Nigerian Journal of Orthopaedics And Trauma

December 2006: 5(2):50 - 53

Floating knee with ipsilateral floating hip injury equivalent

variant: A Case report
* Essoh J.B. Si MD, M. Kodo MD, A. Traor MD, C. Mobiot MD, Y. Lambin MD.
Summary
This report describes a rare case of concomitant
ipsilateral pelvic disruption, hip dislocation,
a femoral shaft fracture, supra and intercondylar
fracture of the femur, and tibial shaft fracture in a
young man who suffered a fall from a moving truck.
The hip dislocation was reduced under general
anaesthesia with a closed procedure. Both femoral
shaft and distal femoral fractures were reduced and
stabilised with a Judet screw-plate via a
posterolateral approach to the femur. The other
fractures were treated conservatively. Emphasis
was placed on the complex injury around the hip.
The surgical management of this constellation of
injuries combining a floating knee and a variant of
floating hip is discussed in the light of the current
principles of management of a multiply injured
patient. The authors propose the inclusion of the
peculiar injury pattern occurred around the hip in
the existing classification systems for floating hip.
Key words: Damage control orthopaedic, Floating
hip, Floating knee, Polytrauma
Introduction
Combined injuries to the lower limbs are almost
always indicative of high energy injury and
associated with life threatening conditions for
which damagecontrol orthopaedics should be
1-6
considered in most cases. Various patterns of
combined skeletal injuries have been reported.1,7
Current literature suggests that both floating hip and
8-11
floating knee injuries are uncommon and severe.
The case report presented here describes a patient
who sustained
in the same limb mainly a pelvic disruption, a hip
dislocation, a femoral shaft fracture,
a supra and intercondylar fracture of the femur, and
a tibial shaft fracture.
Since the long-term prognosis after any hip
Essoh J.B. Si MD, M. Kodo MD, A. Traor MD, C. Mobiot MD, Y.
Lambin MD.
Department of Orthopaedic Surgery, Yopougon University
Teaching Hospital 21 BP 632 Abidjan 21 Cte d'Ivoire Tel: (225)
23-53-75-50 Fax: (225) 23-53-75-60
* siessoh@yahoo.com

dislocation, especially in polytrauma patient must

remain guarded12, and it has been suggested that
lower extremity fractures have a major impact on a
patient's functional recovery following
13
polytrauma , the purpose of this report was to
analyse the patterns of lesions encountered and
highlight the relevant principles necessary to allow
a sound surgical management in our context of this
multiply injured patient by focusing on sequencing
of fracture reduction and implant selection.
Case Report
A 24-year-old male injured his pelvis and left lower
limb when he fell off a moving truck.
He could not recall the exact mechanism. Five hours
later he was transported from the scene of the
accident to the emergency room of the author's
institution. Upon admission, he was conscious but
haemodynamically unstable. The left lower limb
was short and exhibited abduction and external
rotation. He had a marked swelling and pain through
the hip to the leg. The dorsalis pedis was palpable.
Plain radiographs performed after an intensive
resuscitation revealed a bilateral iliosacral
dislocation, the left obturator ring fracture, an iliac
dislocation of the left hip (Fig. 1).

Fig 1. X-ray showing pelvic injuries

and dislocation of the left hip.

Other radiographic findings located on the left side

were a transverse diaphyseal femoral fracture, a
supra and intercondylar fracture of the distal femur, a
nondisplaced fracture of the patella, a comminuted
fracture of the tibial shaft (Fig.2 and 3), and a
fracture of the medial malleolus. Surgery was
50

Essoh J.B. Si, M. Kodo, A. Traor C. Mobiot, Y. Lambin.

undertaken within 12 hours of assessment by the

orthopaedic team. Under general anaesthesia, the
patient lying in a supine position, the hip dislocation
was reduced with a closed procedure (Fig. 4). Then,
the noncontiguous fractures of the femoral shaft and
distal femur were addressed via a posterolateral
approach to the femur and fixed with a Judet screwplate (Fig. 5). The patellar fracture was not fixed and
the fracture of the tibia and the medial malleolus
were stabilised with a plaster splint. Radiographs of
the knee after operation revealed a superior
proximal tibiofibular dislocation (Fig. 3) that was
not seen on the initial X-ray. Postoperatively, a skin
traction was applied to the right lower limb.
He was progressing well so far, but the operation of
the tibiofibular dislocation had not been considered
yet.

