Dr Rohil Singh Kakkar

1. FLOATING KNEE
Dr Rohil Singh Kakkar
Post Graduate Resident
Dept. of Orthopaedics
RHC , India

2. Definition
In 1975, Blake and McBryde
established the concept of the
’Floating Knee’ (FK) to describe
traumatic ipsilateral fractures of
the femur and tibia, where the
knee is disconnected from the rest
of the limb.

4. Classification
Fraser Classification (1978) of
Floating Knee Injuries
Type I
71 %
Also known as True Floating Knee.
Extra-articular fractures of both
bones.

5. Type II
It is subdivided into 3 groups, as follows:
Type IIa ( 08 % ) - Tibia plateau fracture
associated with a femoral shaft fracture.
Type IIb ( 12 % )- Articular fracture of distal
femur associated with a tibial shaft fracture
Type IIc ( 09 % ) – Fracture of the tibia plateau
and articular fracture of the distal femur.

7. Mechanism
Usually a high-energy trauma (RTA)
Collisions between cars
‘Knocked down’ pedestrians

8. Clinical Picture
-The patient would present with injury to
the limb or the injury may be found on
assessment of a polytrauma patient ,
Therefore complete limb examination
must be done.
The neurovascular deficit must be
specifically looked for as these fractures
are frequently associated with damage to
the vessels (popliteal and posterior tibial
arteries) and the nerves ( peroneal nerve)
are common.

10. -The incidence of open fractures is 50-
70%, at single or both fracture sites.
Tibial # has a higher frequency of being
open.
-Injury to the knee ligaments especially
Anterolateral rotatory instability is
commonly found.
-Knee joint injury is indicated by
substantial hemarthrosis.

11. Prognosis
The Karlstrom and Olerud Prognosis
criteria are widely accepted for
evaluating functional outcomes in
adults.
The following data are recorded and
characterized as excellent, good,
acceptable, or poor.

12. Karlstrom and Olerud Prognosis Criteria

14. ASSOCIATED INJURIES
Severe Head Injury
Chest Trauma
Abdominal Injury
Popliteal Art Lesion
Open #
Neuro Vascular Injury
Consideration of Hemodynamic
stability is the first step prior to all.

15. ASSOCIATED INJURIES
STATISTICS

16. Associated Meniscal & Ligament injuries
In a Fraser type II knee, an MRI prior to
surgery can help to indicate the need to
proceed with an arthroscopy exploration
and repair.
Study and Statistical Analysis
(n- 142 Patients)
(Source – JOURNAL EFORT OPEN REVIEWS , VOL -1 , NOV 2016 )
After fracture fixation, clinical examination
of the knee, as well as arthroscopy or direct
exploration in open cases, were performed
during the initial surgery.

17. They found 70.3% ligamentous injuries
comprising:
57% ACL ruptures (6 complete, 15 partial)
8% PCL
27% MCL
19% LCL
A Medial meniscal tear was present in 38%,
And
a Lateral meniscal tear in 30% of cases.

18. MANAGEMENT
-These fractures are almost always produced by
high-energy trauma and are often associated
with other life-threatening conditions, as well as
other fractures and varying degrees of soft-
tissue lesion.
-Therefore, advanced trauma life support
protocols should be followed rigorously and the
patient stabilised before orthopaedic treatment
can be considered.

19. Consideration of Hemodynamic stability is
the first step prior to all.
The “Triad of Death" is a term coined
to describe the decompensation caused
by acute blood loss resulting in
-Hypothermia
-Coagulopathy and
-Acidosis.
The prevention or reversal of these
factors may prevent death from
exsanguination.

20. The use of external fixation as an initial
approach avoids the need for more time-
consuming procedures that can worsen the
"triad of death".
Procedures lasting more than six hours are
particularly dangerous, as they are associated
with higher rates of acute respiratory distress
syndrome(ARDS) and multiple organ failure.
It is essential to diagnose the lesions associated
with floating knee because they may be life
threatening.

21. The MESS (Mangled Extremity
Severity Score) scale takes into
account:
(1) Skeletal and soft-tissue injury;
(2) Limb ischaemia;
(3) Shock;
(4) Patient's age.
This tool has proven to be useful in
the clinical and legal management of
such lesions

23. As mentioned above, associated injuries
(head, chest or vascular injuries and
other fractures) play a significant role in
surgical decision-making regarding the
timing and sequence of surgery.
Damage control treatment for floating
knee involves not only bone stabilisation
using an External Fixator and the
treatment of open fractures by wound
cleansing and debridement, but also,
The treatment of associated lesions such
as vascular injury or compartment
syndrome, in which the corresponding
fasciotomy must be performed.

24. Fraser type IIb floating knee.
Damage control by External Fixation
in each segment.

25. DEFINITIVE TREATMENT
Femoral nailing is performed first, while
the tibia is temporarily stabilised with an
external fixator.
Reason :
If the tibia were stabilised first, the
movement and deformation of the femur
during surgery would cause greater
damage to the soft tissues and pose an
increased risk to the patient’s general
condition, including the increased
incidence of fat embolism.

28. Fraser type I floating knee.
IM Nailing in the two segments done.

29. In type II floating knee, affecting the
joint, it is crucially important to
perform anatomic reduction of the
articular surface.
Metaphyseal-diaphyseal stabilisation
can be performed indirectly, and
minimally invasive fixation achieved
by means of locking plates.

30. CASE
CASE 1 :
20 YRS/ MALE , H/O RTA.
NO NEURAVASCULAR DEFICIT.
IMMEDIATE XRAY DONE S/O : FLOATING
KNEE GRADE 2B

31. IMMEDIATE POST- OP XRAY

32. 3 YEARS POST OP XRAYS

33. CLINICAL PHOTOGRAPHS OF SAME PATIENT AT 3
YRS FOLLOW UP SHOWING RANGE OF MOTION.

34. CASE 2 :
21/M , H/O RTA
XRAY – FLOATING KNEE GRADE 2B

35. IMMEDIATE POST OP XRAY AFTER
DISTAL FEMUR PLATING AND TIBIA
IM NAILING

36. 2 YRS POST OP XRAYS SHOWING
FRACTURE UNITED WITH IMPLANTS
IN SITU

37. CLINICAL PHOTOGRAPHS OF SAME
PATIENT AT 2 YRS FOLLOW UP
SHOWING RANGE OF MOTION

38. CASE 3
( A) Type 2C floating knee.
( B ) The femoral fracture was treated with
dynamic compression screw and the tibial
fracture was treated with plating.
Union occurred 12 months postoperatively.

39. COMPLICATIONS
A- EARLY COMPLICATIONS

40. B- LATE COMPLICATIONS

41. SOURCE AND REFERENCES
1. Blake R, McBryde A Jr. The floating knee: ipsilateral fractures of the tibia
and femur.
South Med J 1975;68:13-16.
2. F raser RD, Hunter GA, Waddell JP. Ipsilateral fracture of the femur and
tibia.
J Bone Joint Surg [Br] 1978;60-B:510-515.

42. THANK YOU