INITIAL EVALUATION OF THE ACUTE

MULTIPLE-LIGAMENT-INJURED KNEE
TIMOTHY C. WILSON, MD, and DARREN L. JOHNSON, MD

The multiple-ligament-injured knee is an orthopaedic emergency. The initial assessment of this injury must
include a thorough and expedient physical examination, with particular attention directed to the vasculari~ of the
extremity. Vascular injuries should be ruled out immediately because a pulseless extremity may result in a below-
knee amputation if the leg is not reperfused within 6 to 8 hours. All patients with a normal vascular examination
must have serial pulse examinations or undergo an arteriogram, because intimal tears may present on a delayed
basis. The neurological examination, particularly of the peroneal nerve, should be documented. A detailed
examination of the knee ligaments is performed on the anterior cruciate ligament, posterior cruciate ligament,
medial collateral ligament, and posterolateral anatomic structures. Initial and postreduction radiographs require
thorough evaluation to assess for peri-articular fractures, direction of dislocation, and adequacy of reduction.
Magnetic resonance imaging will provide detailed information about the ligaments, bone or subchondral bone,
menisci, and articular cartilage. The physical examination must be correlated with the magnetic resonance imaging
findings for preoperative planning. This article provides a treatment algorithm that can be helpful in the initial
assessment and decision-making process of the multiple-ligament-injured knee.
KEY WORDS: knee dislocation, multiple-ligament-injured knee, vascular injury
© 2003 Elsevier Inc. All rights reserved.

A knee dislocation is one of the few true orthopaedic DEFINITION OF INJURY

emergencies. The initial management of these injuries
must be thorough and expedient. Failure to recognize the
full extent of these injuries may have disastrous compli-
cations. Although a knee dislocation leading to a multi-
ligament-injured knee is relatively uncommon, a multiple-
ligament-injured knee has a high rate of associated injuries
that may be limb threatening. The actual incidence of these
injuries is unknown because most of these injuries present
spontaneously reduced and, therefore, are often misdiag-
nosed. Consequently, the treating physician must have a
high index of suspicion. To appropriately diagnose and
treat these injuries, the treating physician must have a full
understanding of knee dislocations, their associated inju-
ries, and their potential complications.
An appropriate history with a thorough physical exam-
ination is helpful in making the correct diagnosis, which
will direct the next course of action. Specific tests such as
radiographs, magnetic resonance imaging, and angio-
grams will provide useful information for diagnosis and
management. Once a limb-threatening injury has been
ruled out, a preoperative plan can be established to ad-
dress the ligament injuries. This article presents basic in-
formation on knee dislocations, and provides a treatment
algorithm for the initial evaluation of multiple-ligament
knee injuries.
From the Kentucky Clinic, Lexington, KY.
Address reprint requests to Darren L. Johnson, MD, University of
Kentucky School of Medicine, The Kentucky Clinic, K415, Lexington, KY
40536-0284.
© 2003 Elsevier Inc. All rights reserved.
1060-1872/03/1103-0003530.00/0
doi:10.1053/otsrn.2003.35912
Many knee dislocations (>50%) spontaneously reduce be-
fore a physician's evaluation. Therefore, the term "multi-
pie-ligament knee injury" may be more appropriate. A
true knee dislocation implies complete displacement of the
tibiofemoral articulation. This is seldom seen. For practical
consideration, a knee with 2 or more ligaments completely
disrupted should be classified as a multiple-ligament in-
jury or knee dislocation. 1 This diagnosis should alert the
examiner to associated injuries and their potentially dev-
astating complications.
INCIDENCE
The true incidence of knee dislocations is unknown. Most
authors agree that the actual incidence is higher than the
0.001% to 0.013% per year published in the literature. 2
Spontaneous reductions, other distracting injuries, and
examiner inexperience may account for this diagnosis of-
ten being overlooked. All knees with 2 or more ligaments
completely disrupted should be classified as a multi-liga-
ment knee injury, requiring the treating physician to eval-
uate for secondary associated injuries with an appropriate
examination and ancillary tests.
CLASSI FICATION
Historically, knee dislocations are classified according to
the position of the tibia in relation to the femur. Kennedy's
classification system described knee dislocations as ante-
rior, posterior, medial, lateral, and rotational. Anterior
dislocations are the most common (40%), followed by
posterior (33%), lateral (18%), medial (4%), and rotational
(5%).3 This classification system is limited because most
dislocations spontaneously reduce.

