Journal I : Initial Assessment of the Acute and Chronic Multiple LigamentInjured Knee

Peter S. Borden, M.D., Darren L. Johnson, M.D.

Summary : A dislocated knee is a true orthopedic emergency and should be evaluated
expediently to avoid potential limb-threatening complications. The initial
assessment of a multiligament-injured knee requires a basic understanding of the
etiology, mechanism, history, and physical examination and awareness of
potential complications. A thorough initial evaluation, whether in the acute or
chronic setting, plays a crucial role in the management of these injuries, which are
often difficult to treat. Adequate preoperative planning involves determining the
extent of injury and formulating an appropriate surgical plan. This may prevent
potential surgical failures or complications.
Initial Evaluation and Management
The patients history regard to the mechanism and energy level of the injury can provide
essential information about a multiligament knee injury. The position of the leg and direction of
force if any, should be determined from the patient or witnesses. Contact versus non contact
injury should be determined, and knowing whether the injury was sports-or trauma-related may
also be helpful. It is also important to learn about the patients other medical conditions, level of
activity before the injury, and prior injuries to the affected knee.
After obtaining an adequate patient history, an initial evaluation and physical examination
should be performed in both the acute and chronic settings. The detailed physical examination

will be different in the acute knee versus the chronically injured knee. A visual inspection of the
leg should include evaluation of the intactness of the skin, color of the skin, presence of a dimple
sign, gross alignment of the extremity and evidence of increased of swelling or tight
compartments of the thigh, leg, and foot. A detailed neurovascular examination should follow the
visual examination, with attention directed toward the motor and sensory findings of the entire
lower extremity, with particular emphasis on the peroneal and tibial nerves. If the knee is grossly
dislocated on initial inspection, the neurovascular examination should be performed
appropriately, focusing on these important potential findings, so that a quick relocation of the
knee can be performed. Immediate relocation of the knee after initial assessment is crucial and
should be facilitated by sedation, analgesia and longitudinal traction. The presence of a dimple
sign should preclude an attempt at closed reduction and immediate arrangements for open
reduction in the operating room should be made. After successful relocation of the knee has been
achieved, the extremity should be reassessed in a similar fashion as the initial examination, and
any changes from the initial examination should be noted. It is important to clearly document all
of the findings both before and after relocation for medicolegal purposes as well as providing a
time reference of relocation. Examining the knee for gross instability after relocation or
suspected knee dislocation with spontaneous reduction is an important component of the initial
physical examination. Testing stability to varus and valgus stress with the knee in full extension
often identifies the presence of a multiligament injury in an acutely painful knee. Opening on
examination usually implies cruciate ligament disruption combined with collateral ligament
rupture or capsular tearing.
It is important to distinguish between a stable and unstable knee after the initial reduction
or examination. A stable knee may be braced in full extension, whereas an unstable knee may

require closed reduction and external fixation in the operating room. After relocation, or in case
of a spontaneous relocation, a period of observation is appropriate to watch for potential delayed
vascular changes, which may warrant emergent surgical treatment. We prefer to admit the patient
and observe him or her overnight, because often the vascular changes associated with an intimal
tear present several hours after the initial injury or relocation. Because of the high incidence of
vascular injuries with knee dislocations, vascular injury should be assumed until proven
otherwise. Signs of significant injury may include diminished or absent pulses, cyanosis, cold
extremity compared with the other, delayed capillary refill, and evidence of compartment
syndrome. If a vascular injury is suspected, then an emergent vascular surgery consultation is
indicated. If, however, gross signs of vascular injury are not present on the initial examination,
then serial examinations with or without a Doppler study are indicated until vascular injury has
been ruled out.
The decision to order an arteriogram at an appropriate time after injury is controversial
among orthopedic surgeons who commonly treat multiligament knee injuries. In the case of
obvious arterial rupture, most vascular surgeons elect to take the patient immediately to the
operating room for a possible on-able arteriogram and definitive surgical exploration. Many
vascular surgeons in this scenario bypass the arteriogram, especially if significant time has
passed from the time of injury to the time received on the operating table. If on the initial patient
assessment there are no gross signs of vascular injury, then there is controversy as to whether an
arteriogram is indicated. Many physicians will order an arteriogram at this time to rule out occult
injury or intimal tears that may not present as signs or symptoms for several hours. Although the
arteriogram procedure is not without complications, it is generally believed that the
complications of a missed arterial injury significantly outweigh those of the arteriogram.

