Best Floating Knee Treatment In Delhi NCR.

Floating knee treatment and cure
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What is Floating Knee?

  • A floating knee is a severe injury characterized by a flail knee joint. This occurs due to fractures in both the femur (thigh bone) and tibia (shin bone) on the same leg.
  • First described by Blake and McBryde, it’s typically caused by high-impact trauma.
  • Often accompanied by significant soft tissue damage and potential life-threatening injuries to other parts of the body (head, chest, abdomen).
Initial Evaluation
  • A thorough initial assessment is crucial to determine the full extent of injuries.
  • This should be followed by a strategic sequence of emergency diagnostic and therapeutic interventions.
  • For unstable patients or those in critical condition, temporary fracture stabilization using external fixation is recommended.
Common Complications of Floating Knee Injuries
  • Despite treatment, complication rates remain high.
  • Common complications include:
    • Infection
    • Nonunion (failure of the bones to heal)
    • Malunion (bones heal in an incorrect position)
    • Knee stiffness
  • These complications can lead to functional limitations and unsatisfactory outcomes.
Pathophysiology of Floating Knee
  • Floating knee injuries can involve various fracture types: diaphyseal (shaft), metaphyseal (end of the bone), and intra-articular (within the joint).
  • Epiphyseal injuries in children can affect growth plates, potentially leading to limb length discrepancies and angular deformities.
Classification

Adults

  • Blake and McBryde used the terms true (or type I) injury and variant (or type II) injury to classify the floating-knee fracture pattern, as follows :-
    • Type I is a pure diaphyseal fracture of the femur and tibia
    • Type II is a fracture that extends into the knee, hip, or  ankle joint.
  • Fraser et al classified floating knee injuries in a similar way by analyzing knee involvement.
    • Type I is the same as the true injury Blake and McBryde described, with extra-articular fractures of both bones
    • Type II is subdivided into three subtypes: type IIa, which involves femoral shaft and tibial plateau fractures; type IIb, which includes fractures of the distal femur and the shaft of the tibia; and type IIc, which indicates fractures of the distal femur and tibial plateau.

In both of these classification systems, type II fractures with intra-articular involvement have been linked with higher complication rates and poorer functional results than those observed with type I injuries.

Children

In children, floating knee injuries are classified according to the Bohn-Durbin or Letts classification systems.

  • In the Bohn-Durbin classification, floating knee injuries are described as follows:
    • Type I – Double-shaft pattern of fracture
    • Type II – Juxta-articular pattern
    • Type III – Epiphyseal

The Bohn-Durbin system does not account for open fractures and cannot be used to predict complications and prognoses.

Unacceptable findings are femoral union in a position of greater than 30° anterior angulation, 15° valgus angulation, and 5° posterior or varus angulation, or greater than 2 cm of shortening. Tibial malunion is defined as greater than 5° angulation in any plane or greater than 1 cm of shortening.

Rotational malunion is defined as any internal rotational deformity exceeding findings on the unaffected side or greater than 20° external rotation of the extremity, as detected during walking or standing.

Etiology

Road traffic accidents are the most common mechanisms of trauma, followed by gunshot wounds and falls from heights.

Epidemiology

This severe injury appears to be increasing in frequency. A male preponderance is observed, particularly in young adults 20-30 years of age.

Presentation
  • The ‘floating knee’ is a serious injury.
  • Floating knee injuries must be included in assessment and treatment protocols for patients with polytrauma.
  • Patients with an isolated floating knee injury will present with complaints of severe leg pain, inability to bear weight, and potentially some knee instability (due to ligamentous disruption which often accompanies these injuries).
  • 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.

  • 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.

  • 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.
  • 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.
Diagnosis

Patients with floating knee injuries are typically polytrauma patients. One must monitor for DVT and fat embolus formation that can occur secondary to skeletal trauma. Patients may also have ligamentous injuries (ACL, PCL, meniscal, etc.). These are non-life-threatening injuries and are manageable after stabilization of the critically ill patient and reduction of associated fractures.

  • Complications
    • 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.

Treatment/Management
  • Treatment and management of the floating knee injury and each fracture is dependent upon multiple variables and factors. It depends on whether the fracture is open or closed, the type of fracture pattern, the location of the fracture, comminution of fracture, as well as skeletal maturity. Skeletally immature patients are more likely to be treated non-operatively with a long leg cast than skeletally mature patients with minimally displaced fractures.Pediatric floating knee,’ classified as isolated physeal fractures of the distal femur and proximal tibia may be treated operatively by fixation with K-wires followed by casting for six weeks.
  • Other, more complicated fractures may require more invasive procedures.Femur fractures are typically treated surgically using one of three options. These are intramedullary nailing (IMN), compression plate screws, or dynamic condylar screws (DCS). IMN is typically the choice for diaphyseal fractures where a functional reduction is more indicated. This approach allows for stability of the fracture while still allowing for callus formation that occurs with secondary bone healing. Compression plate screws may are useful for femoral shaft fractures that require a more anatomic reduction and primary bone healing; this would occur in areas where concern for joint mobility post-operatively exists. Dynamic condylar screws were the choice in intra-articular fractures where an anatomic reduction is a must for maintaining joint mobilization.
  • Tibial fractures are also treated based on the above variables. External fixation is the most common option with open tibial fractures.  Plate screws or locked intramedullary nails are a possible choice for most other tibial fractures.  The tibia typically only requires a functional reduction unless the fracture is intra-articular (the tibial plateau). Intramedullary nailing of both bones, when possible, is the best surgical management associated with good outcomes.

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