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Multiligament Injury
From WikiSM
Contents
Other Names
- Multiligament knee injuries (MLKI)
- Multiligament Knee Injury
Background
- This page refers to multiligament knee injuries (MLKI)
- They should be considered the equivalent of a Knee Dislocation until proven otherwise
- Defined as injury two at least two of the four major ligaments of the knee:
History
Epidemiology
- Estimated to represent 0.02% to 0.20% of all orthopedic injuries[1]
- Likely underestimated as a high proportion are missed on initial evaluation
Pathophysiology
Etiology
- High energy trauma
- Examples include motor vehicle crash, ATV accident
- Often associated with other injuries
- Lower energy trauma
- Sports-related trauma
- Fall from standing
Associated Injuries
- Emergent
- Ligaments
- Other
- Bone contusion, less commonly fracture
Risk Factors
- Needs to be updated
Differential Diagnosis
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
Clinical Features
- History
- High energy or low energy trauma
- If ambulation attempted, likely instability or buckling
- Physical Exam: Physical Exam Knee
- Dimple Sign: buttonholing of of medial femoral condyle through medial capsule
- Very important to document a thorough vascular exam
- Presence of peripheral pulses does not exclude vascular injury
- Abnormal pedal pulse is only 79% sensitive, 91% specific for arterial injury[2]
- Serial vascular exam is mandatory
- Assess Peroneal Nerve, Tibial Nerve
- Carefully examine compartments
- Special Tests
- Ankle Brachial Index: can be used to compare vascular flow to contralateral limb
- Need to perform structural exam assessing ACL, PCL, MCL and LCL
Evaluation

Knee dislocation algorithim proposed by Ng et al[3]
Ankle Brachial Index
- Excellent screening tool since arteriography is impractical in all patients
- If ABI < 0.9, must pursue further vascular workup
- Mills et al: ABI <0.9 has 100% sensitivity, specificity and PPD for vascular injuries in knee dislocations[4]
Radiographs
- Standard Radiographs Knee
- May be normal depending on mechanism
- look for asymmetric, irregular or widening of joint space
- Segund Fracture, Osteochondral Defect may be seen
- Post reduction or post splinting films are necessary
MRI
- Indicated in most cases
- After reduction, prior to surgical intervention if possible
- Helpful to identify degree of soft tissue injury
- Especially in the multi-ligament knee injury
- Consider angiography
CT
- Useful to evaluate for fracture patterns
- Findings
- Tibial eminence fracture
- Tibial tubercle fracture
- Tibial Plateau fracture
- Consider angiography
Ultrasound
- Duplex arterial sonography may be useful to evaluate arterial supply
Classification
Schenck Anatomic Knee Dislocation (KD) Classification
- KD I: Knee dislocation with either cruciate intact
- KD II: Bicruciate with collateral intact
- KD III: Bicruciate injury with one collateral ligament injury
- KD IIIM: Bicruciate + MCL injury
- KD IIIL: Bicruciate + LCL injury
- KD IV: Bicruciate with both colateral ligaments injured
- KD V: Periarticular fracture dislocation
Management
Prognosis
- Levy et al systematic review compared operative to nonoperative management[5]
- Overall, operative treatment results in better functional outcome as compared to nonoperative treatment
- Higher rates of return to work and pre-injury sports activities
- International Knee Documentation Committee [IKDC] excellent/good results 58% operative vs 20% nonoperative
- Return to sport is 29% in operative group vs 10% in nonoperative group
- Range of motion (126° vs. 123°) and flexion (4° vs. 3°) loss were similar among groups
- Timing of surgery
- Levy looked at timing of surgery[6]
- More likely to return to sport if surgery done within 3 weeks
- No difference in functional outcomes between early and late surgery
- Levy looked at timing of surgery[6]
- Staged vs acute reconstruction/repair
Acute
- Follow ATLS protocol when appropriate, based on mechanism
- Examination
- Thorough structural examination
- Examine soft tissue compartments
- Confirm palpable dorsalis pedis, posterior tibia and popliteal artery pulses
- Immobilization
- Full extension in long Hinged Knee Brace or Posterior Long Leg Splint
- If posterior capsule injured, may require 20° of flexion to avoid posterior subluxation
- May require temporary external fixation
- Imaging
- Pre and post-reduction radiographs
- Consider CT (with angiography), emergent MRI
- Vascular- consider ABI, duplex arterial sonography
- Emergent surgery
- Irreducible knee dislocation
- Open knee dislocation
- Vascular injury
Nonoperative
- Indications
- Few, but consider in
- Elderly