However, some believe that serial examinations of the patient, with attention to the vascular
aspect of the examination, are sufficient for ruling out vascular injury without the associated
complications and cost of the arteriogram. Several studies evaluating the results of arteriography
have shown a relatively low incidence of arterial injury associated with knee dislocations from
blunt trauma with normal physical examinations. At our institution, all patients with an acute
knee dislocation with no sign of vascular compromise are admitted to the hospital for a 24-hour
observation period, serial examinations, and vascular surgery consultation to prevent the
devastating complications associated with delayed treatment of a vascular injury.
Once the initial assessment of the knee dislocation has been performed and the knee has
been reduced, anteroposterior and lateral radiographs in full extension should be taken of the
entire extremity. The knee joint should be evaluated for associated fractures as well as
assessment of the reduction. Some believe that radiographs should be obtained before reduction
to document and clarify the direction of dislocation; however, we believe that if the knee can be
reduced at the initial assessment, reduction should not be delayed so that radiographs may be
taken.
During the initial assessment, a clinical evaluation of the direction of dislocation can be
made. To evaluate the ligamentous structures and associated soft tissues, MRI can be very
helpful. MRI allows identification of associated injuries to the meniscus and articular cartilage as
well as ligamentous and capsular injury. Bone marrow edema, occult fractures, and bruising may
also be identified. The location of ligament injury (i.e., midsubstance tear or bony avulsion) may
be seen on MRI. Identifying the full spectrum of injury with MRI before surgery can provide the
information necessary for surgical planning. We recommend obtaining an MRI in all cases in
which repair, reconstruction, or both is planned. The information obtained from the MRI allows a

preoperative determination of which structures should be repaired and which should be

reconstructed. This imaging study may be obtained in a non emergent fashion as an outpatient if
needed.
Examination of Specific Ligamentous Structures of the Knee
Gross laxity to varus or valgus stress with the knee in full extension usually implies
disruption of one or both cruciate ligaments, one or both collateral ligaments, or capsular injury.
In the acute initial evaluation, pain and swelling often prevent a thorough physical examination
of the knee ligaments. Flexion is often limited, precluding anterior and posterior drawer tests.
Because of the capsular disruption, the knee may lack a true effusion, often causing the evaluator
to underestimate the degree of injury, especially in a spontaneously reduced dislocation. In a
painful knee with a large tense effusion, a delayed examination in the clinic 1 week later, after
the swelling and pain subside, may be more successful.
The four major ligamentous structures of the knee are the anterior cruciate ligament
(ACL), the posterior cruciate ligament (PCL), and medial collateral ligaments and the
posterolateral complex. Structures of the posterolateral complex include the lateral collateral
ligament, popliteus tendon, popliteofibular ligament, arcuate ligament, fabellofibular ligament,
and posterolateral joint capsule.
Anterior Cruciate Examination
The ACL serves as the primary restraint to anterior tibial translation as well as a
secondary stabilizer to varus, valgus, and rotational stresses on the knee. The physical
examination include Lachman, anterior drawer, and pivot shift tests. The most reliable and
sensitive test for ACL deficiency is the Lachman test. A PCL rupture can often mislead the

