Knee
Dislocati
on
By Dr. HN Amunyela
Medical intern,
Windhoek hospital
complex, 2024
Table of content
1. Introduction
2. Epidemiology
3. Pathophysiology
4. Anatomy
5. Classification
6. Presentation
7. Imaging
8. Treatment
Introduction
• Knee dislocations are high energy traumatic injuries characterized by a
high rate of neurovascular injury.
• It should be recognized and managed appropriately early.
• Knee dislocation is an orthopedic emergency.
Epidemiology
• 0.02-0,2% of orthopedic injuries
• 4:1 male to female ratio
• tibiofemoral articulation (knee joint)
• Risk factors: morbid obesity associated with lower energy knee
dislocation.
Pathophysiology
Mechanism of injury
• high energy (MVA, crush injury, fall from a height, or dashboard injuries)
• low energy (athletic injury or routine walking)
• hyperextension injury leads to anterior dislocations
• posteriorly directed force across the proximal tibia (dashboard injuries)
leads to posterior dislocations
Associate
d injuries
•vascular injury
•nerve injury (common
peroneal nerve injury,
tibial nerve injury is less
common)
•fractures (present in
60% of dislocations)
•soft tissue injuries:
patellar tendon rupture,
periarticular avulsion &
displaced menisci
Anatom
y of the
knee
joint
Neurovascular Supply
The blood supply to the knee joint is through the
genicular anastomoses around the knee, which are
supplied by the genicular branches of the femoral and
popliteal arteries.
The nerve supply, according to Hilton’s law, is by the
nerves which supply the muscles which cross the joint.
These are the femoral, tibial, and common fibular nerves.
Articulati
ng
Surfaces
Knee ligaments
Kennedy • based on the direction of displacement of the
tibia
classification
DISLOCATIONS MECHANISM INJURY ASSOCIATED
Anterior MC Hyperextension injury Posterior capsule, PCL,
ACL tear
Posterior 2nd MC dashboard PCL torn, ↑ vascular
injury
medial Varus/valgus force Disrupt PLC & PCL
lateral Varus/Valgus, Tears of both ACL & PCL
flexion/adduction
rotatory Rotation around PCL, Posterolateral MC
iireducible
Schenck Classification
• based on a pattern of multi
ligamentous injury of knee
dislocation (KD)
Symptoms
• history of trauma and deformity of the knee
• knee pain & instability
Physical exam
Look: deformity, swelling, abrasions, ecchymosis,
Presentati erythema or any skin changes, posture (symmetry),
any rotation or limb length discrepancy
on Feel: tenderness (maxi point tenderness), skin
temperature (above & below the joint, compare
opposite limb), deformities, effusion, swelling (intra
vs extra-articular)
Move: active movement limited by pain, weakness
due to tendon, muscle or nerve pathology, stiffness,
and bony abnormalities. ↑or↓ range of motion.
Passive movement, crepitus between joints
Present of obvious deformity
Reduce immediately, especially if absent pulses
Pucker sign’ or ‘dimple sign’ - buttonholing of medial femoral
condyle through the medial capsule
is an important physical sign denoting irreducibility and possible
neurovascular compromise. Prompt open reduction and ligamentous
repair is the treatment of choice. Delay in diagnosis or missed diagnosis
can result in skin necrosis.
Vascular exam
• priority is to rule out vascular injury on exam both before and after
reduction
• serial examinations are mandatory
• palpate the dorsalis pedis and posterior tibial pulses on injured and
contralateral side
• if pulses are present and normal: does not indicate the absence of
arterial injury
• collateral circulation can mask a complete popliteal artery occlusion
• measure Ankle-Brachial Index (ABI) on all patients with suspected KD
Ankle-
Brachial
Index (ABI)
•if ABI >0.9
•then monitor with serial
examination (100% Negative
Predictive Value)
•if ABI <0.9
•perform an arterial duplex
ultrasound or CT
angiography
•if arterial injury confirmed
then consult vascular
surgery
If pulses are absent or diminished
• confirm that the knee joint is reduced or perform immediate reduction
and reassessment
• immediate surgical exploration if pulses are still absent following
reduction
• ischemia time >8 hours has amputation rates as high as 86%
• imaging contraindicated if it would delay surgical revascularization
• if pulses present after reduction then measure ABI then consider
observation vs. angiography
• assess sensory and motor function of
peroneal and tibial nerve as nerve
deficits often occur concomitantly with
Neurologi vascular injuries
• stability
c exam • diagnosis based on instability on physical
exam (radiographs and gross
appearance may be normal)
• may see recurvatum when held in
extension
Peroneal
nerve injury
include
• Decreased sensation, numbness or
tingling in the top of the foot or
the outer part of the upper or
lower leg.
