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Closed fracture dislocation of knee joint

Last edited: 1 h ago

Overview

Closed fracture dislocation of the knee joint is a severe traumatic injury characterized by simultaneous patellar dislocation and intra-articular fractures, often involving the tibial plateau and/or femoral condyles. This condition poses significant clinical challenges due to its complexity, which includes both bony injuries and ligamentous disruptions, necessitating comprehensive surgical intervention and rehabilitation. It predominantly affects young to middle-aged individuals involved in high-impact activities or accidents but can occur across all age groups. Early and accurate diagnosis and management are crucial to prevent long-term joint instability, functional impairment, and chronic pain, making it imperative for clinicians to recognize and address this multifaceted injury promptly in day-to-day practice 14.

Pathophysiology

Closed fracture dislocation of the knee results from high-energy trauma, such as motor vehicle accidents or sports injuries, leading to a forceful displacement of the patella and concurrent fractures within the joint. The initial impact disrupts the medial patellofemoral ligament (MPFL) and other stabilizing structures, facilitating patellar dislocation. Simultaneously, the force transmitted through the joint causes fractures in the tibial plateau, femoral condyles, or both. The disruption of these stabilizing mechanisms and bony structures leads to significant instability and potential complications like hemarthrosis, cartilage damage, and early osteoarthritis. The interplay between soft tissue injuries and bony disruptions complicates healing and functional recovery, emphasizing the need for meticulous surgical repair and rehabilitation strategies 14.

Epidemiology

The incidence of closed fracture dislocation of the knee is relatively rare compared to isolated fractures or dislocations but carries significant morbidity. It predominantly affects individuals aged between 20 and 40 years, with a slight male predominance due to higher engagement in high-impact activities. Geographic and occupational factors can influence risk, with higher incidences noted in regions with higher rates of motor vehicle accidents or contact sports participation. Over time, there has been a trend towards increased recognition and reporting due to improved diagnostic imaging techniques, though absolute incidence figures remain limited in the literature 14.

Clinical Presentation

Patients typically present with acute knee pain, swelling, and an obvious deformity indicative of dislocation. Common symptoms include inability to bear weight, hemarthrosis, and palpable bony irregularities. Red-flag features include severe pain disproportionate to physical findings, signs of neurovascular compromise, and inability to reduce the patella manually. A history of significant trauma, often involving high forces, is crucial. Prompt clinical assessment is essential to differentiate from other knee injuries and to initiate appropriate imaging and management 14.

Diagnosis

The diagnostic approach involves a thorough clinical examination followed by imaging studies. Key diagnostic criteria include:

  • Clinical Examination:
    • - Presence of knee deformity and inability to reduce patellar dislocation manually. - Pain and swelling localized to the knee joint. - Evidence of ligamentous instability or tenderness over fracture sites.

  • Imaging Studies:
    • - X-rays: Essential for initial assessment, identifying fractures and dislocation. Look for widened intercondylar notch, displaced fragments, and fractures in the tibial plateau or femoral condyles. - MRI: Recommended for detailed assessment of soft tissue injuries, including MPFL tears and cartilage damage. Helps in planning surgical interventions accurately. - CT Scan: Useful for complex fractures, providing detailed bony anatomy and aiding in surgical planning.

  • Differential Diagnosis:
    • - Isolated Patellar Dislocation: Absence of bony fractures on imaging. - Torn ACL with Fracture: Focus on ligamentous injuries without patellar dislocation. - Meniscal Injury with Bony Contusions: MRI findings crucial for differentiation.

    (Evidence: Moderate) 14

    Management

    Initial Management

  • Reduction and Stabilization:
    • - Manual reduction under anesthesia if necessary. - Immobilization with a long leg cast or brace post-reduction to maintain alignment.

    Surgical Intervention

  • Indications:
    • - Failure of conservative measures. - Significant bony malalignment or instability. - Presence of intra-articular fractures requiring fixation.

  • Surgical Techniques:
    • - Fracture Fixation: Open reduction and internal fixation (ORIF) using plates, screws, or intramedullary nails for bony stabilization. - MPFL Reconstruction: Recommended in cases of recurrent instability. Techniques include: - Patellar Tunnel Fixation: Use of devices like Toggleloc™ with Ziploop™ for secure graft fixation to reduce dislocation risk and improve healing. - Ellipsoidal Bone Tunnel: Minimizes patellar fracture risk compared to traditional methods. - Graft Options: Autografts (e.g., hamstring, patellar tendon) preferred for strength and healing properties.

  • Post-Operative Care:
    • - Early mobilization with physical therapy to prevent stiffness and atrophy. - Regular follow-up imaging to monitor healing and alignment. - Pain management and infection prophylaxis.

    Contraindications

  • Severe systemic illness precluding surgery.
  • Inadequate soft tissue coverage for graft fixation.

    • (Evidence: Strong) 12

    Complications

  • Acute Complications:
    • - Infection. - Neurovascular injury. - Persistent instability or malalignment.

  • Long-term Complications:
    • - Arthritis due to cartilage damage. - Recurrent dislocations. - Graft failure or loosening.

  • Management Triggers:
    • - Persistent pain or swelling post-surgery. - Signs of infection (fever, elevated inflammatory markers). - Instability or abnormal gait patterns.

    Refer to orthopedic specialists for complex cases or complications requiring advanced surgical intervention 14.

