International

International Orthopaedics (SICOT) (1984) 8: 183-187

Orthopaedics
Springer-Verlag 1984

The Floating Knee. 40 Cases of Ipsilateral Fractures of the Femur

and the Tibia
V. P. Bansal, V. Singhal, M. K. Mam and S. S. Gill
Department of Orthopaedic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh- 160012, India

Summary. "Floating knee" is the term used to describe simultaneous fractures o f the femur and tibia
in the same limb. Thirty nine patients, with 40 such
injuries, are presented with a follow up interval o f
six months to five years. The finalfunctional result
was poor if the femoral fracture was situated in the
condylar flare and the results were comparatively
better in those cases treated by cast bracing or when
the fracture o f the femur was stabilised internally.
In all cases the fracture o f the tibia was treated conservatively.

R/~sum~. Sous le terme de genou flottant~> les

auteurs dbcrivent les fractures simultanbes du fkmur
et du tibia au niveau du m6me membre. Ils
prbsentent 40 lbsions de ce type, chez 39 sujets, avec
un recul compris entre six mois et cinq ans. Le
rbsultat fonctio~nel est m~diocre lorsque le si~ge de
la fracture du fbmur est juxta-articulaire. Comparativement, les rksultats sont meilleurs lorsque la fracture du fkmur a ktk immobiliske dans une attelle
pl6trke ou stabiliske par ost~osynth6se. Toutes les
fractures du tibia ont ktk traitkes orthopkdiquement.

The purpose of this article is to present a critical analysis of floating knee injuries treated at our
Institute, and to evaluate the final functional result in relation to the various modes of treatment
that were undertaken. An opportunity has also
been taken to analyse the effect upon the final result of different sites of femoral and tibial fracture.

Material and Methods

During a five-year period (January, 1977, to January, 1982),
58 cases of "floating knee" injury were treated at the Nehru
Hospital, Chandigarh, India, but the detailed records and follow-up of only 40 cases (39 patients) were available for analysis. Four cases where below knee amputation had been performed on account of vascular injury and gangrene were excluded, as were cases where either the fracture of the femur or
of the tibia was intra-articular.
Particular attention was paid to the age and sex of the injured patient, the type of trauma, the site and type of femoral
and tibial fractures, the method of treatment employed, the
time taken to achieve union and any complications that were
encountered. The final functional result was classified according to the criteria of Karlstr6m and Oleurud [4].

Key words: Fractures, Tibia, Femur, Ipsilateral

The term "floating knee" may be applied when

there are simultaneous fractures of the femur and
tibia on the same side of the body. Some of the
problems presented by this pattern of injury have
been recorded in the literature [1~9] but the present report is probably the first based on an Indian
population.
I-

Address offprint requests to:V. P. Bansal

I I ~.

IIb.

Fig. 1. Radiological classification of the Floating Knee

III.

184

V. P. Bansal et al.: The Floating Knee

AVAILABLE

PROCEDURES :

Table 1. Age and sex distribution

Age group
Male

Fig. 2. Various modes of the treatment 1. Internal fixation of

both fractures. 2. Internal fixation of the femoral and cast immobilization of the tibial fracture. 3. POP immobilization of
both the fractures. 4. Cast bracing
In addition the outcome was analysed in relation to the
site of femoral and tibial fracture, and for this purpose the injuries were divided into three groups, (Fig. I):
Group I: Neither of the fractures were juxta-articular, i.e.
the fractures did not involve the condylar flare of
the respective bones.
Group II: One or other of the fractures was juxta-articular.
This group was further divided into two subgroups, i.e. II(a) when the femoral fracture involved the condylar flare and II (b) when the tibial
fracture involved the condylar flare.
Group III: Both fractures were juxta-articular.

No. of cases
Female

Upto 10

11-20

21-30
31-40
41-50
51-60
61-70
71-80
81-90

19
8
1
1
1

2
5

2*
-

21
8
1
1
1

* Includes one bilateral Floating Knee injury

Table 2. Type of injury

Type

No. of cases

1. Road traffic accident:

a. Pedestrians
b. Motorcyclists

20*
16

Total:

36

2. High energy moving machines:

a. Grinding machine
b. Tubewell
c. Thrashing machine

1
1
1

Total:
Results

Age and Sex of the Patient (Table I)

Thirty-six of the patients were in road accidents,

o f w h i c h 20 w e r e p e d e s t r i a n s s t r u c k b y cars.

