Review Article

Acute Management of Traumatic

Knee Dislocations for the
Generalist

Abstract
Robert H. Boyce, MD Acute knee dislocations are an uncommon injury that can result in
Keerat Singh, MD profound consequences if not recognized and managed appropriately
on presentation. Patients presenting with knee pain in the setting of
William T. Obremskey, MD, MPH
high- or low-energy trauma may have sustained a knee dislocation
that spontaneously reduced. Prompt reduction of the dislocated knee
and serial neurovascular examinations are paramount. Damage to the
popliteal artery is a common associated injury that can be diagnosed
on physical examination using ankle brachial indices (ABIs), CT
angiography, or standard angiography. After reduction, patients with
a normal pulse examination and an ABI $0.9 may be observed, with
serial examination performed to document vascular status and
monitor for compartment syndrome. Patients with asymmetric pulses
or an ABI ,0.9 in the presence of pulses may be treated urgently
depending on the results of additional vascular imaging, and patients
with absent pulses and clear signs of vascular compromise should be
treated emergently. Some knee dislocations are not reducible and
should be taken emergently to the operating room for an open
reduction. Persistent joint subluxation or severe soft-tissue injuries
after reduction require temporary external fixation before definitive
repair or reconstruction of ligaments is performed.
From the Department of Orthopaedic
Surgery Vanderbilt University,

A
Nashville, TN. cute knee dislocation is a rare at another hospital), a prompt and
Dr. Obremskey or an immediate family injury that has an estimated thorough evaluation is crucial.
member serves as a board member, incidence of ,0.02% of orthopaedic Knee dislocation predominantly
owner, officer, or committee member
injuries1 or 2 to 29 injuries per mil- occurs in a younger population, with
of the Orthopaedic Trauma
Association and the Southeastern lion annually.2,3 In comparison, hip a male-to-female ratio of 4:1.4 Dis-
Fracture Consortium. Neither of the fractures in young males occur at location can result from both high-
following authors nor any immediate
a rate of $100 per million annually.4 energy mechanisms (eg, fall from
family member has received anything
of value from or has stock or stock The incidence of acute knee dis- a height, crush injury, motor vehicle
options held in a commercial company locations likely has been under- collision [MVC], pedestrian versus
or institution related directly or reported in the literature given their motor vehicle) or low-energy mech-
indirectly to the subject of this article:
Dr. Boyce and Dr. Singh. propensity to self-reduce and the anisms (eg, misstep during routine
potential for misdiagnosis. Approx- walking, martial arts kicks, tram-
J Am Acad Orthop Surg 2015;23:
761-768 imately 50% of knee dislocations poline fall).6 Although it is true that
spontaneously reduce before a for- half of these injuries are the result of
http://dx.doi.org/10.5435/
JAAOS-D-14-00349 mal evaluation.5 Whether the patient a MVC or high-energy mechanism,
presents with an acutely dislocated approximately one third of the cases
Copyright 2015 by the American
Academy of Orthopaedic Surgeons. knee or an occult dislocation (ie, one result from a lower energy mecha-
that has been reduced in the field or nism, which often occurs in sports

December 2015, Vol 23, No 12 761

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Management of Traumatic Knee Dislocations for the Generalist

Figure 1 dislocation regardless of the velocity tibia as is seen in the “dashboard”

