ABSTRACT
Multiligament injury of the knee, which may include joint dislocation, is a severe injury that can devastate knee function. It usually results in rupture of three of the four major stabilizing ligaments of the knee, but occasionally only two of the ligaments are torn. Evaluation and management is made more complex due to associated articular and meniscal cartilage injury, bony fractures, and neurovascular injury. What is considered best treatment is often varied and controversial. This article discusses the diagnosis and management of multiligament knee injury and the role of imaging in the context of the published literature and our own experience.
KEYWORDS
Knee - dislocation - multiligament - multiligament injury
REFERENCES
-
1
Kennedy J C.
Complete dislocation of the knee joint.
J Bone Joint Surg Am.
1963;
45
889-904
-
2
Taylor A R, Arden G P, Rainey H A.
Traumatic dislocation of the knee. A report of forty-three cases with special reference to conservative treatment.
J Bone Joint Surg Br.
1972;
54(1)
96-102
-
3
Meyers M H, Moore T M, Harvey Jr J P.
Traumatic dislocation of the knee joint.
J Bone Joint Surg Am.
1975;
57(3)
430-433
-
4
Almekinders L C, Logan T C.
Results following treatment of traumatic dislocations of the knee joint.
Clin Orthop Relat Res.
1992;
(284)
203-207
-
5
Frassica F J, Sim F H, Staeheli J W, Pairolero P C.
Dislocation of the knee.
Clin Orthop Relat Res.
1991;
(263)
200-205
-
6
Sisto D J, Warren R F.
Complete knee dislocation. A follow-up study of operative treatment.
Clin Orthop Relat Res.
1985;
(198)
94-101
-
7
Harner C D, Waltrip R L, Bennett C H, Francis K A, Cole B, Irrgang J J.
Surgical management of knee dislocations.
J Bone Joint Surg Am.
2004;
86-A(2)
262-273
-
8
Mariani P P, Santoriello P, Iannone S, Condello V, Adriani E.
Comparison of surgical treatments for knee dislocation.
Am J Knee Surg.
1999;
12(4)
214-221
-
9
Wascher D C, Becker J R, Dexter J G, Blevins F T.
Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
Am J Sports Med.
1999;
27(2)
189-196
-
10
Duthon V B, Barea C, Abrassart S, Fasel J H, Fritschy D, Ménétrey J.
Anatomy of the anterior cruciate ligament.
Knee Surg Sports Traumatol Arthrosc.
2006;
14(3)
204-213
-
11
Butler D L, Noyes F R, Grood E S.
Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study.
J Bone Joint Surg Am.
1980;
62(2)
259-270
-
12
Fanelli G C, Orcutt D R, Edson C J.
The multiple-ligament injured knee: evaluation, treatment, and results.
Arthroscopy.
2005;
21(4)
471-486
-
13
Amis A A, Bull A M, Gupte C M, Hijazi I, Race A, Robinson J R.
Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments.
Knee Surg Sports Traumatol Arthrosc.
2003;
11(5)
271-281
-
14
Gupte C M, Smith A, McDermott I D, Bull A M, Thomas R D, Amis A A.
Meniscofemoral ligaments revisited. Anatomical study, age correlation and clinical implications.
J Bone Joint Surg Br.
2002;
84(6)
846-851
-
15
Amis A A, Gupte C M, Bull A M, Edwards A.
Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments.
Knee Surg Sports Traumatol Arthrosc.
2006;
14(3)
257-263
-
16
Warren L F, Marshall J L.
The supporting structures and layers on the medial side of the knee: an anatomical analysis.
J Bone Joint Surg Am.
1979;
61(1)
56-62
-
17
Robinson J R, Sanchez-Ballester J, Bull A M, Thomas RdeW, Amis A A.
The posteromedial corner revisited. An anatomical description of the passive restraining structures of the medial aspect of the human knee.
J Bone Joint Surg Br.
