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 below.

Lateral knee dislocation (before reduction).

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Lateral knee dislocation after reduction.

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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.

Medication

Georgiadis AG, Mohammad FH, Mizerik KT, Nypaver TJ, Shepard AD. Changing presentation of knee dislocation and vascular injury from high-energy trauma to low-energy falls in the morbidly obese. J Vasc Surg. 2013 May. 57(5):1196-203. [QxMD MEDLINE Link].
Henrichs A. A review of knee dislocations. J Athl Train. 2004 Oct-Dec. 39(4):365-9. [QxMD MEDLINE Link].
McDonough EB Jr, Wojtys EM. Multiligamentous injuries of the knee and associated vascular injuries. Am J Sports Med. 2009 Jan. 37(1):156-9. [QxMD MEDLINE Link].
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. 2007 Oct. 63(4):855-8. [QxMD MEDLINE Link].
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. 2004 May. 86-A(5):910-5. [QxMD MEDLINE Link].
Knutson T, Bothwell J, Durbin R. Evaluation and management of traumatic knee injuries in the emergency department. Emerg Med Clin North Am. 2015 May. 33 (2):345-62. [QxMD MEDLINE Link].
Bouaicha S. [The acute knee injury - practical considerations]. Praxis (Bern 1994). 2014 Apr 9. 103 (8):439-44. [QxMD MEDLINE Link].
Richter DL, Bankhead CP, Wascher DC, Treme GP, Veitch A, Schenck RC Jr. Knee Dislocation (KD) IV Injuries of the Knee: Presentation, Treatment, and Outcomes. Clin Sports Med. 2019 Apr. 38 (2):247-260. [QxMD MEDLINE Link].
Gottlieb M, Koyfman A, Long B. Evaluation and Management of Knee Dislocation in the Emergency Department. J Emerg Med. 2019 Nov 8. [QxMD MEDLINE Link].
Mohseni M, Simon LV. Knee Dislocation. 2019 Jan. [QxMD MEDLINE Link]. [Full Text].
Fanelli GC. Knee Dislocation and Multiple Ligament Injuries of the Knee. Sports Med Arthrosc Rev. 2018 Dec. 26 (4):150-152. [QxMD MEDLINE Link].
Tuite MJ, Daffner RH, Weissman BN, Bancroft L, Bennett DL, Blebea JS, et al. ACR appropriateness criteria(®) acute trauma to the knee. J Am Coll Radiol. 2012 Feb. 9 (2):96-103. [QxMD MEDLINE Link].
Naziri Q, Beyer GA, Shah NV, Solow M, Hayden AJ, Nadarajah V, et al. Knee dislocation with popliteal artery disruption: A nationwide analysis from 2005 to 2013. J Orthop. 2018 Sep. 15 (3):837-841. [QxMD MEDLINE Link].
Chowdhry M, Burchette D, Whelan D, Nathens A, Marks P, Wasserstein D. Knee dislocation and associated injuries: an analysis of the American College of Surgeons National Trauma Data Bank. Knee Surg Sports Traumatol Arthrosc. 2019 Sep 26. [QxMD MEDLINE Link].
KENNEDY JC. COMPLETE DISLOCATION OF THE KNEE JOINT. J Bone Joint Surg Am. 1963 Jul. 45:889-904. [QxMD MEDLINE Link].
Moatshe G, Dornan GJ, Løken S, Ludvigsen TC, LaPrade RF, Engebretsen L. Demographics and Injuries Associated With Knee Dislocation: A Prospective Review of 303 Patients. Orthop J Sports Med. 2017 May. 5 (5):2325967117706521. [QxMD MEDLINE Link].
Sonnery-Cottet B, Abreu FG, Saithna A, Ouanezar H, Fernandes LR, Fayard JM, et al. Successful Return to Elite Sport After Bilateral Knee Dislocations: A Case Report. Orthop J Sports Med. 2019 May. 7 (5):2325967119845017. [QxMD MEDLINE Link].
James EW, Williams BT, LaPrade RF. Stress radiography for the diagnosis of knee ligament injuries: a systematic review. Clin Orthop Relat Res. 2014 Sep. 472 (9):2644-57. [QxMD MEDLINE Link].
Snyder WH III, Thal ER, Bridges RA, et al. The validity of normal arteriography in penetrating trauma. Archives of Surgery. 1978. 113:424-426.
Rose SC, Moore EE. Trauma angiography: the use of clinical findings to improve patient selection and case preparation. J Trauma. 1988 Feb. 28(2):240-5. [QxMD MEDLINE Link].
Everhart JS, Du A, Chalasani R, Kirven JC, Magnussen RA, Flanigan DC. Return to Work or Sport After Multiligament Knee Injury: A Systematic Review of 21 Studies and 524 Patients. Arthroscopy. 2018 May. 34 (5):1708-1716. [QxMD MEDLINE Link].
Darcy G, Edwards E, Hau R. Epidemiology and outcomes of traumatic knee dislocations: Isolated vs multi-trauma injuries. Injury. 2018 Jun. 49 (6):1183-1187. [QxMD MEDLINE Link].
Woodmass JM, Johnson NR, Mohan R, Krych AJ, Levy BA, Stuart MJ. Poly-traumatic multi-ligament knee injuries: is the knee the limiting factor?. Knee Surg Sports Traumatol Arthrosc. 2018 Sep. 26 (9):2865-2871. [QxMD MEDLINE Link].
Seroyer ST, Musahl V, Harner CD. Management of the acute knee dislocation: the Pittsburgh experience. Injury. 2008 Jul. 39(7):710-8. [QxMD MEDLINE Link].
