Revista de Medicina Desportiva (English) March 2018 - Page 32

Clinical case

Revista Medicina Desportiva informa , 2018 ; 9 ( 2 ): 30-31 .

Traumatic Knee Dislocation with Associated Neurovascular Injury : Clinical Case and Brief Bibliographic Review

Dr . Ricardo Marta 1 , Dr . Luís Maia 1 , Dr . João Moura 1 , Dra . Sandrina Braga 2 , Dr . João Lourenço 3
1
Interno de Formação Específica de Ortopedia , 2 Assistente Hospitalar de Cirurgia Vascular , 3 Assistente Hospitalar Graduado de Ortopedia . Serviço de Ortopedia do Hospital da Senhora da Oliveira EPE , Guimarães
ABSTRACT
Knee joint dislocation associated with injury of the popliteal artery is a rare condition . Rapid diagnosis and treatment are essential for limb salvage and function . We report a case of traumatic posterior dislocation of the left knee in association with neurovascular lesion and a compartment syndrome , resulting in lower limb acute ischemia . He was promptly submitted to closed reduction of the dislocated knee in emergency room . Right after he underwent popliteal supra-infra articular bypass using a reversed saphenous contralateral vein , fasciotomies of the thigh and leg compartments and external fixation of the knee . He had a poor outcome ( amputated limb ) due to sepsis caused by fasciotomies infection and muscular waste and irreversible neurologic lesion . The present case is important because it reports a very rare occurrence and it highlights the importance of a timely intervention and a team approach to achieve the best results possible .
KEYWORDS
Posterior knee dislocation , popliteal artery disruption , bypass , neurologic lesion
Introduction
Knee dislocations are relatively rare , accounting for 0.001 % to 0.013 % of all orthopedic injuries . 1 , 2 They usually result from high energy accidents in young men , which can cause multiple ligament injuries , meniscal injuries , fractures and neurovascular injuries . 3 , 4 They are associated with vascular injury in 23-32 % of cases and neurological injury in 25-35 %. 5 , 6 The posterior dislocation of the knee occurs in 25 % of the cases of knee dislocation ( second most common ) and is the one that causes a higher rate of vascular injury .
The popliteal artery is especially vulnerable to injury in closed trauma since it is fixed superiorly in the adductor hiatus and inferiorly in the lower border of the popliteus muscle . 2 , 5 , 7 , 8 Of all the arterial lesions of the lower limbs , the popliteal lesion is associated with the most unfavorable of results , especially for coexistent soft tissue lesions . 2 , 5 In addition , if the vascular lesion is not repaired within 8 hours of ischemia , the amputation rate is 86 %. 9
Usually , the neurological injury is caused by a stretching mechanism , which can range from light stretching to complete disruption . In any case , the prognosis is poor and recovery of motor and sensory function may be slow or incomplete . 5 An early diagnosis of compartment syndrome is necessary , due to the immediate need of performing fasciotomy .
Clinical case
A 60-year-old male patient was brought to the Emergency Department one hour after a three-meter fall due to a habitational floor collapse . The patient ’ s personal history was : obesity ( BMI = 43 kg / m 2 ), dyslipidemia , cardiovascular disease with coronary stents and on double antiaggregant therapy .
In the emergency room , he underwent an initial polytraumatized patient evaluation , with no apparent lesion other than the closed trauma of the left lower limb . He complained of pain and functional impotence of the lower limb .
Physical examination revealed obvious deformity of the left knee with edema and knee tension , a cold left foot with no distal pulses ( present in the contralateral limb ), and non-audible popliteal and distal arterial flows .
Radiographs were taken ( Figure 1 ) that confirmed a posterior dislocation of the knee ( Schenck KD-IV classification ) with no associated fractures and Doppler ultrasound confirming acute ischemia due to popliteal injury .
He was immediately submitted to a closed reduction of the dislocation . The patient entered the operating room four hours later ( due to the impossibility of an earlier available operating room ) where the following was performed : intraoperative arteriography ( popliteal interruption ), popliteal supra-infra articular bypass using a reversed saphenous contralateral vein ( Figures 2 and 3 ), thigh and leg compartment fasciotomy ( Figure 4 ) and knee osteotaxis with Hoffmann II external fixators ( Figure 5 ).
Several intercurrences occurred during the postoperative period , namely an acute myocardial infarction , anemia with multiple transfusions and a Gram-negative infection of the fasciotomies despite daily clinical care , initial empirical antibiotic therapy and subsequent surgical debridement in the operating room . The bypass remained permeable with palpable distal pulses throughout hospital stay .
Motor and sensory deficit of the sciatic nerve territory was maintained without recovery after one month , eventually attributing the clinical diagnosis of neurotmesis to this occurrence .
With the worsening of the patient ’ s general condition along with acute renal failure and septic
Figure 1 – AP and lateral X-ray views : posterior dislocation of the knee
30 march 2018 www . revdesportiva . pt
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