pelvic fracture is associated with an ipsilateral

femoral fracture. In the second group, the true
floating hip injury, an acetabular fracture is
associated with an ipsilateral femoral fracture.1,8,9
Our patient's hip injuries can be considered as a
complex form of the floating hip, which to our
knowledge does not fit into the existing
classification.1,8,9 The intermediate segment was
disconnected proximally by the pelvic disruption
and the dislocation of the hip. Distally,

Fig 4. Reduction of the hip dislocation

Fig.2 Left femoral shaft, ipsilateral

supra and intercondylar and
Fig.3 Left tibial shaft fracture
patelar fractures
and the proximal tibiofibular
joint dislocation

Discussion
The overwhelming lesions sustained by our patient
involved several different skeletal units
in the same limb. A host of combined injuries
14-16
patterns can be inferred from this case.
It is our opinion that the striking lesions exhibited by
our patient were: (a) the floating knee injury with
intra-articular extension; (b) the ipsilateral hip
dislocation associated with a pelvic disruption and a
femoral diaphyseal fracture. This extremely rare
constellation of injuries seems not to have been
previously reported in the literature. Such a
distribution of lesions enables one to discuss the
type of injury around the hip. Floating hip injuries
tend to cluster into two groups. In the first pattern, a

NJOT December 2006 Vol 5 No 2

the separation occurred through the femoral shaft

fracture. The posterior type acetabular fracture
(i.e. posterior wall or transverse with posterior wall
fractures) as reported by Liebergall et al1,8 was not
encountered in our case. Such lesions are frequently
seen in the setting of a posterior dislocation of the
hip. We assume even if the posterior
type acetabular fracture lacks that the iliac
dislocation sustained by our patient fuels this kind of
fracture. Interestingly, the diaphyseal location of the
femoral fracture in a transverse fashion and the
associated patellar fracture lend credence to the
17
possibility of a posterior injury pattern. The
superior proximal tibiofibular dislocation, rare event
sustained by our patient and associated with tibia
fracture indicates high energy injury.18 The
management of each of these injuries in isolation has
been well described, however when managed
together there are unique challenges. The goal of
modern trauma in multiply injured patients with hip
dislocation is early reduction of the dislocation with
stable fixation of the fractures.12

51

Fig 5. Fixation of the femoral fractures

with a Judet screw-plae

Closed reduction of the hip dislocation under

general anaesthesia prior to fixation of the femoral
fracture as outlined by Liebergall et al1 along with
Harper15 was performed successfully. This has
allowed us to draw up carefully the plan of treatment
of the remaining fractures. Since the patient was
critically injured and found unable to withstand a
prolonged surgical procedure, those fractures that
were thought to be associated with poor outcomes
if left untreated, or without rigid fixation were
16
prioritised. Thus, femoral fractures were addressed
surgically. The other fractures, particularly the tibial
fracture were treated conservatively. We are
however aware that a more aggressive approach to
floating knee is currently advocated. This can be
attractively achieved in most cases via simultaneous
retrograde femoral and antigrade tibial nailing
10,14
through the same incision in the knee.
External
fixator is the favourite tool of trauma surgeons to
achieve temporary stabilisation of the femur in the
protocol of damage control orthopaedics. This
procedure minimises the impact of surgery on the
2,4,6,19
already traumatised patient.
Managing both
sites of femoral fractures with external fixator would
be technically problematic. Regarding
noncontiguous femoral fractures, their orthopaedic
management becomes increasingly complex
because the preferred treatment for one fracture may
jeopardise the reduction and stabilisation of the
16
other. Due to pelvic fractures, the retrograde
nailing though fraught with operative difficulties
and poor outcome in the event of distal femoral
14
fractures with involvement of the knee joint is
regarded as one of the well-tried methods to tackle

NJOT December 2006 Vol 5 No 2

such a combination of fractures.7,20 The Judet screwplate occupying a firm place in the armamentarium
of techniques in the management of distal femoral
21
fractures in our context was therefore used for both
shaft and distal femoral fractures. In conclusion,
after coming across what we believe to be a unique
case of ipsilateral floating knee and hip dislocation
associated with a femoral shaft fracture, we have
pointed out the countless dilemma the surgeon will
be faced with, when dealing with this peculiar injury
pattern. Although the general principles of damage
control surgery have been followed in the
management, it is crucial to stress that the treatment
protocol we described is inherently our team
approach with the surgeon as the team leader. The
optimal treatment of both floating hip and floating
knee injuries should be undertaken without
compromising the treatment of either. We suggest
inclusion of injury around the hip featured by our
patient as a variant in the classification systems for
floating hip injuries.
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