posterior cruciate ligaments and the posterior joint capsule. The extensor mechanism of the knee may also be disrupted and should be checked postreduction. Because of knee instability reduction very often occurs spontaneously. A severely unstable knee in multiple directions is suspicious for a spontaneously reduced knee dislocation. Suspicion of the injury is important because of the high incidence of associated complications, including popliteal artery injury (50 percent incidence) and peroneal nerve injury (mostly with posterolateral dislocations), in addition to ligamentous and meniscal injury.
FIG. 266-9. Types of dislocations. 1. Anterior; 2. posterior; and 3. lateral. (From DePalma AF. Management of Fractures and Dislocations: An Atlas. Philadelphia, WB Saunders, 1970, p 1621. Used by permission.)
Early reduction of the dislocation employing longitudinal traction is essential. Neurovascular status of the extremity should be documented pre- and postreduction. Hospitalization is required and orthopedic consultation should be obtained immediately.
Controversy exists regarding when to obtain arteriography in patients with knee dislocation. Because of the high incidence of popliteal artery injury (up to one-third of patients) and poor outcomes related to delays in vascular reconstruction, some authors recommend arteriography for all confirmed knee dislocations. 18 Others have suggested clinical examination alone is reliable in identifying patients requiring arteriography and/or surgical intervention. 19 Patients with an absent pulse or other signs of vascular injury (i.e., bruit, distal ischemia) require immediate vascular surgical consultation for surgical exploration. Patients with an absent pulse prereduction with return of a pulse postreduction probably necessitate arteriography. 20 Patients with normal pulses pre- and postreduction along with normal Doppler pressure indices (Ankle-Brachial Index) (see Chap 55) can probably be safely observed in the hospital with serial vascular examinations. Presence of normal distal pulses, however, does not preclude occult popliteal artery injury. 21 As a result, if any doubt exists, arteriography should be performed.
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