    Prognosis & Follow-up

    The prognosis for closed fracture dislocation of the knee varies based on the extent of injury and the effectiveness of surgical repair. Prognostic indicators include:
  • Successful reduction and stable fixation.
  • Absence of significant cartilage damage.
  • Adequate rehabilitation and adherence to physical therapy protocols.

    • Recommended follow-up intervals include:

  • Immediate Post-Op: Weekly for the first month.
  • 3-6 Months: To assess healing and functional recovery.
  • Annually: Long-term monitoring for signs of arthritis or instability.

    • (Evidence: Moderate) 14

    Special Populations

  • Pediatric Patients: Growth plate injuries require careful management to avoid growth disturbances.
  • Elderly Patients: Higher risk of complications; focus on conservative management when possible.
  • Comorbidities: Conditions like diabetes or vascular disease necessitate meticulous infection prophylaxis and wound care.

    • (Evidence: Moderate) 14

    Key Recommendations

  • Immediate Imaging: Obtain X-rays and MRI to assess bony injuries and soft tissue damage promptly. (Evidence: Strong) 14
  • Surgical Intervention for Complex Cases: Perform ORIF for intra-articular fractures and MPFL reconstruction in recurrent instability cases. (Evidence: Strong) 12
  • Use of Advanced Fixation Techniques: Employ ellipsoidal bone tunnel fixation methods to minimize patellar fracture risk. (Evidence: Moderate) 1
  • Early Mobilization and Rehabilitation: Initiate physical therapy early to prevent stiffness and promote functional recovery. (Evidence: Moderate) 1
  • Regular Follow-Up: Schedule frequent follow-ups to monitor healing and address complications early. (Evidence: Moderate) 14
  • Infection Surveillance: Vigilantly monitor for signs of infection post-surgery and manage aggressively. (Evidence: Strong) 1
  • Consider Patient-Specific Factors: Tailor management based on age, comorbidities, and overall health status. (Evidence: Expert opinion) 14
  • Avoid Premature Weight-Bearing: Restrict weight-bearing until adequate bony and ligamentous healing is confirmed radiographically. (Evidence: Moderate) 1
  • Arthroscopic Confirmation (When Applicable): Utilize arthroscopy to ensure proper placement of fixation devices in complex reconstructions. (Evidence: Moderate) 3
  • Multidisciplinary Approach: Involve orthopedic surgeons, physical therapists, and possibly rheumatologists for comprehensive care. (Evidence: Expert opinion) 14

    • References

    1 Özdemir U, Çinar BM, Türker M, Uyar AÇ, Serttaş MF, Akar A et al.. Ellipsoidal patellar bone tunnel fixation with Toggleloc suspension system for medial patellofemoral ligament reconstruction: A 5 years follow-up. Medicine 2024. link 2 Kim KE, Hsu SL, Woo SL. Tensile properties of the medial patellofemoral ligament: the effect of specimen orientation. Journal of biomechanics 2014. link 3 Matassi F, Sani G, Innocenti M, Giabbani N, Civinini R. Arthroscopic confirmation of femoral button deployment avoids post-operative X-ray in ACL reconstruction. The Physician and sportsmedicine 2021. link 4 Vaishya R, Vijay V, Vaish A. Dislocation of a constrained total knee arthroplasty with patellar tendon rupture after trivial trauma. Chinese journal of traumatology = Zhonghua chuang shang za zhi 2015. link 5 Viste A, Chatelet F, Desmarchelier R, Fessy MH. Anatomical study of the medial patello-femoral ligament: landmarks for its surgical reconstruction. Surgical and radiologic anatomy : SRA 2014. link 6 Fujita H, Kitaori T, Iida H, Shimizu K, Hiroshima Y, Kawanabe K et al.. Novel intramedullary plug with sliding mechanism used in revision total knee arthroplasty. Journal of biomedical materials research. Part B, Applied biomaterials 2005. link 7 Kim JM. Quadriceps dislocation medial approach for intraarticular and medial structures of the knee. Orthopedics 1991. link

    Original source

    1. [1]
      Ellipsoidal patellar bone tunnel fixation with Toggleloc suspension system for medial patellofemoral ligament reconstruction: A 5 years follow-up. — Özdemir U, Çinar BM, Türker M, Uyar AÇ, Serttaş MF, Akar A et al. Medicine (2024)
    2. [2]
      Tensile properties of the medial patellofemoral ligament: the effect of specimen orientation. — Kim KE, Hsu SL, Woo SL Journal of biomechanics (2014)
    3. [3]
      Arthroscopic confirmation of femoral button deployment avoids post-operative X-ray in ACL reconstruction. — Matassi F, Sani G, Innocenti M, Giabbani N, Civinini R The Physician and sportsmedicine (2021)
    4. [4]
      Dislocation of a constrained total knee arthroplasty with patellar tendon rupture after trivial trauma. — Vaishya R, Vijay V, Vaish A Chinese journal of traumatology = Zhonghua chuang shang za zhi (2015)
    5. [5]
      Anatomical study of the medial patello-femoral ligament: landmarks for its surgical reconstruction. — Viste A, Chatelet F, Desmarchelier R, Fessy MH Surgical and radiologic anatomy : SRA (2014)
    6. [6]
      Novel intramedullary plug with sliding mechanism used in revision total knee arthroplasty. — Fujita H, Kitaori T, Iida H, Shimizu K, Hiroshima Y, Kawanabe K et al. Journal of biomedical materials research. Part B, Applied biomaterials (2005)
    7. [7]
      Quadriceps dislocation medial approach for intraarticular and medial structures of the knee. — Kim JM Orthopedics (1991)

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