2004;
86(5)
674-681
-
18
Rajeswaran G, Lee J C, Healy J C.
MRI of the popliteofibular ligament: isotropic 3D WE-DESS versus coronal oblique fat-suppressed T2W MRI.
Skeletal Radiol.
2007;
36(12)
1141-1146
-
19
Bottomley N, Williams A, Birch R, Noorani A, Lewis A, Lavelle J.
Displacement of the common peroneal nerve in posterolateral corner injuries of the knee.
J Bone Joint Surg Br.
2005;
87(9)
1225-1226
-
20
Schenck Jr R C.
Classification of knee dislocations.
Oper Tech Sports Med.
2003;
11(3)
193-198
-
21
Schenck Jr R C, Hunter R E, Ostrum R F, Perry C R.
Knee dislocations.
Instr Course Lect.
1999;
48
515-522
-
22
Wascher D C.
High-velocity knee dislocation with vascular injury. Treatment principles.
Clin Sports Med.
2000;
19(3)
457-477
-
23
Stuart M J.
Evaluation and treatment principles of knee dislocations.
Oper Tech Sports Med.
2001;
9(2)
91-95
-
24
Green N E, Allen B L.
Vascular injuries associated with dislocation of the knee.
J Bone Joint Surg Am.
1977;
59(2)
236-239
-
25
Patterson B M, Agel J, Swiontkowski M F, Mackenzie E J, Bosse M J. LEAP Study Group .
Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study.
J Trauma.
2007;
63(4)
855-858
-
26
Cone J B.
Vascular injury associated with fracture-dislocations of the lower extremity.
Clin Orthop Relat Res.
1989;
(243)
30-35
-
27
Huang F S, Simonian P T, Chansky H A.
Irreducible posterolateral dislocation of the knee.
Arthroscopy.
2000;
16(3)
323-327
-
28
Milch H.
Cortical avulsion fracture of the lateral tibial condyle.
J Bone Joint Surg.
1936;
18
159-164
-
29
Goldman A B, Pavlov H, Rubenstein D.
The Segond fracture of the proximal tibia: a small avulsion that reflects major ligamentous damage.
AJR Am J Roentgenol.
1988;
151(6)
1163-1167
-
30
Woods G W, Stanley R F, Tullos H S.
Lateral capsular sign: x-ray clue to a significant knee instability.
Am J Sports Med.
1979;
7(1)
27-33
-
31
Norwood Jr L A, Andrews J R, Meisterling R C, Glancy G L.
Acute anterolateral rotatory instability of the knee.
J Bone Joint Surg Am.
1979;
61(5)
704-709
-
32
Pavlov H, Goldman A B.
The popliteus bursa: an indicator of subtle pathology.
AJR Am J Roentgenol.
1980;
134(2)
313-321
-
33
Dietz G W, Wilcox D M, Montgomery J B.
Segond tibial condyle fracture: lateral capsular ligament avulsion.
Radiology.
1986;
159(2)
467-469
-
34
Delzell P B, Schils J P, Recht M P.
Subtle fractures about the knee: innocuous-appearing yet indicative of significant internal derangement.
AJR Am J Roentgenol.
1996;
167(3)
699-703
-
35
el-Khoury G Y, Daniel W W, Kathol M H.
Acute and chronic avulsive injuries.
Radiol Clin North Am.
1997;
35(3)
747-766
-
36
Hall F M, Hochman M G.
Medial Segond-type fracture: cortical avulsion off the medial tibial plateau associated with tears of the posterior cruciate ligament and medial meniscus.
Skeletal Radiol.
1997;
26(9)
553-555
-
37
Escobedo E M, Mills W J, Hunter J C.
The “reverse Segond” fracture: association with a tear of the posterior cruciate ligament and medial meniscus.
AJR Am J Roentgenol.
2002;
178(4)
979-983
-
38
Hegyes M S, Richardson M W, Miller M D.