examiner into concluding the Lachman test is positive, with abnormal anterior displacement of
the tibia compared with the contralateral knee. In this case, however, because the tibia is
posteriorly displaced as a result of the PCL injury, anterior laxity is falsely perceived. This is
commonly referred to as a false-positive Lachman test, seen arthroscopically as pseudolaxity of
the ACL.
Posterior Cruciate Examination
The PCL serves as the primary restraint to posterior tibial translation. The physical
examination of the PCL should include the posterior drawer test, posterior tibial sag sign,
Godfreys test, quadriceps active test, and the anterior tibial-femoral step-off difference. The
posterior drawer test is the most sensitive diagnostic test for PCL injury. The anterior tibialfemoral step-off is determined with the knee flexed to 90 and by palpating the anterior aspect of
the medial proximal tibia and its relationship to the anterior aspect of the medial femoral
condyle. Normal step-off is approximately 8 to 10 mm (tibia anterior to femur). Grading of the
step-off is described as follows: grade I, 0 to 5 mm; grade II, 6 to 10 mm; grade III, more than 10
mm step-off with the anterior aspect of the tibia beyond that of the femur. A grade III step-off
with no endpoint signifies damage to associated structures.
Medial Collateral Examination
The medial collateral ligament is the primary restraint to valgus knee stress, especially
with knee flexion between 25 and 30. Testing is best performed with knee flexed at 25 to 30
and by placing a valgus stress on the leg while stabilizing the distal lateral thigh. Grade I injury
is defined by 0 to 5 mm of medial laxity, grade II by 6 to 10 mm of laxity, and grade III by more
than 10 mm of laxity without a solid endpoint. The knee should also be tested in a similar fashion

in full extension. Medial laxity in full extension is indicative of a grade III medial collateral
injury, often with associated cruciate ligament as well as capsular/posterior oblique ligament
rupture.
Posterolateral Complex Injury
The posterolateral complex is responsible for resisting varus and rotational forces to the
knee. Testing for posterolateral instability includes varus stress testing, increased external
rotation compared with the other leg at 30 and 90, posterolateral drawer test, external rotation
recurvatum test, and reverse pivot shift test. The reverse pivot shift test is performed with the
knee flexed to 90; as extension of the knee is achieved, a valgus stress with external rotation
force applied to the leg will cause the lateral tibial plateau to shift from a posteriorly subluxed
position to a reduced position.

Journal II : The Multiple-Ligament Injured Knee : Evaluation, Treatment,

and Results
Gregory C. Fanelli, MD., Daniel R. Orcutt, M.D., M.S., and
Craig J. Edson, M.S., P.T., A.T.C.
Abstract : Most dislocated knees involve tears of the anterior and posterior cruciate ligaments
(ACL/PCL) and atleast 1 collateral ligament complex. Careful assessment of the extremity
vascular status is important because possible arterial and/or venous compromise. Systemic
approach that comprises physical examination and imaging enables the surgeon to make correct
diagnosis and to start treatment.
The dislocated knee is a very severe injury resulting from violent trauma. It results in
disruption of at least 3 of the 4 major ligaments of the knee and leads to significant functional
instability. Other possibilities such as vascular and nerve damage, as well as associated fracture
can be challenging to manage.
Initial Evaluation and Management
General Consideration
Obvious deformity may be present on initial examination. However, in polytrauma
patient who is intubated or sedated, the injury may escape initial evaluation. Abrasions or
contusions around the knee, gross crepitus, or laxity may allude to injury in a normal appearing
knee. This importance of immediate recognition lies in recognizing potential vascular injury and
possible vascular compromise. Neurovascular status must be assessed on both lower extremities.
Vascular examination is more vital because ischemia lasting more than 8 hours usually results in
amputation. In the reduced knee, a white, cool limb that is obvious on physical examination and

denotes arterial damage, requires an immediate arteriogram. However, normal pulses, Doppler
signals, and capillary refill do not rule out an arterial injury. Thrombosis may occur hours to
days later, necessitating serial examination. If there is any question of perfusion of the limb, an
arteriogram is warranted.
Imaging Studies
Before any manipulation, anteroposterior and lateral radiographs of the affected extremity
must be completed because it is important to confirm the direction of dislocation and any
associated fractures, and aids in planning reduction maneuver. In the presence of cyanosis, pallor,
weak capillary refill, and decreased peripheral temperature following reduction, arteriography
must be considered. Venography may be required if the clinical picture indicates adequate limb
perfusion but obstruction of outflow. After the acute treatment of the dislocated knee, magnetic
resonance imaging (MRI) may be performed subacutely to confirm and aid in planning the
reconstruction of compromised ligamentous structures.
Physical Examination
Physical examination of ACL/PCL/ postolateral corner injury(PLC) injured knee include
abnormal anterior and posterior translation at both 25 and 90 of knee flexion, which is usually
greater than 15mm at 90 of knee flexion, the tibial step-off is absent, and the posterior drawer
test is 2+ or greater, indicating greater than 10mm of pathologic posterior tibial displacement.
The Lachman test and pivot-shift phenomenon are positive, indicating ACL disruption, and there
may be hyperextension of the knee. We have identified and described 3 types of posterolateral
instability : A, B, and C.

