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Knee Dislocation

Author: H Brendan Kelleher, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...

Overview
Dislokasi genu merupakan kejadian yang jarang tetapi merupakan hal yang penting untuk diketahui
karena seringkali melibatkan kerusakan vaskuler yang dapat berakhir dengan kehilangan kaki. Selain itu,
dislokasi genu seringkali terjadi pada trauma multiple yang menyebabkan deteksinya lebih sulit..[1, 2, 3, 4, 5, 6, 7,
8]

History
Dislokasi genu diklasifikasikan menurut posisi atau sistem klasifikasi anatomi. Klasifikasi menurut posisi
menggambarkan posisi tibia relatif terhadap femur. Banyak dislokasi genu yang telah tereduksi secara
spontan sebelum ke IGD sehingga klasifikasi secara posisi sulit dilakukan. Oleh karena itu, secara umum,
lebih disukai penggunaan klasifikasi secara anatomi karena dapat menggambarkan kerusakan yang
melibatkan ligament, arteri, dan saraf.
Klasifikasi posisional adalah sebagai berikut:

Gambar Jenis dislokasi lutut

Anterior: dislokasi anterior seringkali disebabkan karena hiperekstensi lutut. Penelitian dengan
cadaver menunjukkan bahwa hiperekstensi mendekati 30 derajat diperlukan sebelum terjadinya
dislokasi.
Posterior: Posterior dislokasi terjadi dengan benturan anterior-ke-posterior pada proximal
tibia,seperti dashboard type of injury atau jatuh dengan energy tinggi pada posisi lutut flexi. Gambaran
radiografi dislokasi posterior adalah sebagai berikut :

Posterior knee dislocation.

Medial, lateral, atau rotatory: Dislokasi medial, lateral, dan rotatory membutuhkan komponen
varus, valgus, atau rotatory pada komponen yang terkena benturan.

Lebih dari setengah dari kejadian dislokasi anterior atau posterior atau keduanya, memiliki
insidensi yang tinggi kerusakan arteri poplitea, 20%-30%dari semua dislokasi genu mengalami
komplikasi lanjutan yaitu dislokasi terbuka open joint injury seperti gambar di bawah :

Gambar : Open knee dislocation

Klasifikasi berdasarkan system anatomi dikembangkan oleh Schenck dan dimodifikasi oleh Wascher.
Klasifikasi ini melibatkan ligamen atau sistem anatomi yang lain :

KD I Ruptur multiligamen dengan intak ligamen cruciatum


KD II Ruptur Bicruciate dengan intak kedua kolateral (jarang)
KD IIIM - Bicruciate dan ligamen collateral medial ruptur (MCL)
KD IIIL - Bicruciate dan ligament kolateral lateral (LCL) ruptur
KD IV - Panligament ruptur
KD V Dislokasi genu dengan fraktur periarticular
C (tambahkan di atas) Melibatkan kerusakan arteri
N (tambahkan di atas) - Melibatkan kerusakan nervus

