Knee Dislocation Author: H Brendan Kelleher, Kelleher, MD; Chief Editor: Editor: Barry E Brenner, Brenner, MD, PhD, PhD, FACEP FACEP more...
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Overvie
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Di!lo"a!i #enu meru$a"an "e%adian yan# %aran# teta$i meru$a"an hal yan# $entin# untu" di"etahui "arena !erin#"ali meli&at"an "eru!a"an va!"uler yan# da$at &era"hir den#an "ehilan#an "a"i. 'elain itu, di!lo"a!i #enu !erin#"ali ter%adi $ada trauma multi$le yan# menye&a&"an dete"!inya le&ih !ulit..(), *, +, , -, , /, 01
Hi!tory Di!lo"a!i #enu di"la!ifi"a!i"an menurut $o!i!i atau !i!tem "la!ifi"a!i anatomi. Kla!ifi"a!i menurut $o!i!i men##am&ar"an $o!i!i ti&ia relatif terhada$ femur. Banya" di!lo"a!i #enu yan# telah teredu"!i !e2ara !$ontan !e&elum "e 34D !ehin##a "la!ifi"a!i !e2ara $o!i!i !ulit dila"u"an. Oleh "arena itu, !e2ara umum, le&ih di!u"ai $en##unaan "la!ifi"a!i !e2ara anatomi "arena da$at men##am&ar"an "eru!a"an yan# meli&at"an li#ament, arteri, dan !araf. Kla!ifi"a!i $o!i!ional adalah !e&a#ai &eri"ut:
4am&ar 5eni! di!lo"a!i lutut •
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Anterior: di!lo"a!i di!lo"a!i anterior !erin#"ali !erin#"ali di!e&a&"an "arena "arena hi$ere"!ten!i lutut. lutut. Penelitian den#an den#an 2adaver menun%u""an &aha hi$ere"!ten!i mende"ati +6 dera%at di$erlu"an !e&elum ter%adinya di!lo"a!i. Po!terior: Po!terior di!lo"a!i ter%adi den#an &enturan anterior7"e7$o!terior anterior7"e7$o!terior $ada $ro8imal ti&ia,!e$erti dashboard type of injury atau atau %atuh den#an ener#y tin##i $ada $o!i!i lutut fle8i. 4am&aran radio#rafi di!lo"a!i $o!terior adalah !e&a#ai &eri"ut :
Po!terior "nee di!lo2ation. •
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Medial, lateral, atau rotatory : Di!lo"a!i medial, lateral, dan rotatory mem&utuh"an "om$onen varu!, val#u!, atau rotatory $ada "om$onen yan# ter"ena &enturan. 9e&ih dari !eten#ah dari "e%adian di!lo"a!i anterior atau $o!terior atau "eduanya, memili"i in!iden!i yan# tin##i "eru!a"an arteri $o$litea, *67+6dari !emua di!lo"a!i #enu men#alami "om$li"a!i lan%utan yaitu di!lo"a!i ter&u"a open joint injury !e$erti #am&ar di &aah :
4am&ar : O$en "nee di!lo2ation
Kla!ifi"a!i &erda!ar"an !y!tem anatomi di"em&an#"an oleh '2hen2" dan dimodifi"a!i oleh a!2her. Kla!ifi"a!i ini meli&at"an li#amen atau !i!tem anatomi yan# lain : • • • • • • • •
KD 3 < =u$tur multili#amen den#an inta" li#amen 2ru2iatum KD 33 < =u$tur Bi2ru2iate den#an inta" "edua "olateral >%aran#? KD 333M 7 Bi2ru2iate dan li#amen 2ollateral medial ru$tur >MC9? KD 3339 7 Bi2ru2iate dan li#ament "olateral lateral >9C9? ru$tur KD 3@ 7 Panli#ament ru$tur KD @ < Di!lo"a!i #enu den#an fra"tur $eriarti2ular C >tam&ah"an di ata!? < Meli&at"an "eru!a"an arteri >tam&ah"an di ata!? 7 Meli&at"an "eru!a"an nervu!