Posterolateral instability in the multiple-ligament injured knee includes at least 10 of

increased tibial external rotation compared with the normal knee at 30 and 90 of knee flexion
(positive dial test, and external rotation thigh-foot angle test), and variable degrees of varus
instability depending on the injured anatomic structures. Posterolateral instability (PLI) type A
has increased external rotation only, corresponding to injury to the popliteofibular ligament, and
popliteus tendon only. PLI type B presents with increased external rotation, and mild varus of
approximately 5mm increased lateral joint line opening to varus stress at 30 knee flexion. This
occurs with damage to the popliteofibular ligament, popliteus tendon, and reduction of the
fibular collateral ligament. PLI type C presents with increased tibial external rotation, and varus
instability of 10mm greater than the normal knee tsted at 30 of knee flexion with varus stress.
This occurs with injury to popliteofibular ligament, and lateral capsular avulsion, in addition to
cruciate ligament disruption.
The MCL is tested with valgus stress at 0 and 30 of knee flexion to assess the
superficial MCL, the posterior oblique ligament, and the posterior medial capsule. Extensor
mechanism stability is assessed by medial and lateral patellar glide to assess the integrity of the
lateral and medial patellar retinaculum.
Vascular Injuries
A full spectrum of vascular injuries may be encountered. The overall clinical picture may
vary from an uncomplicated, bicruciate ligament ligament injury wih possible intimal damage
with a normal physical examination to a polytrauma patient, with a closed head injury, intraabdominal bleeding, and dislocated knee with vascular compromise. Life-threatening injuries are
addressed first. The orthopedic surgeon needs to be aware of the total limb ischemia time. If

there is any suspicion of arterial damage, a vascular consult is obtained immediately. Reduction
is performed to see if this restores blood flow to the limb. When the total ischemia time
approaches 6 hours, there is an urgency to restore flow to the lower extremity. An intraoperative
angiogram during vascular exploration and shunting may be required at the expense of a highquality preoperative angiogram. A high-energy injury (ex. Motor vehicle accident or a fall from a
height) may be more suspicious for vascular injury, and one may elect to obtain arteriograms
despite a normal vascular examination.
When an isolated dislocated knee with suspected arterial injury occurs (asymmetric
pulses, Doppler, or ankle-brachial index), arteriography is performed as the simple presence of
pulses does not rule out vascular damage. Any suspicion warrants a vascular surgery
consultation. When the limb is well perfused, and all indices are normal, one may elect to forego
a formal arteriogram if there are frequent neurovascular checks to the lower extremity. Despite
the historical preference to obtain an arteriogram in the presence of a knee dislocation as a
screening tool, it has been shown that arteriography following significant blunt trauma to the
lower extremity with a normal vascular examination has a low yield rate for detecting surgical
vascular lesions. Popliteal vein injury is also possible. When the clinical picture warrants, a
venogram may be useful.