Pemeriksaan Fisik

Paling sering gambaran yang nyata adalah deformitas pada tungkai bawah terutama pada lutut
dengan bengkak dan tidak bisa digerakkan
Banyak dislokasi genu yang berhubungan dengan fraktur oleh karena itu pemeriksaan radiologi
diperlukan Many knee dislocations have associated fractures; thus, it is important to obtain radiographs
prior to ligamentous stressing to avoid promoting fracture displacement. In the absence of coexistent
fracture, a thorough examination of all ligamentous structures is imperative, especially in patients with
head injuries or in those who are intoxicated and may not be able to communicate symptoms
adequately. The finding of varus or valgus instability in full extension of the knee is suggestive of a
spontaneously reduced yet grossly unstable dislocation. In addition, pain out of proportion, or absent or
decreased pulses are red flags of such an injury.
Pemeriksaan vaskuler secara hati-hati perlu dilakukan karena dapat terjadi kerusakan arteri
poplitea pada semua jenis dislokasi/subluksasi genu, dengan insidensi yang dilaporkan berkisar antara
7-64%. [10]
Bila ditemukan "hard signs" dari kerusakan arteri, diindikasikan untuk dilakukan pembedahan
revaskularisasi segera tanpa menunggu hasil arteriografi. Hard sign dari kerusakan arteri diantaranya
adalah tidak adanya denyut nadi, hematom yang membesar dan pulsating, teraba thrill atau terdengar
bruit
Pada kasus tidak ditemukannya hard sign dari kerusakan arteri, dianjurkan untuk dilakukan
pemeriksaan ankle-brachial atau tekanan arteri. Hal ini diindikasikan meskipun denyut nadi teraba
normal hal ini tidak bisa menyingkirkan adanya kerusakan vaskuler secara klinis [11, 12] Rose et al
melaporkan 15 dari 173 kasus (9%) pada tungkai bawah didapatkan pulsasi yang normal meskipun
ternyata terdapat kerusakan arteri.[12] Pengukuran ABI/API kurang dari 0.90 memiliki nilai sensitivitas
95% dan spesifitas 97% pada kerusakan arteri. [13, 14]
Pada kasus yang tidak ditemukan hard findings tetapi ABI/API kurang dari 0.90 sebaiknya
mendapat konsultasi tindakan bedah vaskuler. Beberapa pemeriksaan radiografi yang diperlukan dapat
dengan arteriografi konvensional, atau pemeriksaan lain yang lebih modern dengan duplex
ultrasonography (sensitivitas 100% dan spesifitas 97% secara klinis signifikan untuk kerusakan arteri
[15]
), atau CT angiografi (sensitivitas 95-100% dan spesifitas 97-98% secara klinis signifikan untuk
kerusakan arteri [16, 17] ). Meskipun masih terjadi perdebatan mana aplikasi radiografi yang paling tepat
digunakan, keputusan hendaknya dikonsultasikan dengan dokter bedah vaskuler.
Regardless of the imaging pursued, all knee dislocations not requiring immediate surgical
revascularization should be admitted for serial perfusion checks as delayed intimal flap thromboses,
arteriovenous (AV) fistulas, and pseudoaneurysms of significance certainly occur and may need
subsequent intervention/repair.
Kerusakan nervus peroneus juga terjadi pada 25-35% pasien sehingga pemeriksaan untuk
menyingkirkan hal ini perlu dilakukan. Manifestasinya yang paling sering adalah penurunan sensasi
pada tungkai bawah dan gangguan dorsofleksi dari kaki.

Causes
Genu merupakan sendi yang stabil sehingga membutuhkan energy besar untuk menyebabkan terjadinya
dislokasi. Minimal ada 3 ligamen mayor yang ruptur bila dislokasi terjadi. Mekanisme yang terjadi antara
lain :

Tabrakan sepeda motor


Tabrakan kepada pejalan kaki
Kecelakaan kerja
Jatuh
Cedera olahraga

Differential Diagnoses

Femur Fracture

Knee Fracture

Tibia and Fibula Fracture

Imaging Studies
Plain radiographs are recommended post reduction and prior to any provocative ligamentous stressing. [8]
Briefly, the ankle-brachial index compares the Doppler pressure of an arm to a leg to screen for lower limb
ischemia. This straightforward measurement is performed by recording the highest Doppler sound of the
brachial pulse and comparing it to the highest Doppler sound of the posterior tibial or dorsalis pedis artery.
The ankle Doppler pressure is then divided by the brachial Doppler pressure to calculate the index.
Indexes less than 0.9 indicate an abnormal result and should prompt further vascular
imaging/assessment.
Duplex ultrasonography is a reliable, noninvasive, low-risk, low-cost option. Duplex ultrasonography
appears to be an excellent modality for vascular injury assessment. [18, 19, 15] Fry et al reported 100%
sensitivity and 97% specificity for clinically significant arterial injury.[15] This modality only incurs about 10%
of the cost of arteriography with little to no risk profile. [20]
CT angiography is another reliable alternative to arteriography without the risk of direct arterial injury. It
does require additional contrast beyond that used for chest/abdomen/pelvis body CTs that are often also
indicated in these types of trauma cases; thus, it may have added risk of nephropathy or contrast
reactions over arteriography, which uses less contrast. Inaba et al reported 100% sensitivity and 100%
specificity for lower extremity arterial injury of significance. [16] Soto et al reported 95% sensitivity and 98.7%
specificity.[17, 8]
Direct arteriography is the criterion standard but carries risk of arterial injury from direct catheterization of
the artery while also requiring specialist involvement to perform (ie, interventional radiologist or vascular
surgeon).