Operative Techniques in Sports Medicine, Vol 11, No 3 (July), 2003: pp 187-t92 1 87

 Schenk describes a classification system based on what
ligaments are torn. A KD I is an anterior dislocation with
the anterior cruciate ligament (ACL) torn and the posterior
cruciate ligament (PCL) intact. A KD II involves the ACL
and PCL with the collaterals intact. A KD III M is an ACL,
PCL, and medial collateral ligament (MCL) injury, and a
KD III L is an ACL, PCL, and lateral injury. A KD IV
involves injury to all 4 ligaments. 4 This classification was
modified by Wascher to include a KD V, which includes a
peri-articular fracture. 5 The KD classification is useful with
regards to a specific ligament diagnosis.
In addition to the anatomic classifications, there is a
difference between high energy and low energy with re-
gards to associated injuries. Low-energy dislocations have
been shown to have a much lower incidence of associated
injuries, with vascular injury rates of 5%, meniscal injury
rates of 20%, and an osteochondral fracture rate of 5%. 6 In
high-energy dislocations, the rate of popliteal artery injury
ranges from 14% to 65%. Fifty to 60% of patients will have
fractures, and 41% of patients will have multiple fractures.
Patients with these high-energy injuries often have other
significant injuries to their head or chest, which precludes
early aggressive treatment of their knee ligaments. 5
The chronicity of the injury is also important with re-
gards to associated injuries and surgical planning. Surgical
treatment gives improved results in acute versus chronic
cases. Some structures may be repaired if treated acutely,
whereas late treatment may require a reconstruction pro-
cedure. Although there is no official classification with
regard to timing, a knee dislocation is acute if seen within
the first 3 weeks. Three weeks to 3 months may be con-
sidered subacute, and after 3 months, chronic. 7 This clas-
sification takes into account that the acute knee injury has
tissue that may be more easily repaired within the first few
weeks.
MECHANISM
The mechanism of injury provides useful information with
regards to the direction and degree of injury. Anterior and
posterior dislocations are the most common. These injuries
are caused by force from the opposite direction. For ex-
ample, a posterior dislocation is caused by an anterior
blow to the knee. This injury pattern is commonly seen in
the "dashboard knee." Anterior dislocations commonly
occur from extreme knee hyperextension. This happens
when an anterior blow occurs to the tibia against a fixed
foot, and the femur is forced posterior to the tibia. Medial
and lateral dislocations are most likely to occur in high-
energy accidents with varus and valgus rotational forces. 3
Knee dislocations can occur from a variety of mecha-
nisms and can be divided into high velocity or low veloc-
ity. The most common cause of knee dislocation is a motor
vehicle accident. These traumatic "high-velocity" knee
dislocations can occur as a result of a variety of forces, and
they have a high rate of associated injuries, s Knee dislo-
cations can also result from sports-related, or low-velocity,
injuries. Shelborne reported the most commonly involved
sports were football (35%), wrestling (15%), and running
(10%). Low-velocity knee dislocations have a lower rate of
associated injuries. 6 Industrial accidents and falls are other
common mechanisms. 9
188
Knowledge of each patient's mechanism of injury will
be useful in determining what structures may be injured,
and the potential risk for associated injury.
VASCULAR INJURIES
A knee dislocation should raise suspicion for a possible
vascular injury. The most serious and limb-threatening
injury associated with a knee dislocation is a popliteal
artery disruption or thrombosis. These injuries usually
occur as the result of a traction injury or a complete
disruption. The popliteal artery is the main blood supply
to the lower leg. The intimate anatomical relationship
between the artery and the knee places the vessel at risk.
Proximally, the vessel is tethered at "Hunter's canal" or
adductor hiatus located at the adductor tubercle of the
femur. Distally, the vessel is tethered at the fibrous arch or
trifurcation of the vessels at the soleus muscle. Within the
popliteal space, the popliteal artery gives off the superior
lateral, superior medial, middle, inferior lateral, and infe-
rior medial geniculate arteries. These branches do not
provide collateral flow to the lower leg in the case of a
popliteal artery injury.
Vascular injuries can occur with all types of dislocations.
The risk of arterial injury with knee dislocations is be-
tween 10% and 64o/0.7 Green and Allen reported rupture of
the artery to be as high as 44% with posterior dislocations.
Anterior dislocations are associated with arterial injury as
