Introduction

Floating knee injury is a term used to denote ipsilateral femoral and tibial metaphyseal injuries. But recent literature has however expanded this term to include most ipsilateral fractures of the femur and tibia. They usually occur due to high energy trauma. These are always associated with high morbidity. There are no clear guidelines for the management, as per the available literature. The implant of choice needs to be determined depending on nature of fracture and soft tissue injuries. The incidence of floating knee injuries was reported as 2.6 % of all fractures by Letts et al[1]. These injuries were associated with life threatening injuries such as head injuries, chest injuries and abdominal injuries as shown by Veith [2].

There was extensive soft tissue damage of the limb as well. The soft tissue injuries can also be variable from minor abrasions to grade III open injuries. Injuries to the neurovascular structures add a treacherous component to the whole picture. This often perplexes even the most experienced clinicians in the planning of management.

Material and Methods

A prospective study was conducted in Department of Orthopedics and Traumatology, Gandhi Medical College and Hamidia Hospital, Bhopalfrom Sept 2014- Sept 2016. Thirty non-consecutive patients with ipsilateral femur and tibia fractures who fulfilled the inclusion criteria were included in the study.

The patients were classified according to Blake and Mcbryde’sClassification for floating knee injuries [3].

Inclusion criteria:

1.Patients with age >15 and <70

2.Recent history of trauma (within 1 week)

Exclusion criteria:

1.Patients with age <15 and >70

2.Pathological fractures

3.Associated contralateral hip and ankle injuries.

All patients were managed in emergency department as per ATLS protocol. In Open fractures wound wash and irrigation was done with minimum of 5L of sterile normal saline. Broad spectrum antibiotics were given and prophylactic tetanus toxoid was given. Open fractures were classified according to Gustilo and Anderson classification [4].

Once the patient was stable the femur fracture was fixed prior to the tibia fracture. Thromboprophylaxis was initiated in all patients during the postoperative period. Physiotherapy was started as soon as the pain subsided. Non weight bearing walking using crutches was permitted after 2 weeks, followed by partial weight bearing. Full weight bearing was allowed only after clinical and radiological union had been confirmed.

In the present study also, road traffic accidents was the cause in all 30 patients (100%). Adamson et al in their study encountered 71% major associated injuries with 21% vascular injuries [8]. Hee et al described similar results in their study [9]. In this study right sided injuries (60%) were more common than left sided injuries (30%). Among the femur fractures 18 (60%) were closed, open grade II were 2 (6.6%), open grade III A were 5 (16.6%) and grade III B were 5 (16.6%). Among the tibia fractures, closed were 12 (40%), open grade II were 5(16.6%), open grade IIA were 3 (10%), open grade III B were 8 (26.6%) and grade IIIC were 2 (6.6%). Hee et al had described that comminuted and segmental fractures were poor predictors of the functional outcome [9].

Fraser found that poor functional outcome was seen in intraarticular fractures [7]. Similar results were shown by Bansal et al [10]. In our study, 17 (28.3%) cases had intraarticular fractures and 13 cases had extrarticular fractures.Blake and McBryde [3] were one of the pioneers to classify floating knee injuries. After an extensive study, they had classified floating knee injuries as Type I fractures involving both shafts, Type II A- fractures involving the knee joint, Type IIB- fractures involving the hip or ankle joints. In this study we had 20 (66.66%) of type-I, 10 (33.33%) of type-IIA and none (0%) cases were type-IIB injuries as per Blake and McBryde.

There are only few studies in literature which shows specific treatment for floating knee injuries. Initially non operative management was described by Ul-Haque et al in 1983 [11]. In 1984 Katada et al described that both femoral and tibial fractures, must be fixed rigidly [12].. In 1986 Letts et al 1described that at least one fracture should be rigidly fixed either internally or externally, usually the femur. Femoral fixation and non operative management for associated ipsilateral tibial fractures by plaster of paris was described by Bansal et al 10 in 1984. Flexible intramedullary nails were described by Behr et al in 1987 [13].

Soft tissue sparing surgery like percutaneous plating was described by Lobenhoffer 1996 [14]. Single incision nailing for both tibia and femur was described by Rethnam et al in 2006 [15]. Dwyeret al 2005 described that the preferred method of fixation in both femoral and tibial diaphyseal fracture was intramedullary nailing [16]. In study done by Gregory et al in 1996, he described retrograde nailing of the femur and undreamed nailing for the tibia [17].

In our study, all fractures were fixed rigidly Retrograde intramedullary nailing was done in 2 ( 6.6% ) antegrade nailing in 16 cases and plating in 12 cases of femur fractures. Among the tibial fracture 2 (6.6%) were fixed with External fixators out of which both had poor outcome. 12 patients were treated with plating and they had good outcome. 16 patients were treated with intramedullary nailing and out of which 9 patients had either excellent or good outcome. Infection was the most common complication seen in 33% patients .The complications were found to be more in open fractures. Scheidts et al conducted similar study for malunion [18].