Knee Fracture Management in the Emergency Department Treatment & Management

Updated: Apr 13, 2020
  • Author: Mark Steele, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

Emergency Department Care

Patella 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. [25, 28, 29]

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. [25, 28, 29]

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. [28]

Tibial spine fracture

For a nondisplaced fracture (and stable knee joint), immobilize the knee. [25, 28, 29]

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. [25, 28, 29]

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. [25, 28, 29]

Obtain an orthopedic consultation for displaced (depressed) fractures, which require open reduction and internal fixation. [30] Articular depression greater than 3 mm may be considered for surgery. In an elderly patient, a total knee arthroplasty is a less common option. [31]

 

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Complications

Complications include the following:

  • Neurovascular injury: This includes popliteal artery injury due to displaced distal femur or tibial plateau fractures and 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. [32]  Compartment syndrome by definition has increased compartment pressures; therefore, palpation of the affected area frequently aids in the diagnosis. [32]  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. [32]

  • Soft tissue infection

  • Osteomyelitis secondary to an open fracture

  • Delayed union or nonunion

  • Fat embolism

  • Thrombophlebitis

  • Posttraumatic arthritis or knee stiffness

  • Chondromalacia patella

Nonunion, infection, posttraumatic arthritis, arthrofibrosis, symptomatic hardware, and extensor mechanism insufficiency have all been described following patellar repair, and the risk of their occurrence may be augmented by patient-, injury-, and treatment-related factors. [9]

In pediatric patients, complications of healing after tibial fractures are uncommon, although some tibial shaft fractures exhibit delayed union or nonunion, infection, and soft tissue complications. [33]

Tibial tubercle fractures represent high-energy injuries with potential complications such as compartment syndrome and/or vascular compromise. [34]

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