Floating Knee


Article Author:
Ryan Card
Jason Lowe


Article Editor:
Abdullah Bokhari


Editors In Chief:
Shivajee Nallamothu
Matthew Varacallo
Joshua Tuck


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/4/2019 3:06:13 PM

Introduction

As early as 1975, the term floating knee was initially used by Blake and McBryde to describe fractures of the ipsilateral femur and tibia. Fractures can occur anywhere along the femur and the tibia and must occur in both bones to be considered a floating knee injury.[1]The term floating knee refers to the knee joint and not necessarily the connection to either long bone. Although tibial and femur fractures are not uncommon, having injuries to both bones simultaneously on the ipsilateral limb is uncommon.  Floating knee injuries are usually complex in nature, with various mechanisms of injury, as well as often complicated treatments.

Floating knee (also known as "flail knee") injuries have been classified using various classification systems including the first classification used by Blake and McBryde, the Letts-Vincent, and the Bohn-Durbin classification systems.

Blake and McBryde first classified the injuries based on the injury sites as type I, type II-A, and II-B.  Type I fractures include fractures of both shafts of the two long bones.  Type II-A involves the knee joint whereas type II-B fractures require the involvement of the hip or ankle joints.[2]

The Letts-Vincent and the Bohn-Durbin are pediatric classification systems that first classify the region of the fracture and whether it is an open or closed fracture. Letts-Vincent classifies the fractures A-E, with Type A fractures being two closed diaphyseal fractures.  Type B injuries are composed of two closed fractures with one being diaphyseal and the other metaphyseal; Type C injuries include two closed fractures with one being diaphyseal and the other epiphyseal; Type D injuries have at least one open fracture,  and Type E fractures are composed of both fractures open.

Bohn-Durbin classification has three types; Type I are double shaft fractures, Type II injuries are juxta-articular, and Type III have an epiphyseal component.[3]

Fraser et al. further classify floating knee injuries as Type I: shaft fractures of both bones without the involvement of either fracture into the knee, Type II fractures extended into the knee and were further sub-divided.  Type IIa involved the tibial plateau, Type IIb involved the distal femur into the knee, and type IIc involved both the tibial plateau and the distal femur within the knee joint.[4]

Etiology

As with most complex fractures, floating knee injuries are associated with high-velocity mechanisms and often accompanied by other injuries to other parts of the body including severe soft tissue injury.  These high-velocity mechanisms include: motor vehicle accidents, falls from an extreme height, pedestrian vs. auto accidents, cyclist vs. auto accidents, and other mechanisms that involve blunt trauma to the area.[3][5]

Epidemiology

Floating knee injuries are rare, and there is not enough data to date to definitively estimate the prevalence amongst populations. However, there is a strong predominance in males over females.  This male to female predilection may be related to the high velocity and strenuous activities seen more in males than females. Also, there seems to be a higher prevalence in males over females engaging in more risk-taking behaviors and activities.

History and Physical

Patients with floating knee injuries typically will have incurred multiple trauma injuries to that region and should not be overlooked. Furthermore, patients will most likely present with a history of trauma — for example an MVA, a fall from a height, pedestrian vs. auto, etc.  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).  On physical examination, there will usually be tenderness to palpation at both the tibial and femoral fracture sites along with gross deformities and shortening of the affected limb.  More advanced classification fractures may also be present in one or more of the fractured components.  Neurovascular status may or may not be compromised and requires a thorough examination.

Evaluation

Patients with floating knee injuries should undergo evaluation according to standard protocols for trauma and as per clinical presentation. If polytrauma was involved, then basic ATLS protocol should be implemented first. Therefore, most urgent needs should be addressed first before any intervention elsewhere, which includes examining the patient's airway, breathing, circulation, disability, and exposure to harmful substances or situations (ABCDE’s). Generally, standard trauma workup will be a requirement in most instances and stabilization of a critically ill patient will need to be first prior to any intervention to musculoskeletal complaints.  Once the patient is stable, and other life-threatening injuries have been dealt with or ruled out, focusing on other injuries such as the floating knee is then indicated. 

