FLOATING KNEE
A 55-year-old man is brought to the emergency department after a road traffic accident in which he was the driver of a car in a high-speed collision. He complains of right lower limb pain. The right lower limb is obviously deformed. This is his emergency department radiograph.
Describe your initial management in the emergency department.
This patient would be received and managed as a ‘trauma call’ in the emergency department with assessment and initial management along ATLS guidelines and led by the trauma team leader. The radiograph shows displaced and comminuted fractures of the ipsilateral left femur as well as the tibia with a ‘floating knee’. Following the identification and treatment of any immediately life-threatening injuries I would corroborate the history taken so far, complete the physical exami- nation, including a careful assessment of the soft tissues, looking for evidence of any open wound or soft tissue injury and assessing the neurovascular status of the limb.
I would ensure that the patient had adequate analgesia and I would splint the lower limb in an above knee backslab. I would perform a full secondary survey in order to identify any occult injuries once the patient had been stabilised and ade- quate analgesia given. I would admit the patient for definitive treatment of this injury on a routine trauma list in daytime hours.
How would you manage these injuries definitively?
I would advise surgery for these injuries and my preference would be to treat both injuries with reamed intramedullary nailing. This has the advantage of being rea- sonably quick and efficient and avoids the need for re-draping and re-positioning between procedures. If the patient is positioned supine on a radiolucent table then both fractures can be satisfactorily addressed through the same incision using anterograde nailing for the tibia fracture and retrograde nailing for the femur. This reduces unnecessary movement for the patient who may have other injuries and also reduces surgical time. I would normally plan to stabilise the tibia first as once this has been stabilised it will allow for greater control and traction when performing reduction and intramedullary nail fixation of the femur. In an unstable patient, I would plan to stabilise the femur first regardless in case the patient deteriorates after the first nailing procedure and is unable to tolerate the second. Following surgical stabilisation of both fractures I would perform an examination under anaesthetic of the knee joint in order to identify any ligamentous instability.