Floating Knee: Difference between revisions

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*The term ‘floating’ has been used quite vaguely&nbsp;in the literature to describe various injury patterns&nbsp;/surgical procedures and even congenital anomalies. When the term is used to describe an injury&nbsp;pattern, it commonly implies that a joint/bone has&nbsp;lost its continuity at adjacent ends either as a result&nbsp;of fractures, fracture dislocations or pure disloca-tions and hence has become ‘floating’&nbsp;<ref>AGARWAL A, CHADHA M. Floating injuries :a review of the literature and proposal for a universal classification. Acta Orthop. Belg. 2004, 70, 509-514</ref><br>  
*The term ‘floating’ has been used quite vaguely&nbsp;in the literature to describe various injury patterns&nbsp;/surgical procedures and even congenital anomalies. When the term is used to describe an injury&nbsp;pattern, it commonly implies that a joint/bone has&nbsp;lost its continuity at adjacent ends either as a result&nbsp;of fractures, fracture dislocations or pure disloca-tions and hence has become ‘floating’&nbsp;<ref>AGARWAL A, CHADHA M. Floating injuries :a review of the literature and proposal for a universal classification. Acta Orthop. Belg. 2004, 70, 509-514</ref><br>  
*Blake and McBryde initially described this injury. Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and ipsilateral tibia. Floating knee injuries may include a combination of diaphyseal, metaphyseal, and intra-articular fractures <ref>Rethnam U, Yesupalan RS, Nair R. Impact of associated injuries in the floating knee: a retrospective study. BMC Musculoskelet Disord. Jan 14 2009;10:7. [Medline].</ref>&nbsp;<ref name="1">Veith RG, Winquist RA, Hansen ST Jr: Ipsilateral fractures of the femur and tibia.  J Bone and Joint Surgery1984, 66-A(7):991-1002.</ref>. The fractures range from simple diaphyseal to complex articular types. This complex injury has increased in proportion to&nbsp;population growth, number of motor vehicles on the road, and high speed traffic. Although the exact incidence of the floating knee is not known, it is an uncommon injury.<ref name="knee">Rethnam U, Yesupalan RS, Nair R. The floating knee: epidemiology,prognostic indicators &amp;amp;amp;amp;amp;amp;amp;amp;amp; outcome following surgical management. ournal of Trauma Management &amp;amp;amp;amp;amp;amp;amp;amp;amp; Outcomes 2007, 1:2</ref>&nbsp;
*Blake and McBryde initially described this injury. Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and ipsilateral tibia. Floating knee injuries may include a combination of diaphyseal, metaphyseal, and intra-articular fractures <ref>Rethnam U, Yesupalan RS, Nair R. Impact of associated injuries in the floating knee: a retrospective study. BMC Musculoskelet Disord. Jan 14 2009;10:7. [Medline].</ref>&nbsp;<ref name="1">Veith RG, Winquist RA, Hansen ST Jr: Ipsilateral fractures of the femur and tibia.  J Bone and Joint Surgery1984, 66-A(7):991-1002.</ref>.<br>
 
*<span>&nbsp;</span>The fractures range from simple diaphyseal to complex articular types. This complex injury has increased in proportion to&nbsp;population growth, number of motor vehicles on the road, and high speed traffic. Although the exact incidence of the floating knee is not known, it is an uncommon injury.<ref name="knee">Rethnam U, Yesupalan RS, Nair R. The floating knee: epidemiology,prognostic indicators &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; outcome following surgical management. ournal of Trauma Management &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Outcomes 2007, 1:2</ref>&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<br>
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;<br>  


== Epidemiology  ==
== Epidemiology  ==


*Most of the patients are in their third decade  
*Most of the patients are in their third decade  
*Preponderance of males.
*Preponderance of males.<br>
 
