Ipsilateral Floating Hip and Floating Knee - A Rare Entity.

INTRODUCTION: Ipsilateral floating hip and floating knee are very rare injuries. These injuries so uncommon that only three cases of similar kind have been reported. These injuries are due to high velocity injuries following motor vehicle accidents. Management of such complex injuries is a challenging task even in experienced hands as there are no standard treatment guidelines for such fractures. CASE REPORT: We hereby report a 20 yr old male who sustained ipsilateral floating hip and ipsilateral floating knee injuries following motor vehicle accident. Patient was stabilized initially and later taken up for surgery. Patient was treated with interlocking nail for femur and tibia in the same sitting whereas acetabulam fracture was managed conservatively. At five months all the fractures united well with restoration of good range of motion in both hip and knee.
CONCLUSION: Ipsilateral floating knee and floating hip are very rare injuries seen following high velocity motor vehicle accidents. There are no standard guidelines for treatment of those fractures as only a few cases of similar kind have been reported in literature. Early fixation and aggressive mobilization ensures fracture union and fewer complications.

Introduction

Ipsilateral floating hip and floating joint injury is a simultaneous skeletal disruption above and below a joint. Floating knee and floating hip occurring individually are not rare. Ipsilateral floating knee and floating hip are very rare. This type of uncommon fractures results from high energy trauma with a complex mechanism of injury[1]. To best of our knowledge only three cases of similar kind have been reported in literature [2-4]. Management of such injuries is a challenging task even in experienced hands. We hereby report a twenty year old patient who sustained ipsilateral floating knee and hip injury on right side following a motor vehicle accident.

Case Report

A 20 year old male travelling in a motorcycle struck a car and sustained injuries to right lower limb. Patient had pain and deformity in right lower limb immediately following trauma. Patient was not able to walk and was taken to hospital by bystanders. There were no clinical features suggestive of head injury. Abnormal mobility and crepitus was seen in thigh and leg. There were no open wounds over right lower limb. There were no neurovascular deficits distally. Patient was haemodynamically stable when received in casualty. Lower limb was splinted and adequate analgesics were given. Radiographs revealed undisplaced posterior column fracture and displaced femoral shaft fracture at distal third [Fig 1]. Displaced tibia shaft fracture of mid third was seen on the same side [Fig 2]. CT scan pelvis confirmed undisplaced posterior column fracture and ruled out other injuries [Fig 3-4].

Figure 1

Preoperative photograph showing tibia fracture

Figure 2

Preoperative photograph showing femur fracture

Figure 3

Preoperative radiograph of hip joint

Figure 4

Undisplaced posterior coloumn fracture seen on CT scan

Patient was taken up for surgery next day. Interlocking of the tibia was done first in supine position without fracture table. Patient was put on a fracture table and interlocking of femur was performed. Posterior column fracture stability was checked after femur and tibia nailing under fluoroscope and was found to be stable. Acetabulam fracture was planned for conservative management. Patient was advised bed rest for six weeks.

At six weeks bone grafting of femur fracture was done from iliac crest due to cortical defect on medial side. Patient was started on partial weight bearing after six weeks. Full weight bearing was started at three months. All the fractures united by five months and patient returned daily activities [Fig 5-8]. At one year follow up patient is walking full weight bearing without aid and had good range of motion in both hip and knee joints [Fig 9-10]. There was no leg length discrepancy, rotational and angular malunion.

Figure 5

United fracture tibia

United fracture femur

Clinical photo with patient lying

Discussion

Floating knee and floating hip injuries render both hip and knee joint unstable both proximally and distally. These types of injuries are high-velocity injuries. The injury usually results from a collision between a pedestrian or a motorcyclist and a motor vehicle as seen in our case [4]. There is enough literature for management floating knee and floating hip, but there is no sufficient literature in the management of simultaneous ipsilateral knee and hip floating injuries [6-8]. Liebergall et al. reported 17 patients with ipsilateral acetabular and femoral fractures [9]. They concluded that operative stabilization of the femur and acetabulam gave the best clinical results, while non-operative treatment of acetabulam fractures had to be the treatment of choice in undisplaced or minimally displaced fractures [9-10]. In our case acetabulam fracture was undisplaced and was stable on dynamic fluoroscopy. Closed reduction and interlocking nailing of both femur and tibia was done.

Many studies are there in literature regarding floating knee injuries. Letts et al. described five patterns of ipsilateral tibial and femoral fractures and made treatment recommendations on the basis of these patterns. Because of high prevalence of complications after closed treatment, operative stabilization of both fractures is recommended even for young children. Veith R G et al treated fifty-seven consecutive ipsilateral fractures of the femur and tibia in fifty-four adults. Twenty-one patients had concomitant life-threatening injuries, and in thirty-three extremities the fractures were open. Local complications included below-the-knee amputation, three deep infections, and four ununited fractures. Mortality rate in floating injuries. Mortality rates from floating knees range from 5% to 15% and amputations are reported in approximately 25% of patients [11-16].

In our case there were no neurovascular complications before and after surgery. There was only restriction of terminal 20 degree of terminal flexion in knee joint on the affected side. We opted not to nail both shaft fractures thorough same incision to avoid knee stiffness which is a notorious complications following such injuries. All the fractures were united by five months and patient was able to do routine daily activity. Patient was able to squat and sit cross-legged. We want to emphasize the advantages of early fixation and aggressive mobilization of such complex fractures. Modern anaesthetic and surgical advances have made early fixation of multiple fractures a realistic and often life saving alternative.

We want highlight through this case report that such injuries are very very rare and only few cases of similar kind have been reported in literature. Early fixation and rehabilitation is the key to avoid complications of multiple injuries.

Conclusion

Ipsilateral floating knee and floating hip are very rare injuries seen following high velocity motor vehicle accidents. There are no standard guidelines for treatment of those fractures as only a few cases of similar kind have been reported in literature. Early fixation and aggressive mobilization ensures fracture union and fewer complications

Although ipsilateral floating knee and hip fractures are rare, the management depends on personality of individual fractures. Rehabilitation should be aggressive and good results can be expected depending on severity of primary trauma.