Pemeri"!aan Fi!i" •
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Palin# !erin# #am&aran yan# nyata adalah deformita! $ada tun#"ai &aah terutama $ada lutut den#an &en#"a" dan tida" &i!a di#era""an Banya" di!lo"a!i #enu yan# &erhu&un#an den#an fra"tur oleh "arena itu $emeri"!aan radiolo#i di$erlu"an Many "nee di!lo2ation! have a!!o2iated fra2ture!; thu!, it i! im$ortant to o&tain radio#ra$h! $rior to li#amentou! !tre!!in# to avoid $romotin# fra2ture di!$la2ement. 3n the a&!en2e of 2oe8i!tent fra2ture, a thorou#h e8amination of all li#amentou! !tru2ture! i! im$erative, e!$e2ially in $atient! ith head in%urie! or in tho!e ho are into8i2ated and may not &e a&le to 2ommuni2ate !ym$tom! adeuately. he findin# of varu! or val#u! in!ta&ility in full e8ten!ion of the "nee i! !u##e!tive of a !$ontaneou!ly redu2ed yet #ro!!ly un!ta&le di!lo2ation. 3n addition, $ain o ut of $ro$ortion, or a&!ent or de2rea!ed $ul!e! are red fla#! of !u2h an in%ury. Pemeri"!aan va!"uler !e2ara hati7hati $erlu dila"u"an "arena da$at ter%adi "eru!a"an arteri $o$litea $ada !emua %eni! di!lo"a!i!u&lu"!a!i #enu, den#an in!iden!i yan# dila$or"an &er"i!ar antara /7. ()61 Bila ditemu"an "hard signs" dari "eru!a"an arteri, diindi"a!i"an untu" dila"u"an $em&edahan reva!"ulari!a!i !e#era tan$a menun##u ha!il arterio#rafi. Hard sign dari "eru!a"an arteri diantaranya adalah tida" adanya denyut nadi, hematom yan# mem&e!ar dan $ul!atin#, tera&a thrill atau terden#ar &ruit Pada "a!u! tida" ditemu"annya hard !i#n dari "eru!a"an arteri, dian%ur"an untu" dila"u"an $emeri"!aan ankle-brachial atau te"anan arteri. Hal ini diindi"a!i"an me!"i$un denyut nadi tera&a normal hal ini tida" &i!a menyin#"ir"an adanya "eru!a"an va!"uler !e2ara "lini! ()), )*1 =o!e et al mela$or"an )- dari )/+ "a!u! >? $ada tun#"ai &aah dida$at"an $ul!a!i yan# normal me!"i$un ternyata terda$at "eru!a"an arteri.()*1 Pen#u"uran AB3AP3 "uran# dari 6.6 memili"i nilai !en!itivita! - dan !$e!ifita! / $ada "eru!a"an arteri. ()+, )1 Pada "a!u! yan# tida" ditemu"an hard findings teta$i AB3AP3 "uran# dari 6.6 !e&ai"nya menda$at "on!ulta!i tinda"an &edah va!"uler. Be&era$a $emeri"!aan radio#rafi yan# di$erlu"an da$at den#an arterio#rafi "onven!ional, atau $emeri"!aan lain yan# le&ih modern den#an duplex ultrasonography >!en!itivita! )66 dan !$e!ifita! / !e2ara "lini! !i#nifi"an untu" "eru!a"an arteri ()-1 ?, atau C an#io#rafi >!en!itivita! -7)66 dan !$e!ifita! /70 !e2ara "lini! !i#nifi"an untu" "eru!a"an arteri (), )/1 ?. Me!"i$un ma!ih ter%adi $erde&atan mana a$li"a!i radio#rafi yan# $alin# te$at di#una"an, "e$utu!an henda"nya di"on!ulta!i"an den#an do"ter &edah va!"uler. =e#ardle!! of the ima#in# $ur!ued, all "nee di!lo2ation! not reuirin# immediate !ur#i2al reva!2ulariation !hould &e admitted for !erial $erfu!ion 2he2"! a! delayed intimal fla$ throm&o!e!, arteriovenou! >A@? fi!tula!, and $!eudoaneury!m! of !i#nifi2an2e 2ertainly o22ur and may need !u&!euent interventionre$air. Keru!a"an nervu! $eroneu! %u#a ter%adi $ada *-7+- $a!ien !ehin##a $emeri"!aan untu" menyin#"ir"an hal ini $erlu dila"u"an. Manife!ta!inya yan# $alin# !erin# adalah $enurunan !en!a!i $ada tun#"ai &aah dan #an##uan dor!ofle"!i dari "a"i.