high as 39%, and the incidence with medial injury was
25% and with lateral injury was 6%. 9 Kennedy showed
that rupture of the popliteal artery occurs when the knee is
forced beyond 50 ° of hyperextension.3 Complete rupture
of the popliteal artery is more common with posterior
dislocations, and anterior dislocations more commonly
cause intimal tearing. The arterial ruptures associated with
posterior dislocations are usually obvious on examination
with loss of distal pulses. The intimal tears of the artery
may present in a delayed fashion and are more difficult to
diagnose. The initial physical examination may be com-
pletely normal in a knee with an intimal tear. Intimal tears
cause a gradual thrombosis, which may propagate to com-
plete arterial occlusion. Therefore, it is recommended that
these patients undergo admission to the hospital for close
observation of their vascular status for 48 to 72 hours. Any
change in vascular status mandates immediate evaluation
and treatment.
The initial physical examination must include assess-
ment of the vascular status of the injured extremity. Ab-
sence of pulses is a vascular emergency. A warm foot with
good capillary refill but absent pulses is not normal. Cap-
illary refill is a poor indicator of blood flow. If the injured
extremity is pulseless for 6 to 8 hours, then permanent
damage may occur, and the amputation rate may be as
high as 86%. This compares to an amputation rate of 13%
when a vascular repair is performed within 8 hours. 9 If the
knee is pulseless and still in a position of dislocation, then
the knee should be immediately reduced and the pulses
reassessed. Persistent absence of the pulses requires im-
mediate vascular surgery consultation. Time should not be
wasted getting an arteriogram in the radiology suite or
arranging any other study. The vascular surgeon can get
appropriate studies, such as an on-table arteriogram, in
WILSON AND JOHNSON
the operating room. A present pulse that is diminished
compared with the contralateral extremity necessitates
further vascular study. As long as the extremity shows
signs of perfusion, such as good capillary refill, appropri-
ate color, and warmth, an angiogram may be performed in
the radiology suite. Abnormal pulses may develop as a
result of vessel spasm, thrombosis, or progression of an
intimal tear.
Though less common, injury to the popliteal vein may
also occur with multi-ligament knee injuries. Richter re-
ported 10 ruptures of the popliteal vein in 89 patients with
knee dislocations, compared with 8 arterial ruptures. 1°
These injuries can present with lower extremity edema,
venous stasis changes, thrombophlibitis, and even death
from a pulmonary embolism. Even though these injuries
are rare, they must be evaluated because of their devas-
tating consequences if missed.
NERVE INJURIES
The incidence of nerve injuries with knee dislocations is
between 16% and 40%J -3 The peroneal nerve is most com-
monly injured, but injuries to the tibial nerve have oc-
curredJ l Injuries to the lateral and posterolateral corner of
the knee place the peroneal nerve at increased risk, be-
cause of its superficial location as it curves around the
fibular head. Posterior dislocations have a high incidence
of nerve injuries. The prognosis of peroneal nerve injuries
is poor. Complete nerve injuries only recover about 50% of
the time. Nerve injuries are generally followed conserva-
tively for 3 months. Of these injuries, about one third will
recover, one third will have minor deficits, and one third
will have a complete palsy. 2
OTHER PATHOLOGY
Open dislocations may occur with 19% to 35% of high-
energy dislocations. 12,~3 The highest incidence of open in-
juries is seen in anterior and posterior dislocations. Cole
and Harner report injuries to the patella tendon or biceps
femoris in 20% of these patients. Fractures of the tibia
plateau occur in at least 10% to 20% of high-energy knee
dislocations. 7 The other pathology must be addressed in
the treatment approach to these injuries.
EMERGENT SURGICAL CONDITIONS
Vascular injuries, open dislocations, irreducible disloca-
tions, and compartment syndromes require prompt diag-
nosis and immediate treatment. Vascular emergencies
have already been discussed. Open dislocations must be
reduced with subsequent irrigation and debridement in
the operating room, and be treated with intravenous an-
tibiotics for 48 hours. Soft-tissue wounds should be eval-
uated for problems with closure, as plastic surgery con-
sultation is sometimes necessary. Lateral knee dislocations
may present as an irreducible dislocation. The medial
femoral condyle may become buttonholed through the
medial retinaculum and present with the dimple sign. TM
This particular type of dislocation may require open re-
duction. Prolonged dislocation in this position may cause
EVALUATING ACUTE MULTIPLE-LIGAMENT-INJURED KNEE