<br>  


== Etiology  ==
== Etiology  ==


Road traffic accident (RTA) accounts for majority of the cases&nbsp;and this is followed by fall from height (FFH) 1-5
Road traffic accident (RTA) accounts for majority of the cases&nbsp;and this is followed by fall from height (FFH)&nbsp;<ref>Mc Bryde A Jr, Blake R. The floating knee: ipsilateral fracture of the femur and tibia. Proceedings of the American Academy of Orthopaedic Surgeons. J Bone Joint Surg Am1974;56:1309</ref>&nbsp;<ref>Fraser RD, Hunter GA, Waddell JP. Ipsilateral fracture of the femur and tibia. J Bone Joint Surg Br1978;60:510–5</ref>&nbsp;<ref>Omer GE Jr, Moll JH, Bacon WL. Combined fractures of the femur and tibia in a single extremity: analytical study of cases at Brooke General
 
Hospital from 1961 to 1967. J Trauma1968;8:1026 -41.</ref>&nbsp;<ref>Veith RG, Winquist RA, Hansen ST Jr. Ipsilateral fractures of the femur and tibia. A report of fifty seven consecutive cases. J Bone Joint Surg Am1984;66:991–1002</ref><br>  
<br>  


== Presentation  ==
== Presentation  ==
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*Damage to the vessels (mainly the popliteal and posterior tibial arteries) and lesions of the nerves (eg, peroneal nerve) are common. Vascular injury is common and may be limb threatening if not recognized and addressed. Often, the vascular injury is to the anterior tibial artery and does not result in ischemia and is not treated with vascular repair or reconstruction. However, vascular status needs to be assessed and addressed as appropriate. Traction usually causes neurapraxia, which often resolves, but complete resolution cannot always be anticipated.<ref name="4">http://emedicine.medscape.com/article/1249181-overview#showall</ref>  
*Damage to the vessels (mainly the popliteal and posterior tibial arteries) and lesions of the nerves (eg, peroneal nerve) are common. Vascular injury is common and may be limb threatening if not recognized and addressed. Often, the vascular injury is to the anterior tibial artery and does not result in ischemia and is not treated with vascular repair or reconstruction. However, vascular status needs to be assessed and addressed as appropriate. Traction usually causes neurapraxia, which often resolves, but complete resolution cannot always be anticipated.<ref name="4">http://emedicine.medscape.com/article/1249181-overview#showall</ref>  
*The incidence of open fractures is high, approaching 50-70%, at 1 or both fracture sites. The most common combination is a closed femoral fracture with an open tibial fracture.<ref name="4">http://emedicine.medscape.com/article/1249181-overview#showall</ref>  
*The incidence of open fractures is high, approaching 50-70%, at 1 or both fracture sites. The most common combination is a closed femoral fracture with an open tibial fracture.<ref name="4">http://emedicine.medscape.com/article/1249181-overview#showall</ref>  
*Simultaneous skeletal disruption of two strong bones of the body almost always occurs following high-velocity impact.&nbsp;The ipsilateral femoral and tibial shaft fractures and knee ligament injury appear to be part of a continuum of combined injuries resulting from complex, high-energy forces.&nbsp;The most common pattern is an open tibia and closed femur fracture.<ref name="imp">Kumar R. The floating knee injury. JCOT 2011; 2:69-76</ref>
*Simultaneous skeletal disruption of two strong bones of the body almost always occurs following high-velocity impact.&nbsp;The ipsilateral femoral and tibial shaft fractures and knee ligament injury appear to be part of a continuum of combined injuries resulting from complex, high-energy forces.&nbsp;The most common pattern is an open tibia and closed femur fracture.<ref name="imp">Kumar R. The floating knee injury. JCOT 2011; 2:69-76</ref>  
*This injury may be associated with multiple remote organ damage that may &nbsp;range from head injury to foot fractures.  
*This injury may be associated with multiple remote organ damage that may &nbsp;range from head injury to foot fractures.  
*The soft tissue trauma is usually immense and most of the patients are hemodynamically compromised.  
*The soft tissue trauma is usually immense and most of the patients are hemodynamically compromised.  
*A well-documented finding is injury to the knee ligaments that occur in association with ipsilateral femoral and tibial fractures. Anterolateral rotatory instability is the most common pattern of instability. Knee ligament injury is not always suspected, and joint swelling due to hemarthrosis should not be mistaken for a sympathetic effusion.&nbsp;<ref>Van Raay JJ, Raaymakers EL, Dupree HW. Knee ligament injuries combined with ipsilateral tibial and femoral diaphyseal fractures: the "floating knee". Arch Orthop Trauma Surg. 1991;110(2):75-7. [Medline].</ref>  
*A well-documented finding is injury to the knee ligaments that occur in association with ipsilateral femoral and tibial fractures. Anterolateral rotatory instability is the most common pattern of instability. Knee ligament injury is not always suspected, and joint swelling due to hemarthrosis should not be mistaken for a sympathetic effusion.&nbsp;<ref>Van Raay JJ, Raaymakers EL, Dupree HW. Knee ligament injuries combined with ipsilateral tibial and femoral diaphyseal fractures: the "floating knee". Arch Orthop Trauma Surg. 1991;110(2):75-7. [Medline].</ref>  
*In skeletally immature patients, floating knee is uncommon. Few studies of this injury have been conducted in children. Data from available studies show that findings observed in children are comparable to those in adults in terms of the mechanism of fracture, the incidence of associated major injuries, and the complexity of treatment.<ref name="4">http://emedicine.medscape.com/article/1249181-overview#showall</ref>
*In skeletally immature patients, floating knee is uncommon. Few studies of this injury have been conducted in children. Data from available studies show that findings observed in children are comparable to those in adults in terms of the mechanism of fracture, the incidence of associated major injuries, and the complexity of treatment.<ref name="4">http://emedicine.medscape.com/article/1249181-overview#showall</ref><br>
 