of the mechanism of injury. Accord- injury.15 Lateral and medial dis-
ing to the recent literature, injury to locations comprise 18% and 4% of
the popliteal artery occurs at rates knee dislocations, respectively.16 In
ranging from 1.6%3 to 40%.8 It is rotatory dislocations, the PCL re-
likely that the average rate is mains intact as the tibia rotates
approximately 16%.13 A delay of about the femur.
.8 hours in reestablishing arterial Some knee dislocations are reduced
blood flow resulted in an amputation before evaluation, making a classifi-
rate of 85% in a study of 18 patients cation based on the direction of
with knee dislocation and an asso- displacement somewhat challenging;
ciated injury to the popliteal therefore, a classification system
artery.14 Prolonged warm ischemia based on the severity of ligamentous
time was the primary factor in damage was developed by Schenk
associated vascular injury and knee et al17 and modified by others18,19
dislocation in the Lower Extremity (Table 1). KD (knee dislocation) I is
Assessment Project study, which re- a single cruciate ligament injury. KD II
ported an amputation rate of 20%.14 is bicruciate disruption only, and
Treating orthopaedists must under- KD III refers to a bicruciate injury with
stand the pathophysiology, anat- posteromedial or posterolateral dis-
omy, and management options for ruption. KD IV is a bicruciate injury
AP radiograph of the knee knee dislocation to avoid suboptimal with posterolateral and posteromedial
demonstrating an anterolateral
dislocation. outcomes. disruption. KD V is a fracture-
dislocation. Subdesignations of C
and N indicate vascular and neural
injuries. A population-based study of Pathophysiology and injuries, respectively. The direction of
the rate of knee dislocation in Fin- Classification knee dislocation does not necessarily
land over an 11-year period dem- predict which ligaments are ruptured.
onstrated that 46% of dislocations A knee dislocation is a disruption of Both classifications schemes are sim-
were caused by a low-energy fall.3 the tibiofemoral articulation, which ple and can be used to guide further
There is increasing evidence that can occur in any direction and typi- evaluation and management, but
morbid obesity is a risk factor for cally involves at least two ligaments these schemes alone must not be
knee dislocation.7 Azar et al8 re- (Figure 1). Knee dislocations can be relied on for clinical decision making.
ported on 17 cases of knee disloca- described based on the direction of
tion in patients with an average body dislocation or the severity of liga-
mass index of 48 following “ultra- mentous damage. Kennedy15 cate- Vascular Anatomy
low-velocity” activities of daily liv- gorized the dislocation based on the
ing. Dislocations in patients who are direction of displacement of the Given the vulnerability of vessels
obese have a similar and potentially tibia. Five types of knee dislocations around the knee, particular attention
higher incidence of neurovascular were described: anterior, posterior, should be paid to the vascular anat-
injury relative to high-energy dis- medial, lateral, and rotatory. omy. The superficial femoral artery
locations.8 Open knee dislocations Cadaver studies have shown that an enters the adductor hiatus between
represent 5% to 17% of all knee anterior dislocation is caused by the adductor and hamstring portion
dislocations.9 Bilateral dislocation a hyperextension mechanism that of the adductor magnus muscle,
occurs in approximately 5% of ca- causes a sequential failure of the where the artery is relatively con-
ses.10,11 Knee dislocations associated posterior capsule, posterior cruciate strained and continues in a posterior-
with sports injuries have a lower ligament (PCL), and sometimes the inferior direction into the popliteal
incidence of neurovascular injury anterior cruciate ligament (ACL).15 fossa. Here, it becomes particularly
compared with those resulting from Both the ACL and PCL are often vulnerable because only the fat of the
a MVC.12 disrupted.11 Posterior dislocations, popliteal fossa cushions it from the
The potential for limb loss or the the second most common type, are posterior body border. It provides
irreversible consequences of limb caused by a significant posteriorly five geniculate branches and travels
ischemia is present with any knee directed force across the proximal inferiorly in the tendinous arch of the

762 Journal of the American Academy of Orthopaedic Surgeons

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 Robert H. Boyce, MD, et al

Table 1 Figure 2
Anatomic Knee Dislocation Classification System
Classification Description

KD I KD with PCL intact. Collateral ligaments may be injured.

KD II KD with both PCL and ACL injured and collateral
ligaments intact.
KD IIIa KD with both PCL and ACL injured and one collateral
ligament injured, either medial or lateral.
KD IV KD with ACL, PCL, and both collateral ligament injury.
KD V KD with a periarticular fracture

ACL = anterior cruciate ligament, KD = knee dislocation, PCL = posterior cruciate ligament
a
For KD III injury, the injury is written as KD IIIM or KD IIIL, depending on whether the medial or
lateral collateral ligament is damaged. The subdesignations C and N indicate the presence of
vascular and neural injury, respectively (eg, KD IVCN is a knee dislocation with neurovascular
compromise).
Adapted with permission from Wascher DC: High-velocity knee dislocation with vascular injury:
Treatment principles. Clin Sports Med 2000;19(3):457-477.