skin necrosis. Compartment syndrome must always be
ruled out, and emergent fasciotomies are required -when
this condition exists or is impending.
INITIAL EVALUATION AND MANAGEMENT
Although some knee dislocations present with obvious
deformity, most multiple-ligament knee injuries spontane-
ously reduce. One must have a high index of suspicion for
these injuries. The patient's history provides essential in-
formation regarding the mechanism of injury and poten-
tial associated injuries. The direction of the force to the
knee and the position of the leg are important variables.
Contact versus noncontact is worth documenting. A high-
energy motor vehicle accident is important to differentiate
from a sports-related dislocation, because of the usual
severe soft-tissue injury and associated injuries. 5,6
After obtaining the history, a thorough physical exam-
ination is performed. Examination of the entire extremity
is critical. A visual inspection should note any obvious
deformity or wound, as well as any subtle changes in skin
discoloration. The presence of a dimple sign or tight com-
partments should also be assessed. A detailed neurovas-
cular examination follows the visual inspection. The dor-
salis pedis and posterior tibialis pulses are palpated.
Never assume that a decreased pulse is normal and the
result of spasm. Ankle brachial indices are assessed; a
decrease of 0.15 or greater indicates a significant vascular
injury, s The patient is also asked to actively dorsiflex his or
her foot and to activate the extensor hallicis longus tendon.
These specific tests assess the peroneal nerve function.
Sensation in all of the nerve distributions, as well as motor
function of the tibial nerve should be examined.
A knee that presents still dislocated should undergo an
expedient examination so that an immediate reduction can
be obtained. Immediate reduction is performed with the
application of longitudinal traction, and this can be facil-
itated by the use of sedatives and analgesics. The presence
of a dimple sign suggests that an open reduction may be
necessary. After a reduction is achieved, a repeat neuro-
vascular examination is necessarv. It is important to doc-
ument all examination finding before and after reduction.
An examination of the mjured ligaments may be per-
formed after reduction. The presence of sedation and an-
algesia will allow the stability examination to be per-
formed. Testing varus and valgus in full extension may
often illicit positive findings in a multiple-ligament-in-
jured knee. Opening to varus or valgus stress in full ex-
tension suggests that one or both of the cruciates as well as
a collateral ligament a n d / o r capsule has been disrupted.
It is important to distinguish between a stable and un-
stable knee injury. Stability is judged on the ability of the
knee to remain in a reduced position. A stable knee may be
immobilized in extension, whereas an unstable knee must
be placed in an external fixator in the operating room.
Postreduction radiographs must be obtained, and the knee
will need to be followed clinically and with radiographs to
assure that reduction is maintained.
After manual or spontaneous reduction of the disloca-
tion, a period of observation is appropriate to watch for
any delayed vascular changes. We prefer to admit the
patient overnight to the hospital. Because of the high
189
 incidence of vascular injuries, an arterial injury should be
assumed until proven otherwise. Signs of obvious vascu-
lar injury, such as pulselessness, coolness, and pallor, re-
quire immediate consultation with a vascular surgeon. If
gross signs are not present, then serial exams may be
performed.
The decision to get routine arteriograms on patients
with a knee dislocation in the presence of a normal exam-
ination is controversial. Many surgeons will argue that the
presence of a normal examination does not rule out an
occult or intimal tear. An intimal tear may clinically
present on a delayed basis. 15,16 Although an arteriogram
procedure is not without complications, most surgeons
agree that the complications of a missed arterial injury are
more severe and outweigh the potential complications of
the diagnostic procedure. Fanelli and Feldman recom-
mend arteriography in patients with acute three-ligament-
injured knees to rule out vascular damage, especially in-
timal tears. 17 Several studies have shown that serial exam-
inations are an effective method of ruling out a significant
arterial injury. Arteriogram studies have shown a rela-
tively low incidence of arterial injury from knee disloca-
tions associated with normal examsJ s-20 Dennis reported
that a physical examination predicted the need for vascu-
lar surgery with 100% accuracy. The 7 minimal arterial
lesions found by arteriography in the 36 patients with a
normal examination were treated nonoperatively.21