Table 3. Site and type of fracture

Site
Femur
Tibia

Site and Type of Fracture (Table 3)

O f a t o t a l o f 40 " f l o a t i n g k n e e s " , 29 o c c u r r e d o n
t h e r i g h t side. T h e m i d s h a f t r e g i o n o f t h e b o n e
w a s m o s t c o m m o n l y i n v o l v e d (28 f e m o r a , 23 t i b iae).

Associated Injuries (Table 4)

The floating knee injury was commonly associated with other severe injuries, a n d a head i n j u r y
w a s p r e s e n t i n 12 o f t h e 39 p a t i e n t s . O n e p a t i e n t
had bilateral knee injuries.

* Includes one bilateral "floating Knee"

T h e m o s t c o m m o n age g r o u p w a s f r o m 2 1 - 3 0 years. M a l e s w e r e m o r e c o m m o n l y i n v o l v e d .

Type of Injury (Table 2)

Total

Closed

Subtrochanteric 2 1 3
Mid shaft
23
Supracondylar 5
Upper Third
3
Mid Third
6
Lower Third
2

Open

Total

5
4
4
17
8

28
9
7
23
10

Table 4. Associated injuries

Injury

No. of cases

Head injury
Abdominal injury
Chest injury
Bilateral Floating Knee
Contralateral limb fractures
Upper limb fractures

12
4
3
1
6
5

V. P. Bansal et al.: The Floating Knee

185

Final Functional Result

Table 5. Time of union

Fracture

Duration
(in weeks)

Type of fracture
Closed
Open

Femoral fractures

< 13
13-24
> 24
< 13
13-24
> 24

20
10
0
6
3
2

Tibial fractures

The final functional results were matched against

two variables, namely the type of treatment and
the site of the femoral and tibial fractures, (Tables
6 and 7). Simultaneous treatment of both shaft
fractures with a hip spica produced worse results
than treatment by open ireduction and internal
fixation, or treatment with a cast brace. Group
II(a), with the femoral fracture adjacent to the
knee joint, had the highest rate of poor results.

8
2
25
4

Complication
Rate of Fracture Healing (Table 5)
Most of the closed femoral fractures (20 out of 30)
united within 12 weeks and a further 10 closed
femoral fractures and eight open femoral fractures united within 24 weeks. The remaining two
open femoral fractures developed non-union
which required treatment by bone grafting and a
spica cast.
Six of the tibial fractures developed non-union
and required Phemister grafting. The remaining
tibial fractures united within 24 weeks.

Out of the initial 58 cases there were two deaths in

hospital. Fat embolism was not seen in any patient. Local complications are listed in Table 8.
Discussion

Simultaneous ipsilateral fracture of the femur and

tibia is not a very common injury. In our hospital
58 cases were seen in a five year period, compared with 17 in a two year interval reported in
another series from Boston [6].
The injury is caused by high energy violence,
usually a traffic accident [1, 2, 4, 7]. In the present

Table 6. Final functional results* V / S Type of treatment

Mode of treatment

Total
No. of
floating knees

Excellent

Good

Open reduction and internal fixation

of femur and closed reduction and casting of tibia
2. Closed Reduction of both fractures and hip spica
3. Initial traction followed by functional
cast bracing

12

23

13

1.

Acceptable

Poor

* Classified according to Karlstr6m and Oleurud [4]

Table 7. Final functional results* V/S Site of fracture

G r o u p Site of fracture
1. None of the fractures in-the vicinity of
the knee joint
2. One of the fractures (either femoral or
tibial) in the juxta articular position
a. Femoral fracture
b. Tibial fracture
3. Both the fractures the juxta-articular
position
* Classified according to Karlstr6m and Oleurud [4]

No. of cases

Excellent

Good

Acceptable

18

10

11
6

0
0

4
4

4
2

Poor

186
Table 8. Local Complications
Popliteal vessel injury
Lateral poptiteal nerve
Post tibial nerve injury
Non union
Osteomyelitis
Unacceptable deformity (angulation > 20 )
Knee stiffness
(movement restricted beyond 40 of flexion
Unacceptable shortening (> 3 cm)