Cau!e! 4enu meru$a"an !endi yan# !ta&il !ehin##a mem&utuh"an ener#y &e!ar untu" menye&a&"an ter%adinya di!lo"a!i. Minimal ada + li#amen mayor yan# ru$tur &ila di!lo"a!i ter%adi. Me"ani!me yan# ter%adi antara lain : • • • • •
a&ra"an !e$eda motor a&ra"an "e$ada $e%alan "a"i Ke2ela"aan "er%a 5atuh Cedera olahra#a
Differential Dia#no!e! •
Femur Fra2ture
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Knee Fra2ture
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i&ia and Fi&ula Fra2ture
3ma#in# 'tudie! Plain radio#ra$h! are re2ommended $o!t redu2tion and $rior to any $rovo2ative li#amentou! !tre!!in#.(01 Briefly, the an"le7&ra2hial inde8 2om$are! the Do$$ler $re!!ure of an arm to a le# to !2reen for loer lim& i!2hemia. hi! !trai#htforard mea!urement i! $erformed &y re2ordin# the hi#he!t Do$$ler !ound of the &ra2hial $ul!e and 2om$arin# it to the hi#he!t Do$$ler !ound of the $o!terior ti&ial or dor!ali! $edi! artery. he an"le Do$$ler $re!!ure i! then divided &y the &ra2hial Do$$ler $re!!ure to 2al2ulate the inde8. 3nde8e! le!! than 6. indi2ate an a&normal re!ult and !hould $rom$t further va!2ular ima#in#a!!e!!ment. Du$le8 ultra!ono#ra$hy i! a relia&le, noninva!ive, lo7ri!", lo72o!t o$tion. Du$le8 ultra!ono#ra$hy a$$ear! to &e an e82ellent modality for va!2ular in%ury a!!e!!ment.()0, ), )-1 Fry et al re$orted )66 !en!itivity and / !$e2ifi2ity for 2lini2ally !i#nifi2ant arterial in%ury.()-1 hi! modality only in2ur! a&out )6 of the 2o!t of arterio#ra$hy ith little to no ri!" $rofile. (*61 C an#io#ra$hy i! another relia&le alternative to arterio#ra$hy ithout the ri!" of dire2t arterial in%ury. 3t doe! reuire additional 2ontra!t &eyond that u!ed for 2he!ta&domen$elvi! &ody C! that are often al!o indi2ated in the!e ty$e! of trauma 2a!e!; thu!, it may have added ri!" of ne$hro$athy or 2ontra!t rea2tion! over arterio#ra$hy, hi2h u!e! le!! 2ontra!t. 3na&a et al re$orted )66 !en!itivity and )66 !$e2ifi2ity for loer e8tremity arterial in%ury of !i#nifi2an2e.()1 'oto et al re$orted - !en!itivity and 0./ !$e2ifi2ity.()/, 01 Dire2t arterio#ra$hy i! the 2riterion !tandard &ut 2arrie! ri!" of arterial in%ury from dire2t 2atheteriation of the artery hile al!o reuirin# !$e2iali!t involvement to $erform >ie, interventional radiolo#i!t or va!2ular !ur#eon?.
Preho!$ital Care Preho!$ital $er!onnel !hould !$lint the e8tremity and $rovide ra$id tran!$ort to a medi2al fa2ility. Perform field redu2tion for $atient! ith eviden2e of va!2ular 2om$romi!e.
e8t 'e2tion: Emer#en2y De$art
Emer#en2y De$artment Care 5an#an menunda redu"!i $ada "a"i den#an tanda #an##uan va!"uler yan# %ela!. Hanya $a!ien den#an $ul!a!i $erifer yan# &ai" Do not delay redu2tion in lim&! ith o&viou! va!2ular im$airment. Only $atient! ith #ood $eri$heral $ul!e! !hould under#o $reredu2tion radio#ra$h!. =edu2tion i! !trai#htforard and often ea!ily a22om$li!hed in the ED. After adeuate !edation, lon#itudinal tra2tion ill relo2ate the ma%ority of "nee di!lo2ation!. Preredu2tion and $o!tredu2tion $hoto! of a lateral "nee di!lo2ation are !hon in the ima#e! &elo.
9ateral "nee di!lo2ation >&efore redu2tion?.
9ateral "nee di!lo2ation after redu2tion.
