Floating Knee

Introduction

The term “floating” has been used vaguely in the literature to describe various injury patterns/surgical procedures and even congenital anomalies. When the term is used to describe the damage pattern, it usually means that the joint/bones have lost continuity at adjacent ends Fracture-dislocation or pure dislocation of the fracture, thus becoming “floating” [1] This injury was originally described by Blake and McBryde. Floating knee is a flail knee caused by a shaft or adjacent metaphyseal fracture of the femur and ipsilateral femur tibia. Floating knee injuries may include a combination of diaphyseal and intra-articular fractures [2] [3]. Fractures range from simple diaphyseal fractures to complex joint types. This complex of injuries increases with the number of motor vehicles on the road and high-speed traffic. Although the exact incidence of floating knee is unknown, it is an uncommon injury. [4]

Type 1 floating knee (Blake & McBryde classification) [4] Type 2A floating knee shows involvement of the distal femur and proximal tibia [4] Type 2B floating knee shows hip involvement [4]

Epidemiology

• Most patients are in their thirties
• Preponderance of males.

Etiology

Road Traffic Accidents (RTA) accounted for most, followed by Fall from Height (FFH) [5] [6] [7] [8]

Presentation

• A “floating knee” is a serious injury.
• Floating knee injuries must be included in the evaluation and treatment of polytrauma patients.
• Vascular injury (mainly the popliteal and posterior tibial arteries) and nerve injury (eg, peroneal nerve) are common. Vascular injuries are common and can endanger a limb if not recognized and treated. Vascular injury is usually the anterior tibial artery and does not result in In ischemia and not treated by vascular repair or reconstruction. However, vascular conditions need to be assessed and managed as appropriate. Traction usually results in nerve palsy, which usually resolves, but complete resolution is not always expected. [9]
• The incidence of open fractures is high, approaching 50-70% at 1 or 2 fracture sites. The most common combination is a closed femoral fracture with an open tibial fracture. [9]
• Simultaneous skeletal destruction of the body’s two strong bones almost always follows a high-velocity impact. The ipsilateral femoral and tibial shaft fractures and knee ligament injuries appear to be part of a series of combined injuries caused by complex high-energy forces. most The common pattern is open tibial and closed femoral fractures. [10]
• This injury may be associated with a variety of distal organ injuries, ranging from head injuries to foot fractures.
• Soft tissue trauma is often massive and hemodynamics are compromised in most patients.
• A well-documented finding is knee ligament injury associated with ipsilateral femoral and tibial fractures. Anterolateral rotational instability was the most common instability pattern. Knee ligament damage is not always suspected, joint swelling from hemarthrosis should be Not to be mistaken for a sympathetic effusion. [11]
• Floating knees are uncommon in skeletally immature patients. Few studies of this impairment have been conducted in children. Data from available studies suggest that outcomes observed in children are comparable to those observed in adults with regard to fracture mechanism, incidence of associated major morbidity Complexity of injury and treatment. [9]

 Complications

• Injury to the epiphysis can adversely affect the open growth plate, predisposing children to limb length differences and angular deformities.
• There is a relatively high incidence of infected nonunions, malunions, and knee stiffness. These complications lead to dysfunction and often to unsatisfactory outcomes. [9]

Management 

Early reports support nonoperative management [12]. Floating knee is a complex multisystem injury with extensive soft tissue damage in the affected limb. The need for early mobilization is recognized, but immobilization techniques do not provide the expected stability. this Surgeons prefer life to limb. The current recommendation for floating knees is surgical stabilization of the fracture. There are multiple ways to do this, but no single ideal technique. The sequence of surgery should be individualized for each patient, and each fracture should be Treat it according to its personality. The chosen approach depends on fracture type, fracture location, available resources for soft tissue injury, surgical ability, and preference. The effect of the osteosynthesis technique on the overall physiology of the patient should be kept within [13] Rehabilitation [14] Following surgical stabilization of a fracture, the knee should be checked for range of motion and stability. Collateral ligament laxity is best controlled by bracing for 6 weeks. Reconstruction of injured ligaments is usually delayed until full recovery bone damage. The patient should have regained a good range of motion in the knee joint. Adequate pain control with epidural catheters or systemic opioid infusions is imperative in the early postoperative period. Weight bearing in type I patterns is delayed until callus is visible on x-ray. in type II Weight-bearing variants are allowed only after 10 weeks to prevent sinking of joint debris. Regardless of the injury pattern, the likelihood of optimal outcomes depends on early mobilization of the knee. This is more necessary for intra-articular fractures. The benefits of early exercise on cartilage and periarticular tissue health are well documented in the literature. Salter’s work leads the field concluding that floating knee injuries are indicators of severe trauma. Distant organ damage should be suspected and systematically searched for. Following a standardized resuscitation protocol, early stabilization of the fracture and aggressive postoperative rehabilitation provide the best chance for optimal outcome.

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