Knee Dislocation with Tibial Shaft Fracture

Acute knee dislocation is a limb threatening emergency due to complications such as extensive soft tissue injury and disruption of regional arteries [1]. Since 50% of knee dislocations reduce spontaneously [2], they make it difficult to diagnose damage to the ligaments as well as the accompanying vascular injury, and if missed, can cause significant dysfunction in the limb [3]. This partly explains why, despite the low incidence of knee dislocations, the injury is associated with a high rate of complications such as amputation [4].

There is still debate about how to manage a traumatic complex, multiple ligamentous knee injury, and choosing between surgical treatment options or closed immobility is a controversy [5]. Concomitant fractures, including ipsilateral tibial diaphysis fractures, often challenge immediate ligament repair. Simultaneous occurrence of tibial diaphysis fracture and an anterior knee dislocation, leading to multiple ligamentous injury, is uncommon which occurs in only 2% of tibial fractures [6,7].

The treatment of choice for tibial shaft fractures is intramedullary nailing (IMN) [8]. Recent studies, however, show that transtibial tunnels implantation is difficult and challenging in the event of simultaneous occurrence of knee ligament injury and tibial shaft fracture and approach to both injuries at the same time should be avoided, and repair of ligament damage should be delayed until bone damage has healed [9]. We report a case of traumatic close left tibial shaft fracture and an anterior knee dislocation associated with extensive injuries in lateral, anterior, and posterior compartments of the knee.

A 53-year-old man was admitted to the emergency department of Sina Hospital following a car accident causing his left leg trapped between two vehicles. The principles and protocols of Advanced Trauma Life Support (ATLS) was applied on admission. After the initial examination and stabilization of the patient, he had severe pain, deformity and swelling on his left knee. There were skin abrasions on the left knee, left leg, and left medial malleolus. Physical examination was not possible, because of the severe pain. Neurovascular examinations of the limb were normal. There was no numbness or weakness in the limb, and pulsation was normal. Plain radiography and Magnetic Resonance Imaging (MRI) of left lower limbs were taken.

Radiographies revealed an anterior dislocation of the knee, a spiral-oblique fracture through the one-third mid-distal diaphysis of the tibia and fibula, and an avulsion fracture of the fibula (Figure 1). A closed reduction of dislocation was performed under sedation in operation room, and neurovascular examinations were rechecked. Then the limb was immobilized with a splint.

Figure 1: Initial radiographs showing the dislocated knee with simultaneous fracture of the tibial shaft. (A) Tibial shaft fracture. (B) Anterior dislocation of the knee combined with LCL and PFL avulsion. (C) Anterior dislocation of the knee.

MRI scan of the patient demonstrated a longitudinal meniscal tear, extending to the posterior horn and meniscofemoral ligament and a complete tearing of Lateral Collateral Ligament (LCL). Anterior Cruciate Ligament (ACL) was entirely torn, and Posterior Cruciate Ligament (PCL) had a high-grade intra-sheath tearing. Medial Patellofemoral Ligament (MPFL) showed a grade 2 sprain along with a partial avulsion from femoral insertion. Arcuate fracture at the fibular tip along with subjacent edema was also noticed as a result of Popliteofibular Ligament (PFL) avulsion (Figure 2).

According to the MRI report, it was a severe injury. 3 out of 4 compartments of the knee were severely injured. To detect any neurovascular injury The patient was carefully examined.

The surgery was performed after stabilizing the patient’s condition which was two days after the accident. Tibial shaft fracture was fixed using plates and screws to obtain proper stability and facilitate a later, second stage ligament reconstruction. Four days after initial surgery, the patient was taken back to operation room to repair the ligament injury. ACL and LCL tearing were fixed using suture anchors and PFL tearing was fixed with a screw (Figure 3). Hinged knee brace was used for immobilizing the limb for six weeks. After six weeks, gradual rehabilitative exercises began, and three month later the patient was able to do daily activities. In the case of knee joint capsule sprain and acute phase edema, PCL injury was managed non-operatively.

Figure 2: The preoperative MRI images. (A) ACL is completely torn. (B) LCL is completely torn. (C) MCL is severely injured.

Figure 3: Immediate postoperative radiographs. (A) and (B) Tibial shaft fracture fixation with plate and screw. (C) and (D) Suture anchor used for fixation of LCL avulsion.

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