Po!terolateral di!lo2ation! are $arti2ularly diffi2ult and often reuire o$erative redu2tion. hi! i! e!$e2ially true hen the medial femoral 2ondyle &utton7hole! throu#h the medial a!$e2t of the %oint 2a$!ule andor MC9 G an o22urren2e that i! often a22om$anied &y a dim$le !i#n overlyin# the medial a!$e2t of the "nee.
After redu2tion, !$lint the loer e8tremity in a$$ro8imately *6 de#ree! of fle8ion to avoid $o!tredu2tion re7 di!lo2ation, a$$ly i2e, and "ee$ the "nee elevated. Po!tredu2tion radio#ra$h! !hould &e o&tained, $refera&ly &efore further li#amentou! !tre!!in#a!!e!!ment. Po!tredu2tion hard !i#n! of arterial in%ury !hould $rom$t emer#ent va!2ular !ur#i2al intervention that !hould not &e delayed for arterio#ra$hy. 3n thi! !ettin#, arterio#ram! may indeed &e 2ontri&utory to the !ur#i2al de2i!ion matri8 &ut 2an &e $erformed in the o$eratin# room &y the va!2ular !ur#eon ith le!! 2ontra!t admini!tration than traditional arterio#ra$hy tend! to u!e. All redu2ed "nee di!lo2ation! ithout hard !i#n! of arterial in%ury !hould &e a!!e!!ed ith AB3AP3 mea!urement!. Any readin# of le!! than 6.6 !hould $rom$t further ima#in# >ie, arterio#ra$hy v! C an#io#ra$hy v! du$le8 !ono#ra$hy?, hi2h !hould &e de2ided u$on in 2on%un2tion ith the va!2ular2on!ult. All "nee di!lo2ation!, re#ardle!! of emer#ent reva!2ulariation need!, !hould &e admitted for !erial $erfu!ion 2he2"!.
Con!ultation! Alay! 2on!ult &oth ortho$edi2 and va!2ular !ur#eon!. Many $atient! have !i#nifi2ant va!2ular in%ury reuirin# !ur#i2al reva!2ulariation, and all $atient! ill at lea!t reuire admi!!ion for !erial va!2ular 2he2"! and further !ur#i2al !ta&iliation 2on!ideration.
Medi2ation 'ummary 'A3D!, anal#e!i2!, and an8iolyti2! are u!ed to treat the $ain a!!o2iated ith di!lo2ation!.
Anal#e!i2! Class Summary Pain 2ontrol i! e!!ential to uality $atient 2are. 3t en!ure! $atient 2omfort, $romote! $ulmonary toilet, and aid! $hy!i2al thera$y re#imen!. Many anal#e!i2! have !edatin# $ro$ertie! that &enefit $atient! ith in%urie!. @ie full dru# information
Fentanyl citrate (Duragesic, Sublimaze) ar2oti2 anal#e!i2 ith #reater $oten2y and mu2h !horter half7life than mor$hine !ulfate. E82ellent 2hoi2e for $ain mana#ement and !edation ith it! !hort duration time >+676 min? and ea!e of titration. Ea!ily and ui2"ly rever!ed &y n alo8one. After initial do!e, !u&!euent do!e! !hould not &e titrated more freuently than +h or h. @ie full dru# information
Meperidine (Demerol) ar2oti2 anal#e!i2 ith multi$le a2tion! !imilar to tho!e of mor$hine. May $ rodu2e le!! 2on!ti$ation, !mooth mu!2le !$a!m, and de$re!!ion of 2ou#h refle8 than !imilar anal#e!i2 do!e! of mor$hine. @ie full dru# information
Oxycodone and acetaminophen (ercocet) Dru# 2om&ination indi2ated for relief of moderately !evere to !evere $ain. DOC for a!$irin7hy$er!en!itive $atient!. @ie full dru# information
!cetaminophen and codeine ("ylenol #$) Dru# 2om&ination indi2ated for treatment of mild to moderately !evere $ain. @ie full dru# information
%ydrocodone bitartrate and acetaminophen (&icodin 'S) Dru# 2om&ination indi2ated for relief of moderately !evere to !evere $ain. @ie full dru# information
Oxycodone and aspirin (ercodan) Dru# 2om&ination indi2ated for relief of moderately !evere to !evere $ain.
