JOURNAL READING

Initial Assesment of the acute and chronic

Multiple-Ligament Injured (Dislocated) knee
Andrew Laurence Merrit, MD
Christopher Wahl, MD

Knee Anatomy

Knee Anatomy

Ligament

a band of dense regular connective tissue

Ligaments connect bones to other bones to form joints
Limit the mobility of articulations.

Ligament Injury :
Sprain

Strain

Rupture

Introduction
Commonly caused by High energy trauma KD
Multi ligament knee disruption
Quick and accurate assesment of knee injuries is
required to determine the presence of any limb
threatening arterial injuries, surgical
consideration or prevent complication.
This article present a complete assesment of
multiple ligament injured knee.

Etiology
KNEE DISLOCATION

Ligament Injuries

Neurovascular Injuries

Fracture

Classification

Assesment of acute MLI knee

Initial Assesment (in the field):
Obvious Dislocation high Posibility vascular injury
emergent reduction
Immobilize transfer to Emergency Department /
tertiary care
ATLS
Critical to communicate the nature of injury, maintain
high suspicion for vascular injury.

Assesment of acute MLI knee

Initial Assesment (ER):
Anamnese Mechanism, energy level, leg position, direction
of force
Reduction
Physical examination
Neurovascular Examination ABI, arthroscopy, arteriogram,
Distal nerve examination
X-ray try to identifiate fx avulsion, asymmetric of iregular
joint space

Assesment of acute MLI knee

Definitive Physical Examination

of MLI Knee
ACL
Lachman test :
Supine position with the knee
20-30 degree flexion.
Grade :
1 : 0-5 mm
2 : 6-10 mm
3 : 11-15 mm
A : firm endpoint
B : no end point (very
loose)

Definitive Physical Examination

of MLI Knee
ACL
Pivot Shift test :
Supine position with the knee
20-30 degree flexion.
Internal rotation valgus
stress
Positive if there is clunk
sensation

Definitive Physical Examination

of MLI Knee
PCL
Posterior drawer test :
Hip flexed 45 degrees, knee bent 90
degree posterior directed force on the
anterior tibia.
Normal : no loss of tibial offset
A : slight tibial offset, stops at anterior
femoral condyle
B : Stops at the femoral condyle
C : Stops at posterior of femoral condyle

Definitive Physical Examination

of MLI Knee
PCL
Posterior Sag sign :
Hip flexed 45 degrees, knee bent
90 degree positive

Definitive Physical Examination

of MLI Knee
LCL/PLC
Varus test:
Hip relaxed knee relaxed, 0 degree
of flexion varus strest positive
if there is no firm end point (latelar
laxity)
1: <5 mm
2: 5-10 mm
3: >10 mm

Definitive Physical Examination

of MLI Knee
LCL/PLC
ER recurvatum tes:
Hip flexed 30-90 degree, knee 0
degree of flexion lift the toe
positive if there is assymmetrical
external rotation and
hyperextension.

Definitive Physical Examination

of MLI Knee
MCL
Valgus test:
Hip relaxed knee relaxed, 0 degree
of flexion valgus strest
positive if there is no firm end point
(medial laxity)
1: <5 mm
2: 5-10 mm
3: >10 mm

Diagnosis and injury pattern

ACL PCL (KD II)
Grade 2A or higher Lachmans
Grade B posterior drawer, possible posterior sag
Rotational testing is symmetric or increased only
at 90 degrees of flexion

Diagnosis and injury pattern

ACL MCL (KD II)
Grade 2A or higher Lachman
Laxity with valgus stress with possible anteromedial rotational
instability
ACL LCL/PLC (KD II)
Grade 2A or higher Lachman
Varus laxity in full extension and 30 degrees of flexion
Increased ER at 30 degrees of flexion but not to the same extent
as combined PCL and LCL/PLC injuries

Diagnosis and injury pattern

PCL LCL/PLC (KD II)
Grade C posterior drawer, posterior sag
Abnormal rotational profile at 30 and 90 degrees of flexion
and positive ER recurvatum test
PCL MCL (KD II)
Grade A or B posterior drawer
Laxity to valgus stress

Diagnosis and injury pattern

ACL - PCL LCL/PLC (KD III L)
Grade 2B or higher lachman
Grade C posterior drawer, posterior sag
Abnormal rotational profile at 30 and 90 degrees of flexion and
positive ER recurvatum test
ACL - PCL MCL (KD III M)
Grade 2B or higher lachman
Grade C or B posterior drawer
Increased medial joint space laxity in slight flexion and in extension

Knee Reduction
High suspicion of limb threatening condition
Emergency Reduction re-examine vascular status
Vascular injury repair immediately if needed
No indication for urgent intervention
Redution in ER, re-examine vascular status
Reconstruction at14-21 days post injury allow the tissue to calm
down, reduce sweling and pain
Immobilized with hinged knee brace 15 degree flexed

Assesment of Chronic Traumatic Multi-ligament injury

Referred to the tertiary medical institution and presents week to

months out from the injury.
Important to recognize neurovascular evaluation small intimal
injuries of the popliteal artery, peroneal nerve neuropraxia.
Re examine the ligament ligament have the ability heal or
tighten up deficits in flexion or extension because the ruptured
ligament didnt attached back to its natural place (addhesion)
FLASCId knee (Flexion and Extension Loss Axial Sagital )

Conclusion
It is the responsibility of the treating physicians to correctly identify
the severity of the injury and to evaluate the injury in an effort to
prevent catastrophic sequelae. A coordinated treatment with general
surgery/ortophaedics and the emergency physicians must be used for
proper treatment. Arterial and nerve injuries are common in KDs and
complete evaluation must include serial evaluation. In chronic
multiple-ligament knee injuries, it is important to evaluate the entire
limb for any deformity and to evaluate why any previous operations
failed. With a high index of suspicion and a detailed, methodical plan
for evaluation and serial monitoring, patients can have the best
chance of avoiding complications and having a successful surgical
outcome.