Knee dislocation. Complications of nonoperative and operative management.
Clin Sports Med.
2000;
19(3)
519-543
-
39
Hoover N W.
Injuries of the popliteal artery associated with fractures and dislocations.
Surg Clin North Am.
1961;
41
1099-1112
-
40
Ottolenghi C E, Traversa C H.
Vascular and nervous complications in injuries of the knee joint.
Reconstr Surg Traumatol.
1974;
14(0)
114-135
-
41
O'Donnell Jr T F, Brewster D C, Darling R C, Veen H, Waltman A A.
Arterial injuries associated with fractures and/or dislocations of the knee.
J Trauma.
1977;
17(10)
775-784
-
42
Jones R E, Smith E C, Bone G E.
Vascular and orthopedic complications of knee dislocation.
Surg Gynecol Obstet.
1979;
149(4)
554-558
-
43
Fabian T C, Turkleson M L, Connelly T L, Stone H H.
Injury to the popliteal artery.
Am J Surg.
1982;
143(2)
225-228
-
44
Ottolenghi C E.
Vascular complications in injuries about the knee joint.
Clin Orthop Relat Res.
1982;
(165)
148-156
-
45
Roman P D, Hopson C N, Zenni Jr E J.
Traumatic dislocation of the knee: a report of 30 cases and literature review.
Orthop Rev.
1987;
16(12)
917-924
-
46
Kendall R W, Taylor D C, Salvian A J, O'Brien P J.
The role of arteriography in assessing vascular injuries associated with dislocations of the knee.
J Trauma.
1993;
35(6)
875-878
-
47
Bryan T, Merritt P, Hack B.
Popliteal arterial injuries associated with fractures or dislocations about the knee as a result of blunt trauma.
Orthop Rev.
1991;
20(6)
525-530
-
48
Gable D R, Allen J W, Richardson J D.
Blunt popliteal artery injury: is physical examination alone enough for evaluation?.
J Trauma.
1997;
43(3)
541-544
-
49
Melton S M, Croce M A, Patton Jr J H et al..
Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage.
Ann Surg.
1997;
225(5)
518-527; discussion 527–529
-
50
Rihn J A, Groff Y J, Harner C D, Cha P S.
The acutely dislocated knee: evaluation and management.
J Am Acad Orthop Surg.
2004;
12(5)
334-346
-
51
Rose S C, Moore E E.
Trauma angiography: the use of clinical findings to improve patient selection and case preparation.
J Trauma.
1988;
28(2)
240-245
-
52
Wascher D C, Dvirnak P C, DeCoster T A.
Knee dislocation: initial assessment and implications for treatment.
J Orthop Trauma.
1997;
11(7)
525-529
-
53
Applebaum R, Yellin A E, Weaver F A, Oberg J, Pentecost M.
Role of routine arteriography in blunt lower-extremity trauma.
Am J Surg.
1990;
160(2)
221-224; discussion 224–225
-
54
Treiman G S, Yellin A E, Weaver F A et al..
Examination of the patient with a knee dislocation. The case for selective arteriography.
Arch Surg.
1992;
127(9)
1056-1062; discussion 1062–1063
-
55
Busquéts A R, Acosta J A, Colón E, Alejandro K V, Rodríguez P.
Helical computed tomographic angiography for the diagnosis of traumatic arterial injuries of the extremities.
J Trauma.
2004;
56(3)
625-628
-
56
Soto J A, Múnera F, Morales C et al..
Focal arterial injuries of the proximal extremities: helical CT arteriography as the initial method of diagnosis.
Radiology.
2001;
218(1)
188-194
-
57
Rieger M, Mallouhi A, Tauscher T, Lutz M, Jaschke W R.
Traumatic arterial injuries of the extremities: initial evaluation with MDCT angiography.
AJR Am J Roentgenol.
2006;
186(3)
656-664
-
58
Inaba K, Potzman J, Munera F et al..