Ensuring the patient is neurovascularly intact is one of the most important things for which to check.  Examining sensation in all dermatomes of the lower extremity as well as pulses of the dorsalis pedis and posterior tibial artery should be tested first after addressing any circulation matters. Posterior displacement of the distal femur may also cause damage to the adjacent popliteal artery. If this is suspected, a Doppler ultrasound should be conducted to rule out intimal tears.[6]  Monitoring patients for signs of fat embolism are in order due to the significant skeletal trauma that usually accompanies these injuries. If any sign of fat embolism is detected, postponement of the surgical management of the fractures is necessary until the patient is stable.[7] 

Radiographs in the form of x-rays are the best initial tool for diagnosis.  X-rays will allow an initial gestalt view of the affected limb to rule in/out any obvious fractures.  CT scan can be used to further investigate any complicated fractures including severity of comminution and bone loss and can assist in the planning of fixation techniques and predicting any complications that may arise. Due to the high incidence of ligamentous injuries associated with floating knee type injuries, an MRI may also be necessary.[7][8][9]

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.[3] '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.[6] 

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 used for diaphyseal fractures where a functional reduction is more indicated.  This 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 (tibial plateau).  Intramedullary nailing of both bones, when possible, is the best surgical management associated with good outcomes.[7]

Differential Diagnosis

Patients with floating knee injuries are typically polytrauma patients.  Because of this, a healthcare provider should always rule out other life-threatening injuries. Also, complications can arise from such traumas. 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. 

Prognosis

According to the study by Kulkarni et al., the average union time for tibial and femur fractures in floating knee injuries was 9.52 (+/-6.6) and 10.5 (+/-7.37) months respectively in a population of 89 patients aged 34.34 (+/- 12.28) years. Segmental femur fractures showed a delay in union time by about six months.  This delay did not manifest in segmental tibial fractures. Over 50% of these patients had either an excellent or good outcome.  Factors accounting for poor outcomes included open tibial fractures and those that required external fixation, segmental fractures, fractures involving the articular surface of the knee joint, and the requirement of additional surgeries to address the injuries.[10] Patients with operative treatment were found to have statistically significant shorter hospital stays than those treated conservatively.[3]

Complications

Malunion is always a possible complication of fractures. With floating knee injuries the patient also runs the risk for limb length discrepancies whether that be due to lengthening or shortening of the affected limb.  Limb length discrepancies may also occur in skeletally immature individuals if there is disruption of the growth plate resulting in premature physeal closure.  Open fractures carry an increased risk of infection.  Infection is also a complication anytime a patient undergoes a surgical procedure.[3] Other complications found to occur with floating knee injuries include compartment syndrome, loss of joint motion, and requirement of limb amputation. 

Complication rate decreases when one or both of the fractures are in the femoral and tibial diaphysis.[7] One study found treatment with a retrograde intramedullary nail (distal to proximal insertion through the knee joint), resulted in an increased risk of heterotopic ossification around the knee compared to anterograde femoral nails (proximal to distal insertion through the proximal aspect of the femur)  The explanation for this result is the fact that anterograde femoral nails never penetrate the knee joint.[11]

Deterrence and Patient Education

Patients should follow instructions given to them by their physician.  Generally, patients have better results when managed surgically and have a healing time on average eight weeks earlier than those treated conservatively.[7] Postoperatively, patients will be non-weight bearing and placed in a long leg cast.  Non-weight bearing time increases in patients not treated with intramedullary nails and more complicated fractures. Non-compliance with weight bearing may cause disruption of hardware and refracture leading to other complications such as non-union. 

Enhancing Healthcare Team Outcomes

Whenever a polytrauma patient comes to the emergency department, hospital or any healthcare setting, the appropriate personnel and healthcare providers must be available and present to manage and treat complicated and critical cases appropriately. It is essential to communicate and document any information that may be pertinent.  Communication is vital in all of medicine and possibly even more important in a trauma setting.  The use of closed-loop communication has shown to decrease the number of medical errors overall and in some studies decrease the time to complete tasks.[12] Clear communication is especially important in a trauma setting where the time factor is critical.


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Floating Knee - Questions

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A 34-year-old male comes into the emergency department after a motor vehicle accident. He is hemodynamically unstable and begins to decompensate. He is transfused and placed in a pelvic binder after the physical exam revealed pelvic instability. He is stabilized and is later diagnosed with a mid-shaft femur fracture and a tibial plateau fracture on x-ray. Based on these findings, what Fraser classification is this floating knee injury?



