Board Review

A Thrilling Bored Review

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Jonny Utah (johnny utah) presents to your ED clutching his knee, grimacing, and firing his weapon unnecessarily into the ceiling. After he puts his weapon down, you assess the leg. He has a deformity to the knee, cannot bear weight, and is NV intact at the foot.

 

Does he need X-Rays?
Yes. See Ottowa knee rules here or here.

And they look like this…IMG_20140922_054626_629 IMG_20140922_054708_629

 

Immediate plan?
Pain control, call ortho/vascular, and the soonest possible attempt at reduction.

 

Hard indications for OR with this injury?
Depends a bit on what you read, but definitely pulse deficit or distal ischemia. Some sources also add in an ankle brachial index (ABI) less than 0.8, active hemorrhage, or an expanding/pulsatile hematoma.

 

After a successful reduction and no hard signs, what is the appropriate plan?
CTA!!! These patients are at very high risk for popliteal injuries. Per uptodate – CTA if ABI < 0.9 or asymmetrical pulse. If ABI>0.9 with good pulses, can admit for serial vascular exams. Also, pre-op labs/ECG.

 

 

By Dr. Andrew Grock and Dr. Sally Bogoch

 

 References

Tintinalli’s

Perron AD, Brady WJ, Sing RF. Orthopedic pitfalls in the ED: Vascular injury associated with knee dislocation. Am J Emerg Med 2001;19(7):583–588.

Emergency Orthopedics

uptodate.com

 

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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