<br>


== <span>&nbsp;Complications</span>  ==
== <span>&nbsp;Complications</span>  ==


*Epiphyseal injury can adversely affect open growth plates, predisposing a child to limb-length discrepancy and angular deformities.  
*Epiphyseal injury can adversely affect open growth plates, predisposing a child to limb-length discrepancy and angular deformities.  
*Rates of infection, nonunion, malunion, and stiffness of the knee are relatively high. These complications can lead to functional impairment and frequently cause unsatisfactory results.<ref name="4" />
*Rates of infection, nonunion, malunion, and stiffness of the knee are relatively high. These complications can lead to functional impairment and frequently cause unsatisfactory results.<ref name="4" /><br>
 
<br>


== Management&nbsp;  ==
== Management&nbsp;  ==
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In adults, all floating knee injuries must be addressed with early anatomic reconstruction and stable surgical stabilization of both fractures. The goal is to allow for early joint mobilization.  
In adults, all floating knee injuries must be addressed with early anatomic reconstruction and stable surgical stabilization of both fractures. The goal is to allow for early joint mobilization.  


*In children, especially those younger than 10 years, treatment of ipsilateral <br>
*In children, especially those younger than 10 years, treatment of ipsilateral&nbsp;
</div>  
</div>  
<br> <br>
== References  ==
== References  ==


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<br>  
<div><br></div><div></div>  
<div><br></div><div></div>  
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]][[Category:Knee]][[Category:Condition]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Knee]] [[Category:Condition]]

Revision as of 21:01, 18 March 2014

Introduction[edit | edit source]

  • The term ‘floating’ has been used quite vaguely in the literature to describe various injury patterns /surgical procedures and even congenital anomalies. When the term is used to describe an injury pattern, it commonly implies that a joint/bone has lost its continuity at adjacent ends either as a result of fractures, fracture dislocations or pure disloca-tions and hence has become ‘floating’ [1]
  • Blake and McBryde initially described this injury. Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and ipsilateral tibia. Floating knee injuries may include a combination of diaphyseal, metaphyseal, and intra-articular fractures [2] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
  •  The fractures range from simple diaphyseal to complex articular types. This complex injury has increased in proportion to population growth, number of motor vehicles on the road, and high speed traffic. Although the exact incidence of the floating knee is not known, it is an uncommon injury.[3]              

Epidemiology[edit | edit source]

  • Most of the patients are in their third decade
  • Preponderance of males.