Multi-slice CT angiography for arterial evaluation in the injured lower extremity.
J Trauma.
2006;
60(3)
502-506; discussion 506–507
-
59
Kaufman S L, Martin L G.
Arterial injuries associated with complete dislocation of the knee.
Radiology.
1992;
184(1)
153-155
-
60
Atteberry L R, Dennis J W, Russo-Alesi F, Menawat S S, Lenz B J, Frykberg E R.
Changing patterns of arterial injuries associated with fractures and dislocations.
J Am Coll Surg.
1996;
183(4)
377-383
-
61
Martinez D, Sweatman K, Thompson E C.
Popliteal artery injury associated with knee dislocations.
Am Surg.
2001;
67(2)
165-167
-
62
Abou-Sayed H, Berger D L.
Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography.
Arch Surg.
2002;
137(5)
585-589
-
63
Miranda F E, Dennis J W, Veldenz H C, Dovgan P S, Frykberg E R.
Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study.
J Trauma.
2002;
52(2)
247-251; discussion 251–252
-
64
Stannard J P, Sheils T M, Lopez-Ben R R, McGwin Jr G, Robinson J T, Volgas D A.
Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography.
J Bone Joint Surg Am.
2004;
86-A(5)
910-915
-
65
Nicandri G T, Chamberlain A M, Wahl C J.
Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries.
Clin J Sport Med.
2009;
19(2)
125-129
-
66
Mills W J, Barei D P, McNair P.
The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study.
J Trauma.
2004;
56(6)
1261-1265
-
67
Meyers M H, Harvey Jr J P.
Traumatic dislocation of the knee joint. A study of eighteen cases.
J Bone Joint Surg Am.
1971;
53(1)
16-29
-
68
Reckling F W, Peltier L F.
Acute knee dislocations and their complications.
J Trauma.
1969;
9(3)
181-191
-
69
White J.
The results of traction injuries to the common peroneal nerve.
J Bone Joint Surg Br.
1968;
50(2)
346-350
-
70
Wood M B.
Peroneal nerve repair. Surgical results.
Clin Orthop Relat Res.
1991;
(267)
206-210
-
71
Tomaino M, Day C, Papageorgiou C, Harner C, Fu F H.
Peroneal nerve palsy following knee dislocation: pathoanatomy and implications for treatment.
Knee Surg Sports Traumatol Arthrosc.
2000;
8(3)
163-165
-
72
Tom J A, Miller M D.
Complications in the multiple-ligament-injured knee.
Oper Tech Sports Med.
2003;
11(4)
302-311
-
73
Reicher M A, Hartzman S, Bassett L W, Mandelbaum B, Duckwiler G, Gold R H.
MR imaging of the knee. Part I traumatic disorders.
Radiology.
1987;
162(2)
547-551
-
74
Reicher M A, Hartzman S, Duckwiler G R, Bassett L W, Anderson L J, Gold R H.
Meniscal injuries: detection using MR imaging.
Radiology.
1986;
159(3)
753-757
-
75
Mink J H, Levy T, Crues III J V.
Tears of the anterior cruciate ligament and menisci of the knee: MR imaging evaluation.
Radiology.
1988;
167(3)
769-774
-
76
Vahey T N, Broome D R, Kayes K J, Shelbourne K D.
Acute and chronic tears of the anterior cruciate ligament: differential features at MR imaging.
Radiology.
1991;
181(1)
251-253
-
77
Murphy B J, Smith R L, Uribe J W, Janecki C J, Hechtman K S, Mangasarian R A.
Bone signal abnormalities in the posterolateral tibia and lateral femoral condyle in complete tears of the anterior cruciate ligament: a specific sign?.
Radiology.
1992;
182(1)
221-224
-
78
Almekinders L C, Dedmond B T.
Outcomes of the operatively treated knee dislocation.
Clin Sports Med.