Treiman also reported the distal pulse examination to be
100% accurate for identifying patients who will need vas-
cular surgery. This study found the physical examination
to be 85% sensitive at diagnosing an arterial injury. 2° At
our institution, all patients with a knee dislocation are
admitted for observation and serial examinations, with
particular attention to the neurovascular assessment. A
vascular surgery consultation is obtained as well to pre-
vent any delay in the treatment of a vascular injury should
one develop on a delayed basis. The initial evaluation
follows the basic steps of a treatment algorithm (Fig 1).
After the initial assessment of the knee dislocation, an-
terior/posterior and lateral radiographs are obtained. The
knee joint is evaluated for associated fractures and the
adequacy of the reduction. Reduction should not be de-
layed for radiographs. Other views include intercondylar
notch and patellofemoral radiographs. These images as-
sess the extensor mechanism, and may visualize possible
ligament avulsion fractures. Magnetic resonance imaging
(MRI) is necessary to evaluate the ligamentous structures
and other soft tissues. It may help diagnose a patella
tendon or quadriceps rupture; in these injuries, an early
repair is indicated. An MRI may also identify meniscus
injuries, cartilage lesions, bone bruises, and occult frac-
tures. The information obtained by these studies is useful
in preoperative planning. We recommend obtaining an
MRI in all cases in which a repair, reconstruction, or both
is planned. This imaging study can be obtained in a non-
emergent fashion.
EXAMINATION OF SPECIFIC LIGAMENTOUS
STRUCTURES
In the acute setting, swelling and pain often prevent a
detailed ligament examination. However, the best possible
190
assessment should be obtained. Gross instability to varus
and valgus testing in extension suggests injury to one or
both cruciate ligaments, the joint capsule, and the collat-
eral ligaments. If the joint capsule has been disrupted, then
there may not be an effusion. Flexion is often not possible.
This precludes anterior and posterior drawer testing. The
information obtained from the physical examination
should be correlated with the history and mechanism of
injury.
The four main ligamentous structures include the ante-
rior cruciate ligament, posterior cruciate ligament, medial
collateral ligament (MCL) with the posteromedial capsule,
and the posterolateral corner (PLC). The PLC is composed
of the lateral collateral ligament, popliteus tendon, popli-
teofibular ligament, arcuate ligament, fabellofibular liga-
ment, and the posterolateral joint capsule. It is important
to specifically examine each of the 4 elements carefully.
The MRI should not be relied on solely, because the accu-
racy of the test is diminished without clinical correlation.
ACL
The ACL serves as the primary restraint to anterior trans-
lation of the tibia in relation to the femur. It provides 86%
of the resistance to anterior translation. 22 The ACL also
serves as a secondary stabilizer to varus, valgus, and ro-
tational stresses about the knee. 23 The most reliable and
sensitive test for assessing ACL deficiency is the Lachman
test. In multiple-ligament-injured knees, this test is more
difficult to perform. For example, PCL-deficient knees can
mislead the examiner because of the abnormal translation.
Also, a complete MCL disruption can give a false-positive
Lachman test if care is not taken to perform the test in
internal rotation. This results from the anteromedial rota-
tional instability secondary to MCL disruption.
PCL
The PCL serves as the primary restraint to posterior trans-
lation of the tibia. 22 The physical examination of the PCL
includes the posterior drawer test, posterior sag sign,
quadriceps active test, and Godfrey's test. The most sen-
sitive test is the posterior drawer test. The anterior tibial-
femoral step-off is important to note when performing this
test. Normal step-off is 8 to 10 mm (tibia anterior to the
femur with the knee flexed 90°). This test is graded ac-
cording to the amount of translation with a posterior
directed force.
MCL
The MCL is the primary restraint to a valgus knee stress at
20 ° to 30 ° flexion. It is also a secondary restraint to anterior
translation. Testing is performed by applying a vagus
stress at 20 ° to 30 ° flexion. This test is graded according to
the amount of joint line opening in millimeters and the
presence of an endpoint. The knee is also tested in full
extension. Opening to valgus testing in full extension im-
plies damage to the posteromedial capsule in addition to
the superficial MCL.24 The posteromedial capsule is part of
the deep MCL, and it may need to be repaired or recon-
structed in certain cases.
WILSON AND JOHNSON
 Multiple-Ligament Knee Injuries
Open Skin "Dimple Sign" Skin Intact