• Foot drop-unable to hold your foot
up
• Slapping gait-where each step
makes a slapping noise
• Toes dragging while walking
• Weakness of the ankles or feet
• Loss of muscle mass.
ACL: anterior drawer test, Lachman test,
Pivot shift sign (gold standard
PCL: posterior drawer test, posterior sag
sign (Godfrey test/step off test)
Assess PLC: Dial test, frog leg test, reverse pivot
shift test
the knee MCL: valgus stress test
LCL: varus stress test
ligaments Meniscus tests: joint line tenderness,
Apley compression test, McMurray’s test
(MC), Thessaly test
Dial test
Knee 1st scenario 3rd scenario
Absent distal pulses or clear, hard
Good pulses and signs of limb ischemia.
dislocation symmetrical, ABI more
than 0.9
Hard, clear signs:
scenarios
Absent pulses
Observe for 24-48 hours Bleeding
with serial neurovascular Expanding hematoma
exam.
Cold cyanotic foot
2nd scenario Soft signs
Decreased pulses, capillary refill,
After reduction, if the temperature and color changes of the
distal pulse are foot.
asymmetrical, or the ABI If present hard signs, do not waste
is less than 0.9 time by doing arteriogram.
Take the patient to the operating
Urgent arterial duplex room, do emergency surgical
ultrasound or CT exploration and then on the table, do
arteriogram and the patient will
angiography probably need fasciotomy.
X-rays of
• AP standing, lateral
• Skyline (patellofemoral joint)
knee • 3-foot standing view (length &
varus/valgus alignment)
• pre-reduction AP and lateral of the
knee
may be normal if spontaneous reduction
look for asymmetric or irregular joint
space
Radiograph Rule out: tibial plateau
fracture/dislocations, proximal fibular
s fractures, avulsion of fibular head.
• post reduction AP and lateral of the
knee
optional views
45-degree oblique if fracture suspected
CT angiogram
Indications
• fracture identified on post reduction plain films
• obtain post reduction CT for characterization of fracture
Findings
• tibial eminence, tibial tubercle, and tibial plateau fractures may be seen
MRI
Indications
• obtain MRI after acute reduction but prior to hardware placement
• required to evaluate soft tissue injury (ligaments, meniscus) and for
surgical planning
Management of knee dislocation
1. Urgent Closed reduction
approach
• anterior dislocation - traction and anterior translation of the femur
• posterior dislocation - traction, extension, and anterior translation of
the tibia
• medial/lateral - traction and medial or lateral translation
• rotatory - axial limb traction and rotation in the opposite direction of
deformity
splinting
• 20 to 30 degrees of flexion
2. Open reduction
Indications
soft tissue
• the medial capsule may need to be pulled over medial condyle if buttonholed
• acute associated soft tissue injuries (patellar tendon rupture, periarticular avulsion,
or displaced menisci) may benefit from acute repair
bone work
• periarticular fractures may be fixed acutely or spanned with external fixator
depending on surgeon preference
instrumentation
• place knee-spanning external fixator in 20-30 degrees of flexion with knee reduced
in AP and sagittal planes
3. Assessment & management of neurovascular injuries
4. Emergent operative repair if vascular injury, open fracture or
irreducible dislocation or compartment syndrome.
5. Early ligamentous reconstruction (<3 weeks)
to restore knee stability is typically performed in a staged fashion
6. Comprehensive physiotherapy
• Associated injuries (tibial, fibula fracture,
extension mechanism injury)
Specific • Popliteal artery injury
complicatio • Peroneal nerve injury
• Capsular tear
ns • Chronic: instability, stiffness, post
traumatic arthritis
References
1. Orthobullets
2. Dr. Ebraheim’s educational animated video (YouTube)