Prehospital Care
Prehospital personnel should splint the extremity and provide rapid transport to a medical facility.
Perform field reduction for patients with evidence of vascular compromise.

Next Section: Emergency Depart

Emergency Department Care


Jangan menunda reduksi pada kaki dengan tanda gangguan vaskuler yang jelas. Hanya pasien dengan
pulsasi perifer yang baik Do not delay reduction in limbs with obvious vascular impairment. Only patients
with good peripheral pulses should undergo prereduction radiographs. Reduction is straightforward and
often easily accomplished in the ED. After adequate sedation, longitudinal traction will relocate the
majority of knee dislocations. Prereduction and postreduction photos of a lateral knee dislocation are
shown in the images below.

Lateral knee dislocation (before reduction).

Lateral knee dislocation after reduction.

Posterolateral dislocations are particularly difficult and often require operative reduction. This is especially
true when the medial femoral condyle button-holes through the medial aspect of the joint capsule and/or
MCL an occurrence that is often accompanied by a "dimple sign" overlying the medial aspect of the
knee.

After reduction, splint the lower extremity in approximately 20 degrees of flexion to avoid postreduction redislocation, apply ice, and keep the knee elevated. Postreduction radiographs should be obtained,
preferably before further ligamentous stressing/assessment.
Postreduction hard signs of arterial injury should prompt emergent vascular surgical intervention that
should not be delayed for arteriography. In this setting, arteriograms may indeed be contributory to the
surgical decision matrix but can be performed in the operating room by the vascular surgeon with less
contrast administration than traditional arteriography tends to use.
All reduced knee dislocations without hard signs of arterial injury should be assessed with ABI/API
measurements. Any reading of less than 0.90 should prompt further imaging (ie, arteriography vs CT
angiography vs duplex sonography), which should be decided upon in conjunction with the
vascularconsult.
All knee dislocations, regardless of emergent revascularization needs, should be admitted for serial
perfusion checks.

Consultations
Always consult both orthopedic and vascular surgeons. Many patients have significant vascular injury
requiring surgical revascularization, and all patients will at least require admission for serial vascular
checks and further surgical stabilization consideration.

Medication Summary
NSAIDs, analgesics, and anxiolytics are used to treat the pain associated with dislocations.

Analgesics
Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and
aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with
injuries.
View full drug information

Fentanyl citrate (Duragesic, Sublimaze)


Narcotic analgesic with greater potency and much shorter half-life than morphine sulfate. Excellent choice
for pain management and sedation with its short duration time (30-60 min) and ease of titration. Easily
and quickly reversed by naloxone. After initial dose, subsequent doses should not be titrated more
frequently than q3h or q6h.
View full drug information

Meperidine (Demerol)
Narcotic analgesic with multiple actions similar to those of morphine. May produce less constipation,
smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
View full drug information

Oxycodone and acetaminophen (Percocet)


Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive
patients.
View full drug information

Acetaminophen and codeine (Tylenol #3)


Drug combination indicated for treatment of mild to moderately severe pain.
View full drug information

Hydrocodone bitartrate and acetaminophen (Vicodin ES)


Drug combination indicated for relief of moderately severe to severe pain.
View full drug information

Oxycodone and aspirin (Percodan)


Drug combination indicated for relief of moderately severe to severe pain.

Anxiolytics
Class Summary
Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to
administer a smaller analgesic dose to achieve the same effect.
View full drug information

Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By
increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including
limbic and reticular formation. Excellent for patients who require sedation for longer than 24 h. Monitor BP
after administering and adjust as necessary.

Nonsteroidal anti-inflammatory agents (NSAIDs)


Class Summary
These agents are used most commonly for the relief of mild to moderately severe pain. Although the
effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for
initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.
View full drug information

Ibuprofen (Ibuprin, Advil, Motrin)


DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory
reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, inhibiting prostaglandin
synthesis.
View full drug information

Ketoprofen (Oruvail, Orudis, Actron)


Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to
patients with a small body size, the elderly, and those with renal or liver disease. Doses higher than 75
mg do not increase its therapeutic effects. Administer high doses with caution and closely observe the
patient for response.
View full drug information

Flurbiprofen (Ansaid, Ocufen)


Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting
prostaglandin biosynthesis.
View full drug information

Naproxen (Anaprox, Naprelan, Naprosyn)


Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing
activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.