Journal III : Radiologic Review of Knee Dislocation : From Diagnosis to

Repair
Richard E. A. Walker, David McDougall, Shamir Patel, John A.
Grant, Peter D. Longino, Nicholas G. Mohtadi
Conclusion : This imaging-based article systematically reviews traumatic knee dislocations.
Although uncommon, traumatic knee dislocation are an important potentially limb-threatening
injury, which if not emergently recognized and appropriately managed, can result in significant
patient morbidity, joint dysfunction, chronic pain, and long term disability. A radiologist familiar
with the imaging appearance and potential neurovascular complications associated with these
injuries can play an integral role in the multidisciplinary team that manages this increasingly
recognized clinical entity.
Assessment of the Patient With Suspected Knee Dislocation
Clinical Assessment
In the setting of multiple trauma, efficient patient assessment and management according
to Advanced Trauma Life Support principle is the initial priority. Once patient is stabilized,
attention is directed to the dislocated knee, and emergency management is focused on ensuring
perfusion, reduction, and stabilization of the injured limb. Hard signs of vascular injury includes
absent or diminished distal pulses, visible or expanding hematoma, palpable thrill or audible
bruit, or pulsatile hemorrhage. These clinical findings alone are indicative of a substantial
vascular injury and mandate emergent vascular surgery exploration.

Reduction of a dislocated knee is important to reduce pressure on both the neurovascular

structures and the skin. Reduction under conscious sedation is successful in most cases; however,
when unsuccessful, intraoperative closed and, rarely, open reduction may be necessary. Lateral
and posterolateral rotatory knee dislocation are associated with a potential for irreductibility
caused by interposition of the medial capsule into the knee joint and buttonholing of the medial
femoral condyle through the medial capsule as the tibia is forced laterally. The classic clinical
presentation is a patient with a grossly deformed knee with a dimple of the medial skin and soft
tissues. The puckering of the skin results from its attachment to the invaginated capsule. Closed
reduction may also be impeded by intraarticular structures, including fractures fragments and
displaced meniscal tears.
Once reduction is obtained, immobilization provides stability and rest for the soft tissues
and aids analgesia. Tpically, a knee immobilizer is all that is required. An external fixator is
recommended in circumstances of gross instability when joint reduction cannot be maintained
with a brace, often in association with intraarticular and periarticular fractures. An external
fixator is also suggested for open knee dislocations to facilitate soft-tissue care of open wounds.
Ideally, this should be done using MRI-compatible equipment with consideration of pin
placement to keep pins in an extraarticular position and well clear of potential graft tunnel sites
required for future reconstruction. After reduction or after application of an external fixator,
anteroposterior and lateral radiography is mandatory to ensure that an anatomic reduction has
been achieved.

Vascular Assessment
Vascular injury represents a potentially limb-threatening complication of traumatic knee
dislocation with a broad range of popliteal artery. Owing to an intrinsically poor collateral
arterial pathway across the popliteal region, delayed recognition of an occlusive injury beyond 8
hours is likely to result in an above-knee amputation. When the tibiofemoral joint disarticulates,
the popliteal artery has imited ability to accommodate the acute increase in distance across the
popliteal fossa because it is connected proximally at the adductor hiatus (Hunter canal) and
distally as it passes behind the fibrous arch of the soleus muscle (soleal arcade). Therefore, the
mechanism of popliteal artery injury occurs predominantly by excessive stretching, with the
vessels at greatest risk with direct anterior and posterior dislocations a circumstance in which the
distance between the proximal and distal tether points increases substantially.
Vascular injury is also thought to occur from direct trauma to the vessels by adjacent
bony structures, particularly in the setting of a posterior dislocation. An arterial injury can range
from transient kink or occlusion to an intimal tear, dissection, acute thrombosis, or complete
transaction. Interestingly, the risk of vascular injury is independent of the intensity of the trauma
and can be found in conjunction with high-energy, low-energy, and ultralow-energy causes knee
dislocation. All traumatic knee dislocations, regardless of the mechanism should be considered to
have an associated arterial injury until proven otherwise, and careful assessment for signs of
impaired circulation, such as asymmetric or absent pulses and skin discoloration or temperature
changes below the knee, should be performed at initial assessment, repeated regularly, and
clearly documented.