Lynch K, Johansen K. Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma?. Ann Surg. 1991 Dec. 214(6):737-41. [QxMD MEDLINE Link].
Johansen K, Lynch K, Paun M, Copass M. Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma. 1991 Apr. 31(4):515-9; discussion 519-22. [QxMD MEDLINE Link].
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. 1993 Dec. 128(12):1368-72. [QxMD MEDLINE Link].
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. 2006 Mar. 60(3):502-6; discussion 506-7. [QxMD MEDLINE Link].
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. 1999 Mar-Apr. 23(2):188-96. [QxMD MEDLINE Link].
Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA. Detecting vascular injury in lower-extremity orthopedic trauma: the role of CT angiography. Orthopedics. 2008 Aug. 31(8):761-7. [QxMD MEDLINE Link]. [Full Text].
Knudson MM, Lewis FR, Atkinson K, Neuhaus A. The role of duplex ultrasound arterial imaging in patients with penetrating extremity trauma. Arch Surg. 1993 Sep. 128(9):1033-7; discussion 1037-8. [QxMD MEDLINE Link].
Zierler RE. Vascular surgery without arteriography: use of Duplex ultrasound. Cardiovasc Surg. 1999 Jan. 7(1):74-82. [QxMD MEDLINE Link].
Cone JB. Vascular injury associated with fracture-dislocations of the lower extremity. Clin Orthop. 1989 Jun. (243):30-5. [QxMD MEDLINE Link].
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. 2002 Dec. 53(6):1109-14. [QxMD MEDLINE Link].
Browner BD, Jupiter JB, Levine AM. Dislocations and soft tissue injuries of the knee. Skeletal Trauma. WB Saunders Co; 1992. Vol 2: 1717-1741.
Chhabra A, Cha PS, Rihn JA, Cole B, Bennett CH, Waltrip RL. Surgical management of knee dislocations. Surgical technique. J Bone Joint Surg Am. 2005 Mar. 87 Suppl 1(Pt 1):1-21. [QxMD MEDLINE Link].
Dennis JW, Jagger C, Butcher JL, et al. Reassessing the role of arteriograms in the management of posterior knee dislocations. J Trauma. 1993 Nov. 35(5):692-5; discussion 695-7. [QxMD MEDLINE Link].
Giannoulias CS, Freedman KB. Knee dislocations: management of the multiligament-injured knee. Am J Orthop. 2004 Nov. 33(11):553-9. [QxMD MEDLINE Link].
Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004 Feb. 86-A(2):262-73. [QxMD MEDLINE Link].
Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg Am. 1963 Jul. 45:889-904. [QxMD MEDLINE Link].
Klineberg EO, Crites BM, Flinn WR, et al. The role of arteriography in assessing popliteal artery injury in knee dislocations. J Trauma. 2004 Apr. 56(4):786-90. [QxMD MEDLINE Link].
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. 2009 Apr. 25(4):430-8. [QxMD MEDLINE Link].
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. 2004 Jun. 56(6):1261-5. [QxMD MEDLINE Link].
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. 2009 Mar. 19(2):125-9. [QxMD MEDLINE Link].
Rihn JA, Groff YJ, Harner CD, Cha PS. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg. 2004 Sep-Oct. 12(5):334-46. [QxMD MEDLINE Link].
Robertson A, Nutton RW, Keating JF. Dislocation of the knee. J Bone Joint Surg Br. 2006 Jun. 88(6):706-11. [QxMD MEDLINE Link].
Rockwood CA, Green DP, Bucholz RW. Injuries of the knee. Fractures in Adults. Lippincott Williams & Wilkins Publishers; 1996. Vol 2: 2112-2126.
Varnell RM, Coldwell DM, Sangeorzan BJ, Johansen KH. Arterial injury complicating knee disruption. Third place winner: Conrad Jobstaward. Am Surg. 1989 Dec. 55(12):699-704. [QxMD MEDLINE Link].
Welling RE, Kakkasseril J, Cranley JJ. Complete dislocations of the knee with popliteal vascular injury. J Trauma. 1981 Jun. 21(6):450-3. [QxMD MEDLINE Link].
Levy BA, Fanelli GC, Whelan DB, et al. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009 Apr. 17 (4):197-206. [QxMD MEDLINE Link].

Media Gallery

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

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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

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

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, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

James E Keany, MD, FACEP Associate Medical Director, Emergency Services, Mission Hospital Regional Medical Center, Children's Hospital of Orange County at Mission

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

Disclosure: Nothing to disclose.

Acknowledgements

Tom Scaletta, MD President, Smart-ER (http://smart-er.net); Chair, 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.

Knee Dislocation Treatment & Management

Emergency Department Care

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