Further Inpatient Care


Historically, conventional arteriography was recommended for all cases of kneedislocation and, though it
remains the criterion standard for popliteal artery evaluation, there is growing debate over its universal
application.
Vascular assessment with the ankle-brachial index, duplex sonography, and/or CT angiography is
changing this paradigm while an increasing number of popliteal injuries are being managed nonsurgically
(generally those that show no significant thrombosis at 48-72 h). Many surgeons thus argue that
arteriography should not be routine and that case-by-case utilization of other imaging modalities
combined with vigilant observation is sufficient.
Untuk dokter jaga IGD, hal yang paling penting adalah melakukan pemeriksaan For the EM physician, it
is important to recognize that vascular examination findings may be normal in the presence of significant
popliteal artery injury[11, 12]and that some combination of further investigation/observation is warranted in all
knee dislocations. This may be different for each institution and/or each surgeon and should be decided
on in a case-by-case basis in conjunction with the vascular consult.
Time is of utmost concern, as vascular repair delayed more than 8 hours after injury carries an
amputation rate of greater than 80%. In contrast, operative vascular repair within 8 hours of injury yields a
limb-salvage rate of 80%.
The repair of coexistent popliteal vein injury is controversial. Fasciotomy is recommended after vascular
repair, as severe swelling and development ofcompartment syndrome are common in the postoperative
phase.
Operative repair of nerve injury remains controversial, as a poor prognosis is common with both operative
and nonoperative care.
Operative ligamentous repair is recommended by most authors, as functional results are better than those
of nonoperative care, but determining the ideal timing of this intervention is complex and is a decision
best left to the orthopedist.

Further Inpatient Care


Historically, conventional arteriography was recommended for all cases of kneedislocation and, though it
remains the criterion standard for popliteal artery evaluation, there is growing debate over its universal
application.
Vascular assessment with the ankle-brachial index, duplex sonography, and/or CT angiography is
changing this paradigm while an increasing number of popliteal injuries are being managed nonsurgically
(generally those that show no significant thrombosis at 48-72 h). Many surgeons thus argue that
arteriography should not be routine and that case-by-case utilization of other imaging modalities
combined with vigilant observation is sufficient.

For the EM physician, it is important to recognize that vascular examination findings may be normal in the
presence of significant popliteal artery injury[11, 12]and that some combination of further
investigation/observation is warranted in allknee dislocations. This may be different for each institution
and/or each surgeon and should be decided on in a case-by-case basis in conjunction with the vascular
consult.
Time is of utmost concern, as vascular repair delayed more than 8 hours after injury carries an
amputation rate of greater than 80%. In contrast, operative vascular repair within 8 hours of injury yields a
limb-salvage rate of 80%.
The repair of coexistent popliteal vein injury is controversial. Fasciotomy is recommended after vascular
repair, as severe swelling and development ofcompartment syndrome are common in the postoperative
phase.
Operative repair of nerve injury remains controversial, as a poor prognosis is common with both operative
and nonoperative care.
Operative ligamentous repair is recommended by most authors, as functional results are better than those
of nonoperative care, but determining the ideal timing of this intervention is complex and is a decision
best left to the orthopedist.

Transfer
See the list below:

Patients considered for transfer should have undergone emergency reduction of the knee
dislocation. Since time is crucial in salvaging the limb after a vascular injury, transfer should be initiated
only if vascular consultation and/or evaluation are not available at the transferring institution or if an
arteriogram has been performed and results are normal.

Complications

Popliteal artery injury


Popliteal vein injury
Peroneal nerve injury
Ligamentous injury
Compartment syndrom

Prognosis
See the list below:

When treated expeditiously and appropriately, 60-70% of patients will have a painless, stable
knee. Of the remaining patients, one half will eventually have reasonable function, while the other half
will have a chronically unstable and painful knee.

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