Etiology[edit | edit source]

Road traffic accident (RTA) accounts for majority of the cases and this is followed by fall from height (FFH) [4] [5] [6] [7]

Presentation[edit | edit source]

  • The ‘floating knee’ is a serious injury.
  • Floating knee injuries must be included in assessment and treatment protocols for patients with polytrauma. 
  • Damage to the vessels (mainly the popliteal and posterior tibial arteries) and lesions of the nerves (eg, peroneal nerve) are common. Vascular injury is common and may be limb threatening if not recognized and addressed. Often, the vascular injury is to the anterior tibial artery and does not result in ischemia and is not treated with vascular repair or reconstruction. However, vascular status needs to be assessed and addressed as appropriate. Traction usually causes neurapraxia, which often resolves, but complete resolution cannot always be anticipated.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • The incidence of open fractures is high, approaching 50-70%, at 1 or both fracture sites. The most common combination is a closed femoral fracture with an open tibial fracture.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Simultaneous skeletal disruption of two strong bones of the body almost always occurs following high-velocity impact. The ipsilateral femoral and tibial shaft fractures and knee ligament injury appear to be part of a continuum of combined injuries resulting from complex, high-energy forces. The most common pattern is an open tibia and closed femur fracture.[8]
  • This injury may be associated with multiple remote organ damage that may  range from head injury to foot fractures.
  • The soft tissue trauma is usually immense and most of the patients are hemodynamically compromised.
  • A well-documented finding is injury to the knee ligaments that occur in association with ipsilateral femoral and tibial fractures. Anterolateral rotatory instability is the most common pattern of instability. Knee ligament injury is not always suspected, and joint swelling due to hemarthrosis should not be mistaken for a sympathetic effusion. [9]
  • In skeletally immature patients, floating knee is uncommon. Few studies of this injury have been conducted in children. Data from available studies show that findings observed in children are comparable to those in adults in terms of the mechanism of fracture, the incidence of associated major injuries, and the complexity of treatment.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

 Complications[edit | edit source]

  • Epiphyseal injury can adversely affect open growth plates, predisposing a child to limb-length discrepancy and angular deformities.
  • Rates of infection, nonunion, malunion, and stiffness of the knee are relatively high. These complications can lead to functional impairment and frequently cause unsatisfactory results.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Management [edit | edit source]

In adults, all floating knee injuries must be addressed with early anatomic reconstruction and stable surgical stabilization of both fractures. The goal is to allow for early joint mobilization.

  • In children, especially those younger than 10 years, treatment of ipsilateral 

References[edit | edit source]

  1. AGARWAL A, CHADHA M. Floating injuries :a review of the literature and proposal for a universal classification. Acta Orthop. Belg. 2004, 70, 509-514
  2. Rethnam U, Yesupalan RS, Nair R. Impact of associated injuries in the floating knee: a retrospective study. BMC Musculoskelet Disord. Jan 14 2009;10:7. [Medline].
  3. Rethnam U, Yesupalan RS, Nair R. The floating knee: epidemiology,prognostic indicators &amp;amp;amp;amp;amp;amp;amp;amp;amp; outcome following surgical management. ournal of Trauma Management &amp;amp;amp;amp;amp;amp;amp;amp;amp; Outcomes 2007, 1:2
  4. Mc Bryde A Jr, Blake R. The floating knee: ipsilateral fracture of the femur and tibia. Proceedings of the American Academy of Orthopaedic Surgeons. J Bone Joint Surg Am1974;56:1309
  5. Fraser RD, Hunter GA, Waddell JP. Ipsilateral fracture of the femur and tibia. J Bone Joint Surg Br1978;60:510–5
  6. Omer GE Jr, Moll JH, Bacon WL. Combined fractures of the femur and tibia in a single extremity: analytical study of cases at Brooke General Hospital from 1961 to 1967. J Trauma1968;8:1026 -41.
  7. Veith RG, Winquist RA, Hansen ST Jr. Ipsilateral fractures of the femur and tibia. A report of fifty seven consecutive cases. J Bone Joint Surg Am1984;66:991–1002
  8. Kumar R. The floating knee injury. JCOT 2011; 2:69-76
  9. Van Raay JJ, Raaymakers EL, Dupree HW. Knee ligament injuries combined with ipsilateral tibial and femoral diaphyseal fractures: the "floating knee". Arch Orthop Trauma Surg. 1991;110(2):75-7. [Medline].