Knee (tibiofemoral) dislocation and reduction
- Michael C Bachman, MD, MBA
Michael C Bachman, MD, MBA
- Department of Pediatric Emergency Medicine
- Sunrise Children's Hospital
- Section Editors
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
Dislocations of the tibiofemoral joint of the knee are true surgical emergencies. Without rapid identification and repair, associated vascular injuries may jeopardize the leg [1,2]. Immediate reduction followed by careful neurovascular assessment is necessary.
This topic will review the mechanisms and management of acute tibiofemoral dislocations. Patellar dislocations and procedural sedation for the performance of joint reduction is discussed separately. (See "Recognition and initial management of lateral patellar dislocations" and "Procedural sedation in adults outside the operating room" and "Procedural sedation in children outside of the operating room".)
The anatomy of the knee is discussed separately; elements of special relevance to tibiofemoral dislocation are reviewed here. (See "Physical examination of the knee", section on 'Anatomy'.)
The four major ligaments responsible for maintaining the stability of the knee are the anterior cruciate, posterior cruciate, medial collateral, and lateral collateral ligaments (picture 1 and figure 1 and picture 2). Tibiofemoral dislocations cause injuries to multiple ligaments. Usually both cruciate ligaments and one or both of the collateral ligaments are injured.
The popliteal artery is the continuation of the femoral artery. It originates at the tendinous hiatus of the adductor magnus muscle, which firmly anchors it to the femoral shaft (picture 3 and image 1). Within the popliteal space, the artery gives off five branches which arise above and below the knee joint creating a collateral system about the knee. Distally, the popliteal artery is held firmly against the bone by the tendinous arch of the soleus muscle. Thus, the popliteal artery is tethered across the popliteal space like a bowstring, making it susceptible to injury during knee dislocation . Up to 40 percent of patients with knee dislocations sustain an associated vascular injury .
- Seroyer ST, Musahl V, Harner CD. Management of the acute knee dislocation: the Pittsburgh experience. Injury 2008; 39:710.
- Rihn JA, Groff YJ, Harner CD, Cha PS. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg 2004; 12:334.
- Reckling FW, Peltier LF. Acute knee dislocations and their complications. J Trauma 1969; 9:181.
- Shields L, Mital M, Cave EF. Complete dislocation of the knee: experience at the Massachusetts General Hospital. J Trauma 1969; 9:192.
- Wood MB. Peroneal nerve repair. Surgical results. Clin Orthop Relat Res 1991; :206.
- Kapur S, Wissman RD, Robertson M, et al. Acute knee dislocation: review of an elusive entity. Curr Probl Diagn Radiol 2009; 38:237.
- Henrichs A. A review of knee dislocations. J Athl Train 2004; 39:365.
- Hollis JD, Daley BJ. 10-year review of knee dislocations: is arteriography always necessary? J Trauma 2005; 59:672.
- Robertson A, Nutton RW, Keating JF. Dislocation of the knee. J Bone Joint Surg Br 2006; 88:706.
- Walker RE, McDougall D, Patel S, et al. Radiologic review of knee dislocation: from diagnosis to repair. AJR Am J Roentgenol 2013; 201:483.
- Sillanpää PJ, Kannus P, Niemi ST, et al. Incidence of knee dislocation and concomitant vascular injury requiring surgery: a nationwide study. J Trauma Acute Care Surg 2014; 76:715.
- Urgüden M, Bilbaşar H, Ozenci AM, et al. Irreducible posterolateral knee dislocation resulting from a low-energy trauma. Arthroscopy 2004; 20 Suppl 2:50.
- Harb A, Lincoln D, Michaelson J. The MR dimple sign in irreducible posterolateral knee dislocations. Skeletal Radiol 2009; 38:1111.
- Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma 1997; 11:525.
- Nicandri GT, Dunbar RP, Wahl CJ. Are evidence-based protocols which identify vascular injury associated with knee dislocation underutilized? Knee Surg Sports Traumatol Arthrosc 2010; 18:1005.