2000;
19(3)
503-518
-
79
O'Donoghue D H.
An analysis of end results of surgical treatment of major injuries to the ligaments of the knee.
J Bone Joint Surg Am.
1955;
37-A(1)
1-13; passim
-
80
Chhabra A, Cha P S, Rihn J A et al..
Surgical management of knee dislocations. Surgical technique.
J Bone Joint Surg Am.
2005;
87(Pt 1, Suppl 1)
1-21
-
81
Noyes F R, Barber-Westin S D.
Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis.
Am J Sports Med.
1997;
25(6)
769-778
-
82
Shapiro M S, Freedman E L.
Allograft reconstruction of the anterior and posterior cruciate ligaments after traumatic knee dislocation.
Am J Sports Med.
1995;
23(5)
580-587
-
83
Noyes F R, Barber-Westin S D.
Surgical reconstruction of severe chronic posterolateral complex injuries of the knee using allograft tissues.
Am J Sports Med.
1995;
23(1)
2-12
-
84
Shelbourne K D, Porter D A, Clingman J A, McCarroll J R, Rettig A C.
Low-velocity knee dislocation.
Orthop Rev.
1991;
20(11)
995-1004
-
85
Yeh W L, Tu Y K, Su J Y, Hsu R W.
Knee dislocation: treatment of high-velocity knee dislocation.
J Trauma.
1999;
46(4)
693-701
-
86
Ibrahim S A, Ahmad F H, Salah M, Al Misfer A R, Ghaffer S A, Khirat S.
Surgical management of traumatic knee dislocation.
Arthroscopy.
2008;
24(2)
178-187
-
87
Poehling G G, Pollock Jr F E, Koman L A.
Reflex sympathetic dystrophy of the knee after sensory nerve injury.
Arthroscopy.
1988;
4(1)
31-35
-
88
Bruner J M.
Safety factors in the use of the pneumatic tourniquet for hemostasis in surgery of the hand.
J Bone Joint Surg Am.
1951;
33(A:1)
221-224
-
89
Klenerman L, Biswas M, Hulands G H, Rhodes A M.
Systemic and local effects of the application of a tourniquet.
J Bone Joint Surg Br.
1980;
62(3)
385-388
-
90
Rorabeck C H, Kennedy J C.
Tourniquet-induced nerve ischemia complicating knee ligament surgery.
Am J Sports Med.
1980;
8(2)
98-102
-
91
Klenerman L.
Tourniquet time—how long?.
Hand.
1980;
12(3)
231-234
-
92
Bruner J M.
Time, pressure, and temperature factors in the safe use of the tourniquet.
Hand.
1970;
2(1)
39-42
-
93
Noyes F R, Spievack E S.
Extraarticular fluid dissection in tissues during arthroscopy. A report of clinical cases and a study of intraarticular and thigh pressures in cadavers.
Am J Sports Med.
1982;
10(6)
346-351
-
94
Reddy A S, Frederick R W.
Evaluation of the intraosseous and extraosseous blood supply to the distal femoral condyles.
Am J Sports Med.
1998;
26(3)
415-419
-
95
Stannard J P, Wilson T C, Sheils T M, McGwin Jr G, Volgas D A, Alonso J E.
Heterotopic ossification associated with knee dislocation.
Arthroscopy.
2002;
18(8)
835-839
-
96
Patton W C, Tew W M.
Periarticular heterotopic ossification after multiple knee ligament reconstructions. A report of three cases.
Am J Sports Med.
2000;
28(3)
398-401
-
97
Irrgang J J, Harner C D.
Loss of motion following knee ligament reconstruction.
Sports Med.
1995;
19(2)
150-159
Adam W MitchellF.R.C.S. F.R.C.R.
Department of Radiology, Chelsea and Westminster Hospital NHS Healthcare Trust
369 Fulham Rd., London SW10 9NH, UK
eMail: adam.mitchell@imperial.ac.uk
