractures each account for 1% of all skeletal fractures. Distal femoral condyle fractures account for 4% of all femur fractures.
Mortality/Morbidity
- Fractures of the knee can result in neurovascular compromise or compartment syndrome, with resultant risk of limb loss. Soft-tissue infection or osteomyelitis can occur with open fractures.
- Other complications include nonunion, delayed union, osteoarthritis, avascular necrosis, fat embolism, and thrombophlebitis.
Clinical
History
Patients with knee fractures may have a history of the following:
- Direct or indirect trauma with resultant pain and edema
- Patella fracture
- Caused by a direct blow, such as a dashboard injury in a motor vehicle accident or a fall on a flexed knee
- Also caused by forceful quadriceps contraction while the knee is in the semiflexed position (eg, in a stumble or fall)
- Femoral condyle fractures due to axial loading with valgus or varus stress
- Tibial eminence fracture
- Due to a direct blow to the proximal tibia with the knee flexed such as falling off a bicycle
- Also due to hyperextension with varus or valgus stress, such as in motor vehicle collisions or athletic accidents
- Tibial eminence avulsion fractures occur most often in children aged 8-14 years but can also occur in the skeletally mature patient.
- Tibial tubercle fracture
- Usually occur with jumping activities such as basketball, diving, gymnastics, and football
- More common in males than in females
- More common in adolescents; infrequent in adults
- Tibial plateau fracture
- Caused by axial loading with valgus or varus forces, such as in a fall from a height or collision with the bumper of a car
- Due to the impaction of the femoral condyle into the tibial plateau
- In elderly persons and those with osteoporosis, tibial plateau fracture can occur with minor trauma.
- Patient is generally unable to bear weight.
- The lateral tibial plateau is fractured more frequently than the medial plateau.
Physical
When examining a patient for a knee fracture, one should first examine the patient for edema, ecchymosis, and point tenderness. A careful neurovascular examination should be performed. Ask the patient to perform a straight-leg raise against gravity to check the integrity of the extensor mechanism, which commonly is disrupted with transverse patellar fractures caused by indirect forces.
- Patella fractures
- Patients present with pain directly over the patella.
- The patient may have pain with leg extension or be unable to extend the knee with a severe fracture.
- Femoral condyle fractures
- Patient will present with pain over the distal femur and often will have a hemarthrosis.
- Patients are often unable to bear weight.
- Tibial eminence fractures
- Patients may present with a knee effusion and pain.
- Patients may represent with an avulsion of the tibial attachment of the anterior cruciate ligament.
- Tibial tubercle fractures
- Patients present with pain over the anterior tibia about 3 cm distal to the articular surface.
- In severe fractures, the patient may be unable to extend the knee.
- Tibial plateau fractures
- Often, patients present with a knee effusion, and tenderness will be present over the medial or lateral plateau.
- Up to 30% of tibial plateau fractures are associated with knee ligamentous injuries (medial collateral or anterior cruciate ligaments with lateral plateau fractures, lateral collateral or posterior cruciate ligaments with medial plateau fractures).
Causes
Knee fractures may be caused by the following:
- Trauma (direct or indirect)
- Chronic stress
- Pathologic conditions
Differential Diagnoses
Dislocations, Knee
Fractures, Femur
Fractures, Tibia and Fibula
Knee Injury, Soft Tissue
Osgood-Schlatter Disease
Trauma, Peripheral Vascular Injuries
Other Problems to Be Considered
- Bipartite patella
- A congential fragmentation of the patella
- Has smooth cortical margins
- Most common location is superolateral pole of patella; however, it can occur in the inferior pole or the lateral margin.
- Stress fractures
- Ligamentous injuries
Workup
Imaging Studies
- Radiographs
- Obtain anteroposterior, lateral, and oblique radiographs of the knee. Four views have been shown to be superior to two views in detecting fractures.
- Oblique views are particularly useful in detecting subtle tibial plateau fractures (internal oblique profiles lateral plateau, external oblique profiles medial plateau). Oblique views also better identify obliquely oriented femoral condyle fractures.
- An axial (or sunrise) view of the patella is useful for detecting vertical patellar fractures, which frequently are missed and nondisplaced. Transverse fractures are most common, followed by comminuted and avulsion-fractures. Adding a sunrise view increases the negative predictive value of radiographs for ruling out patellar fracture.
- A fat-fluid level (lipohemarthrosis) may be identified on a lateral view of the knee; this finding indicates an intra-articular fracture.
- Radiographic evidence of ligamentous injury may be present:
- An avulsion fracture at the site of attachment of the lateral capsular ligament on the lateral tibial condyle (Segond fracture) is a marker for anterior cruciate ligament rupture.