An8iolyti2! Class Summary Patient! ith $ainful in%urie! u!ually e 8$erien2e !i#nifi2ant an8iety. An8iolyti2! allo the 2lini2ian to admini!ter a !maller anal#e!i2 do!e to a2hieve the !ame effe2t. @ie full dru# information
orazepam (!tian) 'edative hy$noti2 in &enodiae$ine 2la!! that ha! !hort on!et of effe2t and relatively lon# half7life. By in2rea!in# a2tion of 4ABA, a ma%or inhi&itory neurotran!mitter, may de$re!! all level! of C', in2ludin# lim&i2 and reti2ular formation. E82ellent for $atient! ho reuire !edation for lon#er than * h. Monitor BP after admini!terin# and ad%u!t a! ne2e!!ary.
on!teroidal anti7inflammatory a#ent! >'A3D!? Class Summary he!e a#ent! are u!ed mo!t 2ommonly for the relief of mild to moderately !evere $ain. Althou#h the effe2t! of 'A3D! in the treatment of $ain tend to &e $atient !$e2ifi2, i&u$rofen i! u!ually the DOC for initial thera$y. Other o$tion! in2lude flur&i$rofen, "eto$rofen, and na$ro8en. @ie full dru# information
*bupro+en (*buprin, !dil, Motrin) DOC for treatment of mild to moderately !evere $ain, if no 2ontraindi2ation!. 3nhi&it! inflammatory rea2tion! and $ain, $ro&a&ly &y de2rea!in# a2tivity of enyme 2y2loo8y#ena!e, inhi&itin# $ro!ta#landin !ynthe!i!. @ie full dru# information
Ketopro+en (Oruail, Orudis, !ctron) I!ed for relief of mild to moderately !evere $ain and inflammation. Admini!ter !mall do!a#e! initially to $atient! ith a !mall &ody !ie, the elderly, and tho!e ith renal or liver di!ea!e. Do!e! hi#her than /m# do not in2rea!e it! thera$euti2 effe2t!. Admini!ter hi#h do!e! ith 2aution and 2lo!ely o&!erve the $atient for re!$on!e. @ie full dru# information
Flurbipro+en (!nsaid, Ocu+en) Ha! anal#e!i2, anti$yreti2, and anti7inflammatory effe2t!. May inhi&it 2y2loo8y#ena!e enyme, inhi&itin# $ro!ta#landin &io!ynthe!i!. @ie full dru# information
aproxen (!naprox, aprelan, aprosyn) I!ed for relief of mild to moderately !evere $ain. 3nhi&it! inflammatory rea2tion! and $ain &y de2rea!in# a2tivity of enyme 2y2loo8y#ena!e, de2rea!in# $ro!ta#landin !ynthe!i!.
Further *npatient Care Hi!tori2ally, 2onventional arterio#ra$hy a! re2ommended for all 2a!e! of "needi!lo2ation and, thou#h it remain! the 2riterion !tandard for $o$liteal artery evaluation, there i! #roin# de&ate over it! univer!al a$$li2ation. @a!2ular a!!e!!ment ith the an"le7&ra2hial inde8, du$le8 !ono#ra$hy, andor C an#io#ra$hy i! 2han#in# thi! $aradi#m hile an in2rea!in# num&er of $o$liteal in%urie! are &ein# mana#ed non!ur#i2ally >#enerally tho!e that !ho no !i#nifi2ant throm&o!i! at 07/* h?. Many !ur#eon! thu! ar#ue that arterio#ra$hy !hould not &e routine and that 2a!e7&y72a!e utiliation of other ima#in# modalitie! 2om&ined ith vi#ilant o&!ervation i! !uffi2ient. Intu" do"ter %a#a 34D, hal yan# $alin# $entin# adalah mela"u"an $emeri"!aan For the EM $hy!i2ian, it i! im$ortant to re2o#nie that va!2ular e8amination findin#! may &e normal in the $re!en2e of !i#nifi2ant $o$liteal artery in%ury()), )*1and that !ome 2om&ination of further inve!ti#ationo&!ervation i! arranted in all "nee di!lo2ation!. hi! may &e different for ea2h in!titution andor ea2h !ur#eon and !hould &e de2ided on in a 2a!e7&y72a!e &a!i! in 2on%un2tion ith the va!2ular 2on!ult. ime i! of utmo!t 2on2ern, a! va!2ular re$air delayed more than 0 hour! after in%ury 2arrie! an am$utation rate of #reater than 06. 3n 2ontra!t, o$erative va!2ular re$air ithin 0 hour! of in%ury yield! a lim&7!alva#e rate of 06. he re$air of 2oe8i!tent $o$liteal vein in%ury i! 2ontrover!ial. Fa!2iotomy i! re2ommended after va!2ular re$air, a! !evere !ellin# and develo$ment of 2om$artment !yndrome are 2ommon in the $o!to$erative $ha!e. O$erative re$air of nerve in%ury remain! 2ontrover!ial, a! a $oor $ro#no!i! i! 2ommon ith &oth o$erative and nono$erative 2are. O$erative li#amentou! re$air i! re2ommended &y mo!t author!, a! fun2tional re!ult! are &etter than tho!e of nono$erative 2are, &ut determinin# the ideal timin# of thi! intervention i! 2om$le8 and i! a de2i!ion &e!t left to the ortho$edi!t.
