12/06/2013 1 Björn Engström, M.D., Ph.D., Associate Professor The Severely Injured Knee Karolinska Institutet IOC Advanced Team Physician Course First of all..... Every knee injury is unique !!! Mechanism of Injury High energy Dashboard knee Pedestrian vs Auto MC Fall from height Low energy Fall on flexed knee Hyperextension Forced flexion + internal rotation Old ACL and/or PCL injury + new injury ESSKA - 2002 The injury mechanism Dashboard injury F. Netter Injury mechanism Hyperextension injury Flexion-Rotation injury
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12/06/2013
1
Björn Engström, M.D., Ph.D., Associate Professor
The Severely Injured Knee
Karolinska Institutet
IOC Advanced Team Physician
Course
First of all.....
Every knee injury
is unique !!!
Mechanism of Injury
High energy
Dashboard knee
Pedestrian vs Auto
MC
Fall from height
Low energy
Fall on flexed knee
Hyperextension
Forced flexion + internal rotation
Old ACL and/or PCL injury + new injury
ESSKA - 2002
The injury mechanism
Dashboard injury
F. Netter
Injury mechanism
Hyperextension injury
Flexion-Rotation
injury
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F. Netter
Flexion-Rotation
injury
Serious injury !
Remember when you examine a
severely injured knee(If possible) ask the patient: ”Exactly what
happened at the moment of injury?”
The distal part of the leg pointing in some
abnormal direction?
Spontaneous reduction or manual reduction?
Is the knee dislocated in anyway (when you
examine)
Is blood supply, motor function, sensory
normal - distal to the injured area?
Pulseless? Dropfoot? Sensory loss?
Knee Dislocation
Remember that many knees that have been
dislocated - are not dislocated at the time they
arrive at the hospital !!
The joint capsule is often ruptured i.e. The
effusion of the hemarthroses will not be
detected because the blood will be extra
articular !!
Classification
I. Direction of displacement
II. Open vs Closed
III. High energy vs Low energy
IV. Ligament Involved Classification
Anatomic Classification of
Knee Dislocation
KD-I. Single cruciate torn (ACL or PCL)
KD-II. Bicruciate disruption, MCL/LCL intact
KD-III. Bicruciate disruption, torn MCL or
LCL/PCL
KD-IV. ACL, PCL, MCL, LCL torn
KD-V. All ligaments torn with fracture
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Lachman test
Which stability tests are possible in
the acute phase?
(and/or Reversed Lachman test) Varus-Valgus test
Posterior sag
Posterior drawer
Tibia step off
Postero-lateral
instability
Reversed
Pivot shift
Dial test
X-ray
Dislocated
Anterior
Posterior
Postero-lateral
Avulsion fracture
Plateau fracture
Segond
fracture
Small
fractures can
tell you a
lot…
On the other hand big cartilage
lesions is sometimes ”hidden”…
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Severe knee injury
The risk of a possible knee dislocation
Be suspicious if you find ACL-PCL rupture
High- or low energy trauma ?
Damage to the nerves and/or the vessels!
Consider:
Severe knee injuryVascular lesions not
repaired within 6-8 hours
� Amputation rate is
> 85%
Amputation caseVascular grafting.
No amputation!
Timing – time since injury?
Do X-ray and MRI immediately !
i.e. X-ray acute and MRI within 1-2 days
The surgical technique is ”easier” in the acute stage and the best period for this injury is within 10-14 days!
i.e. Extraarticular injuries is more difficult to identify(and to repair) after this period.
Brace in 0 degree 4 weeks with partial weight bearing
Week 1 - 2: No ROM training
Week 3 - 4: ROM 0 - 30 degree
Week 5 - 6: Brace and ROM 0 - 60 degree
Week 7 - 8: Brace and ROM 0 - 90 degree
Week 9 - 12: Brace and ROM without limit
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Take home message
KD and trauma with more than one rupturedligament involved. Make a thorough analysis and useMRI (within a few days). ”Overlooked” injuries is not uncommen!
Never forget to check nerve function and vacularisation distal to the injury (several times)!
Get a second opinion from experts, to decide ifsurgery should be performed in the acute phase i.e. tomake it possible to do surgery within 7-10 days.