Cutting edge Orthopedics

38 • CUTTING EDGE - ORTHOPEDICS ments/capsular injuries, they found MRI to be 85–100% accurate as compared to clinical findings, which were found to be 53–82% accurate. In terms of the initial management of the patient, the first action that should be taken is to reduce the knee joint through a closed reduction maneuver, although there is no direct lit- erature that specifically addresses closed reduction of knee dislocations. A joint reduction can often be achieved by direct manipulation of the lower extremity in order to obtain normal ana- tomic alignment. This will provide a more accurate assessment of neurovascular status and will facilitate immobilization and transport of MS. Special attention should be paid to the medial skin. Puckering or dimpling of the skin over the medial joint line has been described in irreducible knee dislocations and often represents the buttonholing of the medial femoral condyle through the medial capsule or structures [3]. Ligamentous knee injuries are a concern with high-energy orthopedic trauma; however, there are many discrepancies in the literature surrounding the management of these injuries due to their 251 achieved by d rect manipulatio of the lower extremity in order to obtain normal anatomic alignment. This will provide a more accurate assessment of neurovascular status and will facilitate immobilization and transport of MS. Special attention should be paid to the medial skin. Puckering or dimpling of the skin over the medial joint line has been described in irreducible knee dislocations and often represents the buttonholing of the medial femoral condyle through the medial capsule or structures [ 3 ]. Ligamentous knee injuries are a concern with high-energy orthopedic tra ma; however, there are many di crepancies in the lit ature surrounding the management of these injuries due to their low incidence of occurre e and h gh incidence of being missed at initial presentation. These injuries are often missed on initial assessment due to spontaneous reduction of the joint, distracting injuries, and absence of abnormality on initial review of plain radiographs. For example, Walker and Kennedy found th t the incidence of occult ligamentous knee injuries can be as high as 48% in patients with femur fractures. They point out that the diagnosis of these ligamentous injuries is often delayed by months [ 4 ]. Moreover, despite the fact that knee dislocations and bicruciate knee injuries can present after spontaneous red ction, spontaneous reduction does not decrease their morbidity. In a Fig. 20.2 ( a, b ) T1 sagittal MRI knee ( c ) T2 sagittal MRI knee ( d ) T2 coronal MRI knee 20 Knee Dislocations Fig. 2. ( a, b ) T1 sagittal MRI knee ( c ) T2 sagittal MRI knee ( d ) T2 coronal MRI knee.