In a patient with a reduced knee joint, symmetric lower extremity pulses, and an anklebrachial index (ABI) > 0.9, the risk of a concomitant vascular injury is low. Serial clinical
vascular examinations over a period of 24-48 hours, however, are recommended to exclude the
delayed development of a limb-threatening vascular injury. It is estimated that this may occur in
the minority of knee dislocations, possibly related to delayed progression of an intimal tear or
secondary ischemia from thrombosis of a previously non-flow-limiting lesion in the acute post
injury period. When present, these occult injuries typically follow a benign course without the
need for vascular surgery. An ABI > 0.9 was found to have a negative predictive value of 100%,
excluding all arterial injuries requiring operative management.
In a patient with a reduced knee joint ad asymmetric lower extremity pulses or an ABI <
0.9, vascular imaging of the injured leg is indicated and historically has been performed using
cathether-based arteriography. More recently, CT angiography (CTA) has been proposed as an
alternative to conventional angiography.
Absent lower extremity pulses or hard clinical sign of a nonperfused distal limb in the
setting of either a reduced or irreducible knee dislocation require immediate vascular surgery
operative intervention with or without on-table arteriography. Consideration for compartment
releases after vascular repair is based on the severity and estimated duration of lower extremity
ischemia time, but prophylactic four-compartment fasciotomy is advised in the following
circumstances; confirmation of compartment syndrome by direct pressure measurements,
concomitant venous repair or ligation, extensive soft-tissue injury and swelling, concomitant
disabling neurologic injury in which clinical assessment may be confounded, and situations in
which a rapid return to the operating theater is compromised.

Neurologic Assessment
Peripheral nerve injuries are commonly associated with knee dislocations and most
frequently involve the common peroneal nerve, a terminal division of the sciatic nerve. Clinical
evidence of common peroneal nerve palsy in the setting of a traumatic knee dislocation
necessitates a clinical and radiologic assessment for a posterolateral corner injury or fibular head
avulsion fracture (arcuate sign) because 44% of patients with such injury will have peroneal
nerve damage.
On MRI, the common peroneal nerve can be clearly identified at the posterolateral aspect
of the knee, visualized immediately posterior to the biceps femoris muscle and deep in relation to
the crucial fascia.
As in the case with vascular injuries, a through neurologic examination such as motor and
sensory function of both the deep and superficial branches of common peroneal nerve is critical
in all patients after traumatic knee dislocation. Intact sensory testing in the setting of a complete
motor deficit and a partial motor deficit are indicative of an incomplete nerve injury. Because
motor and sensory deficits can also be seen in association with compartment syndrome, a gradual
progression of symptoms, especially in the setting of severe pain or a known vascular injury,
would suggest compartment syndrome rather than a peripheral nerve injury. Parasthesia in a
stocking distribution is also indicative of compartment syndrome. Electro-diagnostic studies
(electromyography [EMG] and nerve conduction velocity [NVC]) used to help determine the
severity of peripheral nerve injuries and monitor recovery.

Journal IV : Diagnosis and Management of the Multiligament-Injured Knee

Jack G. Skendzel, M.D., Jon K. Sekiya, M.D., Edward M.
Wojtys, M.D.
Clinical Evaluation
A thorough evaluation of knee stability is critical to guide proper treatment of
multiligament knee injuries. The clinician should be highly suspicious that a knee dislocation
may have occurred if there is deformity, misalignment, or other clinical signs such as massive
soft tissue swelling and disproportionate pain. If the capsule is damaged, there may be no true
joint effusion; rather, blood may diffuse into the adjacent soft tissues. Low-energy injuries, such
as those sustained during sports, may have relatively less soft tissue damage than high-energy
trauma and therefore overlooked. The physical examination of an acutely injured knee can be
difficult because of pain and subsequent muscle guarding, but it remains the single best indicator
knee patholaxity.
In the non acute setting, patients may present with ligament injuries that go unrecognized
or are mismanaged. Symptoms include persistent pain, feelings of instability, especially during
twisting and impact activities, and a mild knee effusion. For all patients undergoing clinical
evaluation who have a history suggesting a knee dislocation, plain radiographs must be obtained.
In addition, a thorough neurological examination must be performed to document sensory and
motor function, as well as a complete vascular examination. Assessment of gait, ligamentous
stability, and knee range of motion should be performed in this setting.