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A 42-year-old male is admitted to the emergency department unable to bear weight on his right leg. He is in the military and had performed a jump from 5,000 feet. His parachute deployed late and caused him to hit the ground with much higher than normal force on his extended right leg. He felt a pop and his leg gave way. He is hemodynamically stable and is taken to radiology for an x-ray. The results show a comminuted mid-shaft fracture of the femur and a displaced oblique fracture of the mid-tibial shaft. Which of the following treatment modalities has been shown to have the best outcomes?



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A 16-year-old male is diagnosed with a floating knee injury. X-rays show a displaced supracondylar femur fracture. The patient is hypotensive and tachycardic. FAST ultrasound exam shows no bleeding in the peritoneum, and a chest x-ray is unremarkable. Which of the following is indicated to determine the underlying cause of the patient's status?



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A 50-year-old male comes into the emergency department after a motor vehicle accident and is wheeled into the trauma bay. You are the first provider in the room and notice the patient has gross deformities in his mid-thigh and lower leg. You suspect a floating knee injury. Which of the following is the best next step in management?



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A patient comes into the emergency department following an auto versus bicycle accident. The patient was riding their bike when they were struck from the side by a truck. The patient complains of severe pain in their right leg. Their vital signs are stable. X-rays show a non-displaced tibial shaft fracture and a non-displaced supracondylar femur fracture. Which of the following patients is most likely to be treated non-operatively?



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Which of the following is true regarding floating knee injuries?



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Which of the following is false regarding floating knee injuries?



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Which of the following is not part of the Letts-Vincent pediatric classification system for floating knee injuries?



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Which of the following is true regarding the management of patients with floating knee injuries?



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Floating Knee - References

References

Anari JB,Neuwirth AL,Horn BD,Baldwin KD, Ipsilateral femur and tibia fractures in pediatric patients: A systematic review. World journal of orthopedics. 2017 Aug 18     [PubMed]
Muñoz Vives J,Bel JC,Capel Agundez A,Chana Rodríguez F,Palomo Traver J,Schultz-Larsen M,Tosounidis T, The floating knee: a review on ipsilateral femoral and tibial fractures. EFORT open reviews. 2016 Nov     [PubMed]
Blake R,McBryde A Jr, The floating knee: Ipsilateral fractures of the tibia and femur. Southern medical journal. 1975 Jan     [PubMed]
Rethnam U,Yesupalan RS,Nair R, The floating knee: epidemiology, prognostic indicators     [PubMed]
Hegazy AM, Surgical management of ipsilateral fracture of the femur and tibia in adults (the floating knee): postoperative clinical, radiological, and functional outcomes. Clinics in orthopedic surgery. 2011 Jun     [PubMed]
Carta S,Riva A,Fortina M,Colasanti GB,Meccariello L, The Challenges of the Femoral Bone Loss in the Management of the Floating Knee IIB According Fraser: A Case Report. Journal of orthopaedic case reports. 2018 Jan-Feb     [PubMed]
Liu Y,Zhang J,Zhang S,Li R,Yue X, Concomitant ligamentous and meniscal injuries in floating knee. International journal of clinical and experimental medicine. 2015     [PubMed]
Othman Y,Hassini L,Fekih A,Aloui I,Abid A, Uncommon Floating Knee in a Teenager: A Case Report of Ipsilateral Physeal Fractures in Distal Femur and Proximal Tibia. Journal of orthopaedic case reports. 2017 May-Jun     [PubMed]
Fraser RD,Hunter GA,Waddell JP, Ipsilateral fracture of the femur and tibia. The Journal of bone and joint surgery. British volume. 1978 Nov     [PubMed]
Kulkarni MS,Aroor MN,Vijayan S,Shetty S,Tripathy SK,Rao SK, Variables affecting functional outcome in floating knee injuries. Injury. 2018 Aug     [PubMed]
Kent WT,Shelton TJ,Eastman J, Heterotopic ossification around the knee after tibial nailing and ipsilateral antegrade and retrograde femoral nailing in the treatment of floating knee injuries. International orthopaedics. 2018 Jun     [PubMed]
El-Shafy IA,Delgado J,Akerman M,Bullaro F,Christopherson NAM,Prince JM, Closed-Loop Communication Improves Task Completion in Pediatric Trauma Resuscitation. Journal of surgical education. 2018 Jan - Feb     [PubMed]

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