soleus muscle, where it is relatively the popliteal artery in the popliteal

constrained.20 Figure 2 shows nor- fossa, courses inferiorly posterior to CT angiogram of the lower extremities
mal arterial flow around the knee the popliteus muscle and enters the demonstrating the normal arterial flow
and the way that flow is disrupted deep compartment of the leg through around the left knee and a disruption
of the flow caused by a dislocation of
with knee dislocation and injury to the tendinous arch of the soleus. the right knee, with an associated
the popliteal artery. Although anas- Peroneal nerve palsies occur in popliteal artery injury.
tomoses do exist between the genic- approximately 25% of knee dis-
ulate arteries and the anterior tibial locations.21 The prognosis is gener-
recurrent artery, these are insuffi- ally poor, and the return of nerve the knee joint (Figure 3). Knee swelling
cient to maintain adequate perfusion function is equivocal at best, with is not universal because the capsule is
to the leg. Rupture of the popliteal rates averaging 50%.22 torn in knee dislocations.23 In addi-
artery is known to occur at 50° of tion to noting hard signs of vascular
hyperextension in cadaver models.15 injury (eg, pallor, coolness to touch,
In anterior dislocations, the popliteal History and Clinical delayed capillary refill, evidence of
artery suffers a traction injury that Presentation pulsatile hematoma), a pulse exami-
leads to intimal damage, whereas nation of the foot (specifically, the
a posterior dislocation results in A thorough evaluation includes dorsalis pedis and posterior tibialis
transection of the popliteal artery a history of the time and details of vessel) is mandatory and should be
from the tibia. Forty-four percent of the mechanism of dislocation, prior documented both before and after
posterior dislocations and 39% of attempts at reduction, and a full reduction and compared with the
anterior dislocations are associated medical history, with particular contralateral extremity. The presence
with vascular compromise.16 attention paid to anticoagulant use of normal pulses postreduction has
Because the potential for nerve and any history of bleeding or clot- historically presented a dilemma. In
palsy exists in the setting of an acute ting disorders. Any symptoms of young patients with a popliteal artery
knee dislocation, an understanding of paresthesias or sensory deficits in the injury, the collateral flow about the
the perigeniculate neural anatomy is leg and foot secondary to potential knee is robust enough to possibly
helpful. The sciatic nerve divides into neurapraxia to the common peroneal sustain a normal pulse in the foot for
the tibial nerve and the common and/or tibial nerve should be noted a short time.24 Therefore, an ankle
peroneal nerve in the distal posterior because these raise the risk of a vas- brachial index (ABI) performed with
thigh. The common peroneal nerve cular injury. the use of a manual blood pressure
travels posteroinferior along the Initial evaluation may reveal gross cuff, and a Doppler probe, should be
biceps femoris muscle and courses deformity about the injured extremity. obtained postreduction regardless
anteriorly at the level of the fibular In cases of a lateral dislocation, a skin whether the pulse examination is
neck. The tibial nerve, being lateral to dimple is seen along the medial side of normal and symmetric.

December 2015, Vol 23, No 12 763

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Acute Management of Traumatic Knee Dislocations for the Generalist

Figure 3 pressure in the brachium. To calcu- hardware was used for fracture fix-
late the ABI, the systolic blood pres- ation because of the scatter from
sure measured at the ankle is divided metal artifact. At times, MRI may not
by that measured at the brachial be feasible despite the use of MRI-
artery. A ratio of ,0.9 is considered compatible external fixation systems.
abnormal and necessitates further Patients may still experience discom-
investigation.25 fort or the heating of pins, particu-
After the knee is reduced, a thor- larly if they are within the coil.27
ough examination should be per-
formed while the patient is still under
conscious sedation because pain and Management
guarding may limit this critical aspect
of the evaluation. The injured knee Joint Reduction
should then be splinted to help Knee reduction should be attempted
maintain reduction. For subacute with the patient under conscious
presentations where the knee may sedation. The reduction maneuver is
have spontaneously reduced or was one that reverses the deforming force.
Clinical photograph of the knee reduced previously at an outside If this cannot be done in the emer-
demonstrating a skin dimple (arrow) hospital or urgent care facility, the gency department, the patient should
seen in the setting of an anterolateral extremity should be fully evaluated in
knee dislocation. be brought to the operating room for
the same manner as an acute pre- a reduction performed under anes-
sentation because of the high risk of thesia. If successful, the knee should
associated neurologic and vascular be splinted in 20° of flexion using
The ABI is the ratio of the systolic injury. The extremity should then be a construct that prevents posterior
blood pressure measured at the ankle splinted for stability, and ABIs should subluxation of the tibia and mini-
to that measured at the brachial be obtained. mizes traction of the vasculature.
artery and is easily calculated. With Immobilization provides stability,
the patient in the supine position, comfort, and relaxation of soft tis-
a blood pressure cuff is placed on the Imaging sues. The splint should be windowed
affected ankle above the malleoli. The appropriately to allow for repeated
ultrasound transducer is used to Prereduction AP and lateral radio- vascular examination of the foot. We
locate the dorsalis pedis or posterior graphs of the affected knee help the believe that a plaster splint provides
tibial artery signal. The blood pres- orthopaedist evaluate for concomi- more stability than does a premade,
sure cuff is inflated while listening to tant fracture and the direction of commercially available knee immo-
the Doppler signal. Once the signal displacement. This assessment is bilizer, particularly in patients who
has disappeared, the pressure in the sometimes difficult in patients who are obese because their leg anatomy
cuff is slowly released until the are morbidly obese. Once the knee is has a shape that fits poorly in most
Doppler signal can be heard again. reduced, a postmanipulation AP off-the-shelf immobilizers. Immedi-
The pressure at which the Doppler and lateral knee radiograph should ate postreduction biplanar radio-
signal in the dorsalis pedis or poste- be obtained to verify alignment. If graphs should be obtained to assess
rior tibial artery returns is the systolic plain radiography reveals the pres- the quality and maintenance of the
blood pressure value for the ankle. ence of a periarticular or intra- joint reduction.
For the brachium, the blood pressure articular fracture, a postreduction
cuff is placed on the arm, and the CT is recommended to fully evalu-
brachial pulse is located in the ante- ate the fracture and for preoperative Vascular Status
cubital fossa using the ultrasound planning. The risk of injury to the popliteal
transducer. The cuff is inflated until MRI aids the diagnosis of ligamen- artery led many authors to suggest
the Doppler signal from the brachial tous, meniscal, and articular damage that angiography should be per-
artery disappears. The cuff is then and should be obtained after a suc- formed for all knee dislocations;28
gently relieved of pressure until the cessful knee reduction.26 Such imag- however, advances in the manage-
signal in the brachial artery returns. ing will help with surgical planning ment of vascular injuries have
The pressure at which the Doppler and will be of higher quality than an challenged this dogmatic approach.
signal returns is the systolic blood MRI obtained postoperatively when A protocol of careful physical

