Traumatic Knee Dislocations

Knee dislocations are catastrophic injuries that demand emergent evaluation and often require a multidisciplinary approach. Long-term outcome studies are relatively scarce secondary to the variability in any given study population and the wide variety of injury patterns between knee dislocations. Multiple controversies exist with regard to outcomes using various treatment methods (early vs late intervention, graft selection, repair vs reconstruction of medial and lateral structures, rehabilitation regimens). Careful clinical evaluation is essential when knee dislocation is suspected.

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Clinicians must be aware of the existence of an irreducible knee dislocation. Use caution during reduction and cognizant of signs (dimple sign, excessive force required for reduction, joint asymmetry after reduction attempt). The cases should undergo open reduction in the operating room.

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Contrary to intuition, the reported incidence of nerve injury in ultralow-energy knee dislocations is higher (44.4%) than the incidence in the higher-energy trauma patients. These patients are often obese; though the operative times are longer and the procedures more difficult, knee range of motion in those operated on was significantly better (average 91.4°) than those treated nonoperatively (average 53.6°).

Secondary

After the limb is reduced, vascular injury is ruled out and grossly unstable knees are stabilized; advanced imaging is appropriate. Computed tomography (CT), MRI, or both may be appropriate. CT is used to better understand the personality of any fracture, whereas MRI can elucidate soft tissue and ligament injuries not appreciated on physical examination. Both aid in operative planning.

Determination of ligamentous injury in the emergency room will govern the next step in the treatment algorithm. If the postreduction knee is grossly unstable, a temporizing knee-spanning external fixator may be placed to provide stability and allow soft tissues to calm down. If the knee is not grossly unstable, placement into a knee immobilizer is recommended instead of circumferential splinting or casting, which increase the chance of compartment syndrome secondary to limited material compliance. Serial examination may reveal increasing swelling and progressing compartment syndrome, which require 4-compartment fasciotomy.

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