Emergency Medicine

308 Orthopaedic Emergencies

INJURIES TO THE LOWER FEMUR, KNEE AND UPPER TIBIA

MANAGEMENT

1 Refer the following to the orthopaedic team, having given adequate analge-

sics:

(i) A tense effusion, including all haemarthroses with a suspected

associated fracture.

(ii) A ‘locked’ knee with sudden loss of ability to extend the knee

fully.

(iii) A suspected torn cruciate ligament.

(iv) Any penetrating wound of the knee suggested by air or foreign

material in the joint on X-ray (which may be absent).

2 Otherwise, if there is only moderate swelling, a good range of joint movement

and no ligamentous laxity:

(i) Aspirate the knee to reduce pain and improve chances of early

mobilization (see p. 492).

(ii) Apply a double-elasticated stockinet bandage to the knee or a

proprietary Velcro™-fitted knee splint.

(iii) Give the patient anti-inflammatory analgesics such as ibuprofen

200–400 mg orally t.d.s. or naproxen 250 mg orally t.d.s.

(iv) Lend the patient crutches to use until the acute symptoms settle.

(v) Review the patient within 5 days.

Dislocation of the knee

DIAGNOSIS AND MANAGEMENT

1 This severe injur y is an ort hopaedic emergency.

2 It is associated with up to 30% incidence of damage to the popliteal vessels

and lateral popliteal nerve, so requires urgent reduction.

3 Insert an i.v. cannula, administer opiate analgesia, check the distal pulses,

X-ray and refer immediately to the orthopaedic team.

Fractures of the tibial condyles

DIAGNOSIS

1 These fractures are caused by falls from a height, or severe lateral or medial

stresses, which in addition may rupture the knee ligaments.

2 A tense haemarthrosis is usual and precludes further detailed examination

of the knee due to pain.

3 Always check for vascular damage by palpating the foot pulses.

4 Check for a lateral popliteal nerve palsy by testing for active foot dorsif lexion

and eversion, and sensation over the lateral aspect of the calf.

5 Request an X-ray to show the tibial condyle fracture either laterally or (rarely)

on the medial side, although sometimes they are subtle and difficult to see.