764 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Robert H. Boyce, MD, et al

examination, ABIs, and selective Figure 4

angiography is well supported by the
current literature.29,30
Subsequent studies have demon-
strated that patients with normal
pulses and ABIs $0.9 can be safely
observed given the absence of evi-
dence of lesions that require surgical
repair.29,31 One study found that
a normal pulse examination has
a negative predictive value of 100%
for determining vascular injury.29 In
a study of 126 patients with knee
dislocations, Stannard et al31 dem-
onstrated that physical examination
alone has a sensitivity of 100% and
a negative predictive value of 100%
in identifying a clinically significant
arterial injury. Patients were exam-
ined by the same physician every 4 Authors’ algorithm for management of concomitant vascular injury in knee
hours for 24 hours after reduction. dislocation injury. (Adapted with permission from Nicandri GT, Chamberlain AM,
Wahl CJ: Practical management of knee dislocations: A selective angiography
When vascular compromise is sus- protocol to detect limb-threatening vascular injuries. Clin J Sport Med 2009;19
pected (ie, ABI ,0.9, absent palpable [2]:125-129.)
and Doppler pulses, or other hard
signs), further vascular imaging and
If a postreduction vascular exami- and should undergo physical therapy
a vascular consultation should be
nation shows absent pulses, an ABI to prevent an equinus contracture.
obtained. An angiogram performed
,0.9, or hard signs of ischemia, CPN palsy alone is not an indication
outside the operating room can
vascular surgery consultation is for immediate nerve exploration or
result in unnecessary delay.30,31
imperative. A warm, pulseless repair unless there is an obvious
Although angiography has been the
extremity is deceptive and should not transection noted through an open
standard of care, a CT angiogram
be accepted because the collateral traumatic wound. If the CPN
(CTA) has a high sensitivity and
flow around a significant arterial palsy persists at the time of defini-
specificity; although it is not the
injury may maintain some perfusion tive reconstruction of the multi-
preferred test, CTA has the advan-
for a period of time. An ABI ,0.9 ligamentous knee injury, nerve
tage of being noninvasive and re-
has been shown to have 100% pos- exploration and neurolysis may be
quires less radiation.32,33 If a CTA
itive predictive value for a vascular indicated for adherent hematoma
cannot be obtained or if there will be
injury requiring repair.25 Figure 4 and fibrosis.35 If no clinical or elec-
significant delay, an on-table angio-
illustrates our algorithm for man- trical evidence of nerve continuity
gram can be performed instead.
agement of a potential vascular exists by 3 months, surgical inter-
Recently, duplex ultrasonography
injury associated with a knee dislo- vention for direct or intercalary
has emerged as an alternative to
cation or multiligamentous injury. nerve repair is indicated.36
CTA or angiography for diagnosis of
vascular injury. In one prospective
study, ultrasonography was shown Neurologic Status The Irreducible Knee
to have a sensitivity and specificity of Injuries to the common peroneal Most knee dislocations either reduce
95% and 99%, respectively.34 nerve (CPN) are reported at a rate of spontaneously or can be reduced
Weaknesses of duplex ultrasonog- 16% to 40% in patients with knee with the patient under conscious
raphy include its potential to miss dislocations.35 In most cases, the sedation; however, cases of irreduc-
small intimal tears, the operator- nature of injury is caused by ible simple knee dislocations and
dependent nature of the test, and stretching of the nerve as opposed to fracture-dislocations in which one or
the availability of a technician; complete transection; therefore, pa- both femoral condyles perforate the
therefore, we do not recommend its tients with CPN palsy should be capsule and surrounding ligament
routine use.19 fitted with an ankle-foot orthosis architecture have been reported.37,38