In cases of low-energy trauma, such as those who dislocate the knee on the playing field,
immediate reduction should be attempted before performing imaging studies. The extremity is
then splinted and the individual is transferred to the emergency room, where radiographs should
be obtained to check for associated fractures of the femur and tibia and to confirm a reduced
tibiofemoral joint.
Regarding acute injury due to a high- or low-energy mechanism, the extent of injury must
be determined. Although the patient often presents with significant pain, swelling and gross
instability, the signs of ligamentous disruption, meniscal tearing, or chondral damage may be
unreliable. Magnetic resonance imaging (MRI) can help detect these lesions once the knee is
stabilized and evaluation for major arterial or nerve injury is completed the presence of a furrow
between the medial femoral condyle and tibial condyle is an indication for open reduction due to
buttonholing of the medial femoral condyle through the medial capsule, with interposition of the
medial collateral ligament (MCL) into the joint.
A thorough examination of the ligamentous structurs should be performed on all patients.
Although an accurate assessment of the extent of ligamentous injury can be difficult in the acute
setting due to pain, hematoma, or associated injuries, an attempt should still be made to examine
and document the presence of gross laxity and instability, which indicate disruption of multiple
ligaments. A more definitive examination can be performed once pain and swelling are
decreased. The examiner should complete a comprehensive evaluation of the integrity of the
anterior cruciate ligament (ACL), posterior cruciate ligament (PLC), medial collateral ligament
(MCL) and lateral collateral ligament (LCL).

The ACL is examined by performing the anterior drawer test and the Lachman test, the
latter of which is considered to be better. With these tests, the amount of translation is graded and
in patients with ACL tear, there may be no firm end point and increased anterior translation when
compared to the contra lateral side. Although these tests can be easily performed in patients with
chronic injury with minimal pain and swelling, their use in those with acute injuries may be
limited. First, under normal circumstances, at 90 of knee flexion, the anteromedial tibia lies
approximately 1 cm anterior to the distal femoral condyle. After disruption of both cruciate
ligaments, this relationship may be altered, making it difficult to appreciate a true ACL injury via
the anterior drawer test due to posterior subluxation of the tibia. Second, in a polytrauma patients
or a patient with excessive pain, soft tissue swelling, and associated injuries, it may be difficult to
position the knee at 90 of flexion, making it impossible to perform the anterior drawer test.
The usefulness of the pivot shift test to detect anterior knee instability in acute
multiligament-injured knees is limited due to the inability to control for hip and leg position,
which can alter the results of the pivot-shift test. In addition, an associated tear or avulsion of the
iliotibial band may not allow the shift to occur as the knee is progressively flexed during testing.
Assessment of the PCL is performed with the posterior drawer test and the posterior sag
test. The posterior drawer test is performed by applying a posterior force to the proximal anterior
tibia, with the thumbs placed on the joint line to quantify posterior tibial translation. A grade III
(greater than 10 mm of posterior translation) posterior drawer test indicates a combined PCL and
PLC injury. In addition, when both the PCL and PLC were injured it is demonstrated that there
were large increases in posterior tibial translation and varus rotation at all knee flexion angles.
The posterior sag test is performed passively, with the hips and knees at 90 of flexion, to note
any posterior translation or sag of the proximal tibia relative to the distal femur.