- Steele HL, Singh A. Vascular injury after occult knee dislocation presenting as compartment syndrome. J Emerg Med 2012; 42:271.
- Varnell RM, Coldwell DM, Sangeorzan BJ, Johansen KH. Arterial injury complicating knee disruption. Third place winner: Conrad Jobst award. Am Surg 1989; 55:699.
- KENNEDY JC. COMPLETE DISLOCATION OF THE KNEE JOINT. J Bone Joint Surg Am 1963; 45:889.
- Borden PS, Johnson DL. Initial assessment of the acute and chronic multiple ligament-injured knee. Sports Med Arthrosc 2001; 9:178.
- Georgiadis AG, Mohammad FH, Mizerik KT, et al. Changing presentation of knee dislocation and vascular injury from high-energy trauma to low-energy falls in the morbidly obese. J Vasc Surg 2013; 57:1196.
- Azar FM, Brandt JC, Miller RH 3rd, Phillips BB. Ultra-low-velocity knee dislocations. Am J Sports Med 2011; 39:2170.
- Peltola EK, Lindahl J, Hietaranta H, Koskinen SK. Knee dislocation in overweight patients. AJR Am J Roentgenol 2009; 192:101.
- Quinlan AG. Irreducible posterolateral dislocation of the knee with button-holing of the medial femoral condyle. J Bone Joint Surg Am 1966; 48:1619.
- Hill JA, Rana NA. Complications of posterolateral dislocation of the knee: case report and literature review. Clin Orthop Relat Res 1981; :212.
- Scuderi GR, Scott WN, Insall JN. Injuries of the knee. In: Rockwood and Green's Fractures in Adults, 4th ed, Rockwood CA, Green DP, Bucholz RW, et al (Eds), Lippincott-Raven, Philadelphia 1996. Vol 2.
- Simon RR, Koenigsknecht SJ. Emergency orthopedics: The Extremities, 3rd ed, Appleton & Lange, Norwalk 1995. p.385.
- Kaufman SL, Martin LG. Arterial injuries associated with complete dislocation of the knee. Radiology 1992; 184:153.
- 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; 56:1261.
- 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; 53:1109.
- McDonough EB Jr, Wojtys EM. Multiligamentous injuries of the knee and associated vascular injuries. Am J Sports Med 2009; 37:156.
- Lynch K, Johansen K. Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma? Ann Surg 1991; 214:737.
- Peng PD, Spain DA, Tataria M, et al. CT angiography effectively evaluates extremity vascular trauma. Am Surg 2008; 74:103.
- Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT angiography: pearls and pitfalls. Radiographics 2005; 25 Suppl 1:S133.
- Inaba K, Potzman J, Munera F, et al. Multi-slice CT angiography for arterial evaluation in the injured lower extremity. J Trauma 2006; 60:502.
- Redmond JM, Levy BA, Dajani KA, et al. Detecting vascular injury in lower-extremity orthopedic trauma: the role of CT angiography. Orthopedics 2008; 31:761.
- Jones RE, Smith EC, Bone GE. Vascular and orthopedic complications of knee dislocation. Surg Gynecol Obstet 1979; 149:554.
- Frykberg ER. Popliteal vascular injuries. Surg Clin North Am 2002; 82:67.
- Gable DR, Allen JW, Richardson JD. Blunt popliteal artery injury: is physical examination alone enough for evaluation? J Trauma 1997; 43:541.
- Chhabra, A, Kline, AJ, Harner, C. Management of the multiple ligament injured knee. Current Opinion in Orthopedics 2005; 16:107.
- Niall DM, Nutton RW, Keating JF. Palsy of the common peroneal nerve after traumatic dislocation of the knee. J Bone Joint Surg Br 2005; 87:664.
- 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; 19:125.
- Levy BA, Dajani KA, Whelan DB, et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy 2009; 25:430.