December 2015, Vol 23, No 12 765

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Acute Management of Traumatic Knee Dislocations for the Generalist

Figure 5 Figure 6 Figure 7

Clinical photograph demonstrating

an irreducible knee dislocation, with
threatened medial skin.
Intraoperative photograph of the
Lateral radiograph of the knee
knee demonstrating open reduction
demonstrating spanning external
of a knee dislocation. The medial
fixation applied after reduction.
femoral condyle (asterisk) has
This often occurs in the setting of
perforated the retinaculum. P =
a lateral or anterolateral dislocation. patella
In the event of unsuccessful reduc- External Fixation
tion in the emergency department If the knee is not able to be held in
under conscious sedation, the patient arthrotomy are approximately the a satisfactorily reduced position, then
should be taken urgently to the same length as those for a total knee the use of a spanning external fixator
operating room for a reduction arthroplasty except that extension is recommended. Two pins placed
under general anesthesia. In many into the quadriceps tendon is not anterolaterally in the femur and two
cases, the irreducible knee has required. The dislocated knee will pins placed anteromedially in the
pinched or threatened skin, particu- have some distortion of the normal tibia are usually sufficient to maintain
larly on the medial aspect of the knee anatomic relationships; the patella the reduction (Figure 7). Care must
(Figure 5). will be tightly approximated to the be taken to avoid placing the pins
The patient should be positioned lateral aspect of the trochlear groove, too close to the knee joint, which
on a radiolucent table that is and the medial femoral condyle will may contaminate the joint or com-
compatible with angiography and have perforated the joint capsule plicate obtaining an MRI.
fluoroscopy. If closed reduction (Figure 6). The key to the reduction Postoperatively, the patient’s neuro-
performed under general or regional is the use of a small retractor that is vascular status should be closely
anesthesia is unsuccessful, the sur- inserted between the capsule and the examined, documented, and observed
geon should be prepared to proceed medial condyle to “shoehorn” the for at least 24 hours before discharge.
to an open reduction of the knee condyle back into the joint. This will The patient is kept non–weight
joint. We recommend against the use produce a clear restoration of joint bearing and wears a knee immobi-
of a tourniquet because this can relationships despite multidirec- lizer, splint, or external fixator until
exacerbate tissue ischemia and tional instability. If this maneuver is definitive repair or reconstruction is
propagate thrombus formation in unsuccessful, the joint arthrotomy performed.
the setting of an intimal tear. A can be extended until the femoral
midline surgical incision with condyle can be reduced. Examina- Repair or Reconstruction
a medial parapatellar arthrotomy is tion of the knee and documentation Definitive management of knee dislo-
useful to address the acute disloca- after joint reduction facilitate the cation remains controversial, with
tion and later ligament recon- definitive repair. Fluoroscopy or management options ranging from
struction. The anatomy is only plain radiography should be per- completely nonsurgical to repair or
slightly distorted in most irreduc- formed at this point to confirm the reconstruction. Nonsurgical manage-
ible dislocations. The incision and reduction and splinting. ment has inferior results compared

766 Journal of the American Academy of Orthopaedic Surgeons

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 Robert H. Boyce, MD, et al

with those of repair or reconstruc- knee pain and has symptoms of neu- age groups in Germany. Am J Public Health
2007;97(10):1733-1734.
tion.39 Management of some associ- rovascular injury. Physical examina-
ated injuries, such as vascular injury tion findings and diagnostic tools (eg, 5. Seroyer ST, Musahl V, Harner CD:
Management of the acute knee dislocation:
or compartment syndrome, cannot be ABI, CTA, angiography) can direct The Pittsburgh experience. Injury 2008;39
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Acute Management of Traumatic Knee Dislocations for the Generalist

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768 Journal of the American Academy of Orthopaedic Surgeons

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