Knee dislocation ext ณัฐ พินิจกิจอนันต์

1. Teleconference
EXT ณัฐ พินิจกิจอนันต์

2. Patient Profile
▷ ผู้ป่วยชายไทยคู่ อายุ 60 ปี
▷ สัญชาติไทย ศาสนาพุทธ
▷ อาชีพ รับจ้าง
▷ ภูมิลาเนา อาเภอคง จังหวัดนครราชสีมา
▷ สิทธิการรักษา บัตรประกันสุขภาพ

3. “
Chief Complaint
ปวดเข่าขวา4 ชั่วโมงก่อนมาโรงพยาบาล

4. Present
Illness
4 ชั่วโมงก่อนมาโรงพยาบาล
ขี่มอเตอร์ไซค์ล้ม ล้มเอียงไปทางขวา เข่าขวากระแทกกับ
พื้นถนนโดยตรง ปวดเข่าขวาทันที เข่าขวาผิดรูป ไม่
สามารถลุกยืนขึ้นได้ ไม่มีบาดแผลภายนอก ศีรษะไม่
กระแทก ไม่สลบ จาเหตุการณ์ได้

5. Primary Survey
Airway maintenance with cervical spine protection
Patent airway, no tender along c spine, and can active
movement of neck
Breathing and Ventilation
Normal chest movement, trachea in midline, CCT negative,
normal and equal breath sound both lungs
Circulation with hemorrhage control
BP 125/92 mmHg, P 82 bpm, no external bleeding
Disability and Neurologic status
E4V5M6, pupil 2 mm RTLBE
Exposure
Swelling and deformity at right knee, no external wound

6. Secondary Survey
Allergy : no history of drug and food allergy
Medication : no current medication
Past History : no underlying diseases
Last Meal : 10.00 AM
Events : Motorcycle accident

7. Physical Examination
Vital signs : BP 125/92 mmHg, P 82 bpm, RR 20/min
General appearance : a Thai middle aged man, alert, good consciousness, well
cooperate
HEENT : no pale conjunctiva, anicteric sclera
CVS : full, regular, symmetrical pulse all extremities, normal s1 s2, no murmur
Respiratory : normal and equal breath sound both lungs
Abdomen : soft, not tender, no guarding, no rebound tenderness
Neuro : E4V5M6, motor power grade V all extremities except right knee due
to pain, sensory intact

8. Physical Examination
Extremities:
• Swelling and deformity at right
knee, no external wound
• Limit ROM of right knee due to
pain
• Can dorsiflexion and
plantarflexion of right ankle
• Can flex and extend all right toes
• Dorsalis pedis artery 2+ and
posterior tibial artery 2+

10. Physical Examination
Post-Reduction
Extremities:
• Anterior drawer test positive
• Drop back sign and posterior drawer test positive
• Varus and Valgus stress test Grade II

11. Investigation
X ray : Right Knee (AP,Lateral)

12. Diagnosis
Right Knee Dislocation with Ligament Injury

13. Management : ER
1.Sedation by Morphine & Diazepam
2.Close reduction right knee
3.Re-evaluate vascular
Physical examination : dorsalis pedis and posterior tibial
artery 2+ both sides, cap refill < 2sec.
Doppler : ABI Right 1.07 Left 1.07
4.Immobilized by posterior long leg slab
5.Post reduction film => Right knee AP,Lateral
5.Admit trauma for observe vascular 48 hrs.

14. Post Reduction Film
X ray : Right Knee (AP,Lateral)

15. Knee Dislocation

16. Anatomy

17. Definition
Knee Dislocations are ligamentous disruptions with
loss of continuity of tibiofemoral articulation.
High energy mechanism Injury :
Motor vehicle collision => Dash Board injury
Falling from height with flexed knee
Low energy mechanism Injury :
Sport injuries => Hyperextension injuries, rotation
Mechanism of Injury

18. Classification
Kennedy classification
based on direction of
displacement of the tibia
•anterior (30-50%)
•posterior (25%)
•lateral (13%)
•medial (3%)
•rotational (4%)
Schenck Classification
based on pattern of multi
ligamentous injury of knee
dislocation (KD)

19. No obvious deformity
▷ 50% spontaneously reduce
▷ may present with subtle signs of trauma (swelling, effusion,
abrasions)
Obvious deformity
Clinical Presentation

20. Associated Injuries
Vascular injury :
Popliteal artery
• 40-50% in
anterior/posterior
dislocations
• due to tethering at
the popliteal fossa
Fracture :
• present in 60%
• tibia and femur
most common
Nerve injury :
Usually common
peroneal nerve injury
Rare tibial nerve in jury

21. Vascular Examination
• Examination both before and after
reduction
• Palpate at the dorsalis pedis and
posterior tibial pulses
Pulses are present and normal
• Ankle-Brachial Index (ABI)
• if ABI >0.9 then monitor with
serial examination
• if ABI <0.9perform arterial
duplex ultrasound or CT
angiography
Pulses are absent or diminished
• perform immediate reduction
and reassessment
• if pulses present after
reduction then measure ABI
then consider observation
vs. angiography
• if pulses are still absent
following
reduction immediate surgical
exploration

22. Neuro Examination
Peroneal Nerve
• EHL & Tibialis anterior strength
• Dorsal 1st web space sensation
Tibial Nerve
• FHL & Gastroc or soleus strength
• Lateral border and plantar surface of foot sensation

23. Stability Examination
ACL : Anterior drawer test and Lachman’s test
PCL : Posterior drawer test and Drop back sign
MCL : Valgus stress test
LCL : Varus stress test

24. ImagingX ray : Knee (AP,Lateral)
MRI Knee
For evaluate soft tissue injury
(ligaments, meniscus) and for
surgical planning

25. Treatment

26. Treatment
Initial Treatment : Emergency close reduction under sedation
Reevaluate arterial flow after reduction by check arterial pulse
and Doppler u/s
• If abnormal arterial flow => Angiography and Surgical
Exploration
Immobilized and admit and serial examination to 48 hrs.
• For observe Post Thrombotic Syndrome

27. Treatment
Indication for Surgery (emergent surgical intervention with
external fixation)
• Vascular injury
• Open fracture and open dislocation
• Irreducible dislocation
• Compartment syndrome
Further Investigation MRI for ligament injury
Surgery : ligament reconstruction/repair

28. Complications
• Stiffness
• Laxity and Instability
• Peroneal nerve injury
• Vascular compromise

29. References
▷ หนังสือออร์โธปิดิกส์ ภาควิชาออร์โธปิดิกส์ คณะแพทยศาสตร์โรงพยาบาล
รามาธิบดี มหาวิทยาลัยมหิดล
▷ ORTHOPAEDIC TRAUMA โดย ธีรชัย อภิวรรธกกุล
▷ http://www.orthobullets.com/trauma/1043/knee-
dislocation

30. Thank You
For Attention