The MCL and LCL are tested with a valgus and varus stress, respectively, with the knee
held at 30 of flexion to isolate the collateral ligaments. Each test is repeated with the knee in full
extension. Excessive lateral joint opening with varus stress in full knee extension suggests injury
to other structures, including the cruciate ligaments and PLC, in addition to an LCL injury.
Likewise, laxity to valgus stress in full knee extension suggests a posteromedial capsular injury
and possible simultaneous cruciate injury in addition to an MCL injury.
The dial test is used to evaluate the structures that contribute to PLC stability, including
the LCL, popliteus tendon, and popliteofibular ligament. The test is performed with the knee held
at both 30 and 90 of flexion. The patient is positioned either supine or prone, and an external
rotation force is applied to the foot as the examiner measures the thigh-foot angle. A difference
greater than 10 between legs is considered significant. Increased external rotation at 30 but not
at 90 is consistent with an isolated PLC injury, while increased external tibial rotation at both
30 and 90 suggests injury to both the PCL and PLC. An increase solely at 90 of flexion
suggests a partial or complete tear of the PCL. The clinician must be aware that an increase in
external rotation at both 30 and 90 during the dial test may also signify anteromedial rotatory
instability instead of a PLC injury.
Vascular Injuries
Failure to recognize a vascular injury may lead to serious consequences, incuding limb
amputation. This incidence of popliteal artery injury in association with knee dislocation is
reported to be between 4.8% and 65%, and the examiner should be very suspicious of possible
arterial injury in high-energy injuries. The vascular examination begins with inspection of the leg
for capillary refill, warmth, and color. The dorsalis pedis and posterior tibial pulses are palpated.

The examiner should be aware that a normal physical examination and a palpable pulse do not
rule out serious vascular injury. If pulses are absent or abnormal and the knee is grossly
dislocated, a reduction should be attempted and the pulses should be re-evaluated. The anklebrachial index is a noninvasive test that can be performed with a Doppler probe and a blood
pressure cuff to supplement the physical examination to detect vascular injury. The ratio between
the systolic pressure in the injured extremity and that in the uninjured arm is calculated. Mills et
al reported 100% sensitivity, specificity, and positive predictive value of an ankle-brachial index
below 0.90 for identifying significant arterial injuries requiring surgical intervention after knee
dislocation.
Any concern for vascular injury warrants prompt vascular surgery consultation. If pulses
are absent and the limb is ischemic, emergent surgical exploration by a vascular surgeon is
warranted. The total warm ischemia time is important because lack of perfusion for longer than 6
to 8 hours is associated with greater risk for amputation. In such cases, the orthopaedic surgeon
may be required to apply temporary fixation, such as an external fixator, to stabilize the knee
joint.

Selective arteriography is justified in patients with abnormal physical examination

findings that are consistent with vascular injury. If no immediate vascular intervention is
required, frequent vascular checks and close monitoring are required, even in those with a
normal vascular examination. popliteal artery disruption to be most common in posterior knee
dislocations, occurring in up to 44% of cases. Popliteal artery injury has also been reported in
ultralow-velocity injuries involving spontaneous dislocation in individuals who were morbidly
obese.

Nerve Injuries
Nerve injury, which is frequently associated with knee dislocation, the peroneal divison is
more involved than the tibial division, of the sciatic nerve. The most significant anatomic
variable responsible for this injury pattern is the tethered course of the common peroneal nerve,
which passes around the proximal fibula. Lateral and posterolateral injuries may place increased
stretch on the nerve. The examination consist of testing tactile sensation in all nerve distribution
of the lower leg and foot. Strength is tested for all muscle innervated by the peroneal and tibial
nerves, which produce movements related to ankle dorsiflexion and plantar flexion, foot
inversion and eversion, and great-toe extension. Overall, the prognosis for recovery of nerve
function lost after a knee dislocation remains poor. Patients with chronic injuries can present
with a foot drop and may benefit from an ankle-foot orthosis or a posterior tibial tendon transfer.
Imaging
Plain radiographs in 2 planes (anteroposterior and lateral) are important to characterize
the knee dislocation in terms of the direction of dislocation and to assess for fractures (eg,
Segond fracture, PCL-avulsion fragment, tibial plateau fracture, osteochondral injury). In
general, in cases of suspected knee dislocation due to a low-energy mechanism (eg, sports), a
reduction should be carried out as soon as possible, because the likelihood of associated fracture
is lower. In high-energy situations (eg, motor vehicle accidents), there is a greater chance of
associated fracture, and thus radiographs should be performed prior to attempting reduction.
However, in all situations, radiographs also must be performed after reduction. MRI is helpful
after dislocation to determine which ligaments were involved and to define the injury pattern,

although it cannot determine the extent of abnormal translation or rotation of the tibia versus the
femur. Moreover, MRI can evaluate chondral surfaces, menisci, and other soft tissues.