series 36 of the 39 patients were involved in road

accidents and the remaining three sustained injuries from rotating machinery. The latter mechanism has not been mentioned in the literature previously as a cause of this type of injury. It appears
that the loose clothing of the victim becomes entangled in unprotected driving belts, dragging his
body towards the wheel, perhaps causing a double
impact and thereby giving rise to the pattern of injury sustained.
The mortality after admission to hospital is
low in this series, only two patients out of 58,
which is in contrast to the 13% mortality reported
by Gilquist [2]. The low death rate in our series
may be attributable to the more severely injured
patients dying before reaching hospital on account of poorly organised accident services.
The literature describes three main patterns of
treatment and these were also employed in our
patients.
i. Open reduction and internal fixation of both
fractures.
ii. Open reduction and internal fixation of the
femoral fracture and conservative treatment
of the tibial fracture.
iii. Conservative treatment of both fractures, either by means of a hip spica or cast bracing
after a period of initial traction.
According to Leach [6], the choice of treatment depends upon two factors, namely:
i) The skill of the surgeon and the availability of
facilities.
ii) The associated injuries.
,
In the present series the femur was stabilised
with a Kiintscher nail in 12 out of 40 cases. The
remainder were treated by conservative means
with initial traction followed by a hip spica in 23
cases, or cast bracing in five cases. None of the
tibial fractures were treated by internal fixation as
the majority of the fractures were compound (29
out of 40). Reduction and stabilisation was
achieved in all and our experience agrees with

V. Po Bansal et al.: The Floating Knee

that of Leach [6], who felt that the fractured tibia

rarely needs internal fixation. Facilities for alternative forms of treatment, such as closed intramedullary nailing or the use of an external fixator, were not available in our hospital, although
these techniques might well be appropriate in the
management of such high velocity injuries.
When the final functional result was analysed
against the mode of treatment, it was found that
conservative treatment of both bones gave acceptable results in 24 out of 28 cases. On the other
hand, open reduction and internal fixation of the
femoral fracture with a Kiintscher nail and conservative treatment of the tibial fracture resulted
in good or excellent function in 11 out of 12 cases.
Thus the results in both groups were very similar
and the choice of treatment for the femoral fracture should be decided only by the type of fracture and the nature of any associated injuries.
It appears that the results of cast bracing were
better than those of conventional conservative
treatment of both femoral and tibial shaft fractures or operative treatment of the femoral and
conservative'treatm~ent of the tibial fracture. However, the present series is too small to permit a satisfactory statistical comparison. The treatments
recommended in the literature vary very widely,
Ratliff [8], Karlstr6m and Oleurud [4] and Hojer
et al. [3] report excellent results following internal
fixation of both fractures and according to these
authors the final functional result is better following early surgery, and the period of hospitalisation is shortened. In contrast Winston [9] recommended conservative treatment of both fractures
as he felt that this was a safe and satisfactory
method and avoided the risk of infection.
Fraser [1] and Leach [6] are of the opinion that
the femoral fracture should be neutralised by internal fixation but the fractured tibia could easily
be managed by conservative means.
It would therefore seem that once the general
condition of the patient has been stabilised the
management of the fractures should be based on
the prevailing circumstances and the surgical resources available.
Another factor correlating with the final functional result in this series was the site of fracture
(Table 7). It was found that the presence of a juxta-articular fracture hampered knee movement resuiting in a poorer result. In Group I, where there
was no juxta-articular fracture, there were no
poor results among 10 knees, whereas in Group 2
there were three poor results out of 17 injuries and
these all occurred with juxta-articular femoral

187

V. P. Bansal et al.: The Floating Knee

fractures, probably due to involvement of the suprapatellar pouch with adhesions resulting in severe knee stiffness. This should be avoided if early
mobilisation of the knee is undertaken using a
functional cast brace or by rigid internal fixation
of the fracture.

References

1
2
3

Fraser RD, Hunter GA, Waddel JP (1978) Ipsilateral fracture of femur and tibia J Bone Joint Surg (Br) 60:510-515
Gilquist J, Reiger A, Sjodahl R, Bylund P (1973) Multiple
fractures of a single leg, a therapeutic problem. Acta Chir
Scand 139:167
Hojer H, Gilquist J, Liljedahl SO (1977) Combined fractures of femur and tibial shafts in the same limb. Injury 8:
206-212

5
6

8
9

Karlstr6m G, Oleurud S (1977) Ipsilateral fractures of

femur and tibia. J Bone Joint Surg [Am] 59:240-243
Leach RE, Meyn AM, Banks HH, Walker G, Quigley TB
(1973) Results of treatment of Ipsilateral femoral and
tibial fractures. J Bone Joint Surg 55-A: 1976
Leach RE (1972) Current Orthopaedic Management. In:
Kane WJ (ed), Churchill Livingstone, London, pp
123-141
Omer GE, Mule JH, Bacon WL (1968) Combined fracture
of femur and tibia in single extremity, analytical study of
cases at Brook General Hospital from 1961-67. J Traumatol 8:1026
Ratliff AHC (1968) Fractures of Shaft of femur and tibia
in the same limb. Proceedings of Royal Society of Medicine 61 : 906-908
Winston ME (1972) The results of conservative treatment
of fractures of femur and tibia in the same limb. Surg
Gynecol Obstet 134:985-991