Further *npatient Care Hi!tori2ally, 2onventional arterio#ra$hy a! re2ommended for all 2a!e! of "needi!lo2ation and, thou#h it remain! the 2riterion !tandard for $o$liteal artery evaluation, there i! #roin# de&ate over it! univer!al a$$li2ation. @a!2ular a!!e!!ment ith the an"le7&ra2hial inde8, du$le8 !ono#ra$hy, andor C an#io#ra$hy i! 2han#in# thi! $aradi#m hile an in2rea!in# num&er of $o$liteal in%urie! are &ein# mana#ed non!ur#i2ally >#enerally tho!e that !ho no !i#nifi2ant throm&o!i! at 07/* h?. Many !ur#eon! thu! ar#ue that arterio#ra$hy !hould not &e routine and that 2a!e7&y72a!e utiliation of other ima#in# modalitie! 2om&ined ith vi#ilant o&!ervation i! !uffi2ient.
For the EM $hy!i2ian, it i! im$ortant to re2o#nie that va!2ular e8amination findin#! may &e normal in the $re!en2e of !i#nifi2ant $o$liteal artery in%ury()), )*1and that !ome 2om&ination of f urther inve!ti#ationo&!ervation i! arranted in all"nee di!lo2ation!. hi! may &e different for ea2h in!titution andor ea2h !ur#eon and !hould &e de2ided on in a 2a!e7&y72a!e &a!i! in 2on%un2tion ith the va!2ular 2on!ult. ime i! of utmo!t 2on2ern, a! va!2ular re$air delayed more than 0 hour! after in%ury 2arrie! an am$utation rate of #reater than 06. 3n 2ontra!t, o$erative va!2ular re$air ithin 0 hour! of in%ury yield! a lim&7!alva#e rate of 06. he re$air of 2oe8i!tent $o$liteal vein in%ury i! 2ontrover!ial. Fa!2iotomy i! re2ommended after va!2ular re$air, a! !evere !ellin# and develo$ment of 2om$artment !yndrome are 2ommon in the $o!to$erative $ha!e. O$erative re$air of nerve in%ury remain! 2ontrover!ial, a! a $oor $ro#no!i! i! 2ommon ith &oth o$erative and nono$erative 2are. O$erative li#amentou! re$air i! re2ommended &y mo!t author!, a! fun2tional re!ult! are &etter than tho!e of nono$erative 2are, &ut determinin# the ideal timin# of thi! intervention i! 2om$le8 and i! a de2i!ion &e!t left to the ortho$edi!t.
ran!fer 'ee the li!t &elo: •
Patient! 2on!idered for tran!fer !hould have under#one emer#en2y redu2tion of the "nee di!lo2ation. 'in2e time i! 2ru2ial in !alva#in# the lim& after a va!2ular in%ury, tran!fer !hould &e initiated only if va!2ular 2on!ultation andor evaluation are not availa&le at the tran!ferrin# in!titution or if an arterio#ram ha! &een $erformed and re!ult! are normal.
Com$li2ation! • • • • •
Po$liteal artery in%ury Po$liteal vein in%ury Peroneal nerve in%ury 9i#amentou! in%ury Com$artment !yndrom
Pro#no!i! 'ee the li!t &elo: •
hen treated e8$editiou!ly and a$$ro$riately, 67/6 of $atient! ill have a $ainle!!, !ta&le "nee. Of the remainin# $atient!, one h alf ill eventually have rea!ona&le fun2tion, hile the other half ill have a 2hroni2ally un!ta&le and $ainful "nee.