Reduction ~ No Reduction Reduction

To OR Immediately To OR Immediately Physical Exam

Irrigation Open Reduction Pulses Present Pulses Absent

Unstable Stable PE for Stability Vascular Consult

Ex-Fix B~ace Stable Unstable OR/Arteriogram

Fig 1. Treatment algorithm
for multiple-ligament knee
injuries. IV Antibiotics Immobilize To OR NL Injury

Observe X-ray Reduction Reduction Repair

Reduced Unreduced Ex-Fix Stable Unstable Ex-Fix

"a
Observe To OR Observe Immobilize Ex-Fix Observe

Reduce Observe Observe

Ex-Fix

+
Observe

PLC a n d treat an injury of the PLC of the knee in a patient w h o

The PLC resists v a r u s a n d rotational forces to the knee.
The a n a t o m i c structures of the PLC can be d i v i d e d into 3
layers. L a y e r 1 is c o m p o s e d of the iliotibial b a n d a n d the
biceps femoris tendon. L a y e r 2 consists of the lateral reti-
n a c u l u m a n d lateral patellofemoral ligaments. Layer 3 is
the d e e p e s t a n d contains the lateral collateral l i g a m e n t or
fibular collateral ligament, the fabellofibular ligament, the
popliteus, the arcuate complex, a n d the i m p o r t a n t poplit-
eofibular ligament. Testing of the PLC consists of v a r u s
stressing the knee at 0 ° a n d 30 °. Increased external rotation
of the tibia at 30 ° a n d 90 ° is tested a n d c o m p a r e d w i t h the
contralateral knee. O t h e r tests include the posterolateral
d r a w e r test, external rotation d r a w e r test, a n d reverse
p i v o t shift test. Increased o p e n i n g to v a r u s stress at 30 °
w i t h o u t o p e n i n g at 0 ° or other signs of a PLC injury
suggests an isolated tear of the FCL. 25 Failure to diagnose
has a tear of the ACL or PCL can result in failure of the
reconstructed ligament.
CONCLUSIONS
The initial diagnosis of a knee dislocation or multiple-
l i g a m e n t knee injury is an orthopaedic emergency. A vas-
cular injury m u s t be a s s u m e d until it can be ruled out. A
t h o r o u g h n e u r o v a s c u l a r e x a m i n a t i o n should be per-
f o r m e d before a n d after reduction of the knee joint. These
patients should then be o b s e r v e d for a n y changes in their
vascular examination. All patients w i t h a p e r f u s e d extrem-
ity b u t a b n o r m a l vascular status should u n d e r g o an arte-
riogram. Patients w i t h o u t pulses or a n o n p e r f u s e d extrem-
ity should go i m m e d i a t e l y to the operating r o o m w i t h a
vascular s u r g e o n w h o can p e r f o r m an on-the-table anglo-

EVALUATING ACUTE MULTIPLE-LIGAMENT-INJURED KNEE 191

gram. After the vascular status has been documented,
radiographs followed by MRI should be obtained. A com-
plete ligament examination will help correlate the findings
of the MRI, and a preoperative plan can be established.
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