- Cortical avulsion fracture of medial tibial plateau (uncommon) is associated with tears of the posterior cruciate ligament and medial meniscus.
- A patellar spur at the superior portion of the patella is associated with a ruptured quadriceps tendon.
- Use of the Ottawa rules for obtaining knee radiographs have proven sensitive for fracture and have reduced ED waiting times and costs. The rules include the following patient findings:
- Age 55 years or older
- Tenderness at head of fibula
- Isolated tenderness of patella
- Inability to flex knee to 90 degrees
- Inability to bear weight (4 steps) immediately after injury and in ED
- CT scans and MRIs
- CT scans may be necessary to fully delineate the extent of tibial plateau fractures and other complex knee fractures.
- Compared to CT scans, plain radiography underestimates the amount of articular depression of tibial plateau fractures in most tibial regions. This is significant as the amount of tibial plateau depression is an indicator for operative repair.
- CT scans are also useful in severely injured patients when obtaining radiographs in all angles is difficult.
- MRIs also are useful and have the added benefit of depicting associated soft-tissue (eg, ligamentous, meniscal) injury.
Procedures
- Arthrocentesis may be of diagnostic and therapeutic benefit for tense effusions. Presence of blood and glistening fat globules indicates lipohemarthrosis, which is pathognomonic for intraarticular knee fracture.
Treatment
Prehospital Care
- Document the neurovascular status.
- Apply a sterile dressing to open wounds.
- Splint the injury.
- Administer parenteral analgesics for isolated extremity injury.
Emergency Department Care
Care for various fractures is as follows:
- Patellar fracture
- Nondisplaced transverse fractures with an intact extensor mechanism are treated with a knee immobilizer, crutches, restriction to only partial weight bearing, and 6 weeks of immobilization.
- Displaced fractures, or fractures associated with a disrupted extensor mechanism, are referred to orthopedics for possible open reduction and internal fixation. A partial or total patellectomy may be required for severe comminution.
- Patients with open fractures should receive antibiotics and orthopedics should be consulted for emergency irrigation and debridement.
- Femoral condyle fracture
- These may be supracondylar, intercondylar, or condylar.
- Due to the proximity of the neurovascular structures, a thorough neurovascular examination must be obtained.
- Obtain an orthopedic consult. Nonoperative management may be used for nondisplaced or incomplete fractures. Open fractures, displaced fractures, and those with neurovascular injury will need operative fixation.
- Tibial spine fracture
- For a nondisplaced fracture (and stable knee joint), immobilize the knee.
- Obtain an orthopedic consultation for an unstable knee, a complete avulsion of the tibial spine, or a displaced fracture for possible surgical fixation.
- Tibial tubercle fracture
- For nondisplaced fractures, immobilize the knee.
- Obtain an orthopedic consultation for displaced fracture to consider open reduction and internal fixation.
- Tibial plateau fracture
- Immobilize nondisplaced fractures and have patient remain nonweightbearing.
- Obtain an orthopedic consultation for displaced (depressed) fractures, which require open reduction and internal fixation. Articular depression of greater than 3 mm may be considered for surgery.
- The goal of treatment is a stable, aligned, mobile, and painless knee joint to minimize risk of posttraumatic osteoarthritis.
Consultations
- Orthopedic referral is recommended for all knee fractures.
- Nondisplaced fractures may be splinted, with orthopedic follow-up care within a few days.
- Displaced or open fractures require prompt orthopedic consultation.
Medication
Opioid analgesics and nonsteroidal anti-inflammatory agents are the DOCs for pain associated with fractures.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Most commonly used for relief of mild to moderate pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen usually is the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderate pain, if no contraindications exist; inhibits inflammatory reactions and pain, probably by decreasing cyclooxygenase activity, which results in prostaglandin synthesis.
Dosing
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 tid/qid
>12 years: Administer as in adults
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Precautions
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 congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing cyclooxygenase activity, which decreases prostaglandin synthesis.
Dosing
Adult
500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d; may increase to 1.5 g/d for limited periods
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity
Precautions
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 may be at risk for acute renal failure; leukopenia occurs rarely and is transient, and condition usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation
Ketoprofen (Oruvail, Orudis, Actron)
Used for relief of mild to moderate pain and inflammation.
Administer small dosages initially to smaller patients, older persons, and those with renal or liver disease. Doses >75 mg do not increase its therapeutic effects. Administer high doses with caution and closely observe patient for response.
Dosing
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 prn
>12 years: Administer as in adults
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity
Precautions
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 congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
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 who have sustained fractures.
Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)
DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs and in those with upper GI disease or those taking oral anticoagulants.
Dosing
Adult
325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Interactions
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Contraindications
Documented hypersensitivity; known G-6-P deficiency
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in persons with chronic alcoholism, with various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen is in many OTC products, and combined use with these products may result in cumulative doses exceeding the recommended maximum dose
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for treatment of mild to moderate pain.
Dosing
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab PO q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose PO based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Interactions
Toxicity increases with use of CNS depressants or tricyclic antidepressants
Contraindications
Documented hypersensitivity
Precautions
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 the relief of moderate to severe pain.
Dosing
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose based on acetaminophen content PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d
Interactions
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Contraindications
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Precautions
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 acetaminophen (Percocet)
Drug combination indicated for relief of moderate to severe pain; DOC for aspirin-sensitive patients.
Dosing
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose based on oxycodone content PO; not to exceed 5 mg/dose of oxycodone PO q4-6h prn
Interactions
Phenothiazines may decrease analgesic effects; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Contraindications
Documented hypersensitivity
Precautions
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 patients; be aware of total daily dose of acetaminophen; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity
Oxycodone and aspirin (Percodan)
Drug combination indicated for relief of moderate to severe pain.
Dosing
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone PO q4-6h prn
Interactions
Phenothiazines may decrease analgesic effects; conversely, toxicity increases when administered with CNS depressants or tricyclic antidepressants; may potentiate anticoagulant effects of warfarin
Contraindications
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; <16 y with flu (because of association of aspirin with Reye syndrome)
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis
Morphine Sulfate (Duramorph, Astramorph, MS Contin)
DOC for narcotic analgesia due to its reliable and predictable effects, safety, and ease of reversibility with naloxone; IV doses vary and commonly are titrated until desired effect is obtained.
Dosing
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC, and reassess hemodynamic effects of dose
Pediatric
Infants and children: 0.1-0.2 mg/kg/dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose
Interactions
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects
Contraindications
Documented hypersensitivity; hypotension; potentially compromised airway where rapid establishment of airway control would be difficult
Precautions
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
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Follow-up
Transfer
- Transfer is appropriate if inpatient beds or operating rooms are unavailable or if an orthopedic specialist's services are indicated.
Complications
- Neurovascular injury
- Popliteal artery injury due to displaced distal femur or tibial plateau fractures
- Peroneal nerve injury due to proximal fibula fractures
- Compartment syndrome of the lower leg
- Signs of compartment syndrome include pain with passive movement of the involved muscles, paresthesias, pallor, and a very late finding of pulselessness.
- Compartment syndrome by definition has increased compartment pressures; therefore, palpation of the affected area frequently aids in the diagnosis. However, a soft extremity does not rule out compartment syndrome.
- If compartment syndrome is suspected, obtain an emergent orthopedic consultation and measure the compartment pressures. If untreated, increased compartment syndrome can cause permanent disability.
- Soft-tissue infection
- Osteomyelitis secondary to an open fracture
- Delayed union or nonunion
- Fat embolism
- Thrombophlebitis
- Posttraumatic arthritis or knee stiffness
- Chondromalacia patella
Prognosis
- A good prognosis is expected with patellar and tibial spine or tubercle fractures.
- A fair prognosis is expected with tibial plateau and femoral condyle fractures. A recent prospective study in patients with tibial plateau fractures showed that only 14% of patients recover full quadriceps muscle strength 1 year after injury. Also, 20% will have residual knee stiffness after 1 year.
Patient Education
- For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles, Knee Dislocation and Knee Injury.
Miscellaneous
Medicolegal Pitfalls
- Failure to identify neurovascular injury
- Failure to identify open fractures and obtain urgent orthopedic consultation
- Failure to check the integrity of and to identify injuries to extensor mechanism of the knee
- Failure to identify patients at risk of developing a compartment syndrome
References
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Keywords
knee fracture, patellar fracture, patella fracture, femoral condyle fractures, tibial eminence fracture, tibial spine fracture, tibial tubercle fracture, tibial plateau fracture, fracture of the knee, knee injury
Contributor Information and Disclosures
Author
Mark Steele, MD, Associate Dean for Truman Medical Center Programs, Professor, Department of Emergency Medicine, University of Missouri-Kansas City
Mark Steele, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Jeffrey G Norvell, MD, Clinical Assistant Professor of Emergency Medicine, University of Kansas School of Medicine
Jeffrey G Norvell, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Medical Editor
Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.
Managing Editor
Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
CME Editor
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
Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment
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