- Poor surgical candidates, multiple comorbidities
- Poor ambulatory function at baseline
- Hinged Knee Brace
- Physical Therapy
Operative
- Indications
- Virtually all cases
- Technique
- Repair
- Reconstruction
Rehab and Return to Play
Rehabilitation
- Overall, there is a paucity of evidence guiding rehabilitation of repaired MLKI
- General consensus is protected non-weight bearing for 4-6 weeks
- Followed by active mobilization, progressive weight bearing, avoid passive stretching[9]
- Mook et al showed early mobilization resulted in better range of motion, stability[8]
Return to Play
- Needs to be updated
Complications
- Popliteal Artery injury
- Reported in 18 to 64% of knee dislocations[10]
- Approximately 80% are repaired, 12% require amputation
- Lower risk in sports-related injuries than high-velocity injuries[11]
- Early interventions within 8 hours (11%) is associated with lower rates of amputation than beyond (86%)[12]
- Highest risk with KD IV injuries
- McDonough case series on popliteal artery injuries following MLKI[13]
- 4/12 identified by physical exam, 5/12 identified with arteriography and 3/12 identified in OR with vascular exam and arteriography
- Peroneal Nerve Injury
- Most commonly the Common Peroneal Nerve, however Superficial Peroneal Nerve, Deep Peroneal Nerve also affected
- Injured in between 25% and 33% of dislocations, particular posterior and lateral[14][15]
- As high as 41% in posterlateral corner injuries[16]
- Among sports, skiing and football are most commonly associated[17]
- Approximately 30% have a complete palsy, with only 38.4% of them having a functional recovery
- Approximately 70% have an incomplete palsy, 87.3% of them have a functional recovery[18]
- Inability to return to sport
- Chronic instability
- Chronic pain
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Howells NR , Brunton LR , Robinson J , Porteus AJ , Eldridge JD , Murray JR . Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury 2011;42:1198–1204.
- ↑ Barnes CJ , Pietrobon R , Higgins LD . Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. J Trauma 2002;53:1109–1114
- ↑ Ng, Jimmy Wui Guan, Yulanda Myint, and Fazal M. Ali. "Management of multiligament knee injuries." EFORT Open Reviews 5.3 (2020): 145-155.
- ↑ Mills WJ , Barei DP , McNair P . The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 2004;56:1261–1265.
- ↑ Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, et al. Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy. 2009;25:430–8.
- ↑ Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, et al. Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy. 2009;25:430–8.
- ↑ Jiang W , Yao J , He Y , Sun W , Huang Y , Kong D . The timing of surgical treatment of knee dislocations: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015;23:3108–3113
- ↑ 8.0 8.1 Mook WR , Miller MD , Diduch DR , Hertel J , Boachie-Adjei Y , Hart JM . Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation. J Bone Joint Surg Am 2009;91:2946–2957.
- ↑ Lynch AD , Chmielewski T , Bailey L , et al.; STaR Trial Investigators. Current concepts and controversies in rehabilitation after surgery for multiple ligament knee injury. Curr Rev Musculoskelet Med 2017;10:328–345
- ↑ Medina, Omar, et al. "Vascular and nerve injury after knee dislocation: a systematic review." Clinical Orthopaedics and Related Research® 472.9 (2014): 2621-2629.
- ↑ Shelbourne KD, Klootwyk TE. Low-velocity knee dislocation with sports injuries. Treatment principles. Clin Sports Med. 2000;19:443–56
- ↑ Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am. 1977;59:236–9.
- ↑ McDonough EB Jr , Wojtys EM . Multiligamentous injuries of the knee and associated vascular injuries. Am J Sports Med 2009;37:156–159
- ↑ Meyers MH, Harvey JP. Traumatic dislocation of the knee joint: a study of eighteen cases. J Bone Joint Surg Am 1971;53:16-29.
- ↑ Samson D , Ng CY , Power D . An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2017;1:362–367
- ↑ Niall DM, Nutton RW, Keating JF. Palsy of the common peroneal nerve after traumatic dislocation of the knee. J Bone Joint Surg Br. 2005;87:664–7.
- ↑ Cho D, Saetia K, Lee S, Kline DG, Kim DH. Peroneal nerve injury associated with sports-related knee injury. Neurosurg Focus. 2011;31:E11.
- ↑ Woodmass JM, Romatowski NP, Esposito JG, Mohtadi NG, Longino PD. A systematic review of peroneal nerve palsy and recovery following traumatic knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2015;23:2992–3002.
Created by:
John Kiel on 18 December 2020 22:31:21
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Last edited:
4 October 2022 15:51:12
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