Injury

(1990)
21,398-400 Printed in GreatBrifuin

398

injury of knee ligament associated with ipsilateral

femoral shaft fractures and with ipsilateral femoral
and tibia1 shaft fractures
M. J. Szalay, 0. R. Hoskmg and P. Annear
The Royal Perth Hospital, Perth, Western Australia
Sir Charles Gairdner Hospital, Perth, Western Australia

A seriesof 710 patientswith 114fracfure of thefemur were reviewed an

average of 3.9 yews after injuy. Demonstrable knee ligament kzxity was
present in 31 (227per cent) of these pafienfs,while 13 (11 per cent)
complained ofinstability. Thirty-three patients with 34 ipsikateralfemoral
and tibial shaft fmc&res were examined ati average of 3.7 years after
injuy. Demonstrable knee ligament kzrity was present in 18(53percent)
of these patients, while 6 (18percent) complained of instability.
Most of the patients with instability had a rupture of the anterior
cruciate ligament with or without damage to other ligaments.
We conclude that knee ligamentinjuy is more common with ipsilaferal
fracture of the femur and fibia than withjust a single ipsikzteralfemoral
fracture. We advocate careful assessment of the knee in all cases of fracture
of the femur.

Introduction
Most fractures of the shaft of the femur are caused by
high-energy
trauma. It would be expected that in many
cases the ipsilateral knee ligaments are subjected to severe
stress. In the presence of a mobile fracture of the femur,
examination of the knee is difficult. Knee swelling due to
haemarthrosis may be mistaken for a sympathetic effusion.
Previous studies have reported that the incidence of knee
ligament injury associated with femoral shaft fracture is
between 33 and 70 per cent (Dunbar and Coleman, 1978;
Walker and Kennedy, 1980; Walling et al., 1982; Lakshman
and Scotland, 1985).
Ipsilateral fracture of the femur and tibia is regarded as a
serious injury with a poor prognosis.
Patients treated
non-operatively
fare badly with a high incidence
of
malunion, non-union and knee stiffness (Fraser et al., 1978).
Veith et al. (1984) found that internal fixation of both
fractures improved results, but a number of patients have
residual symptoms and poor function. Some of the poor
results are due to the fractures themselves but many have
unstable knees.
In this study, we sought to establish the incidence and
type of knee instability occurring in patients with femoral
fractures alone, or ipsilateral fractures of the femur and tibia,
at long-term follow-up.
0 1990 Butterworth-Heinemann
002O-1363/90/060398-03

Ltd

Materials and methods

A multicentred study was performed at the St George and
Sutherland Hospitals (Sydney) and the Sir Charles Gairdner,
Royal Perth, and Fremantle Hospitals (Perth). The medical
records of patients with fractures of the femoral shaft
presenting to these hospitals between 1978 and 1987 were
studied. Patients aged under 16 years or over 45 years, those
with previous knee injury, and those with an intra-art&u
fracture of the knee were excluded.
Patients were contacted by letter or telephone and asked
to attend for examination.
Details of the injury and
treatment were extracted from the hospital records. The
patients were asked whether the knee was unstable and, if
so, what level of activity precipitated giving way of the
knee, how they managed stairs, and whether their knee
caused any other restriction of their daily activities. Clinical
tests performed on all patients were the Lachrnann, anterior
and posterior draw at 90 of flexion and in internal and
external rotation of the knee, valgus and varus stress at 0
and 30 flexion, pivot shift and reverse pivot shift, and the
external rotation recurvatum test (Hughston and Norwood,
1980). Findings were graded normal, mild laxity or marked
laxity.
Patients were subsequently classified as having important
or unimportant
instability on the basis of their symptoms.
Those with important
instability had symptoms which
interfered with their daily activities, such as giving way
while walking, or being able to negotiate stairs only by
holding onto a rail. If the patient had laxity on examination
but no episodes of giving way or limitation of daily activity,
they were classified as having unimportant instability.
The x2 test with a Yates correction was used to assess
statistical significance.

Results
A total of 344 medical records were reviewed. Of these, 143
patients presented for examination.
In the group with femoral fractures alone, I10 patients
with 114 fractures were examined. There were 82 males and
28 femdes. The average age was 22 years (range 16.3-45.5

Szalay et al.: Knee ligament injury with femoral and tibiai shaft fractures
years). The average follow-up was 3.9 years (range 6
months-II.7
years).
Thirty-three patients with 34 ipsilateral femoral and tibia1
shaft fractures were reviewed; 27 were male and 6 female.
Mean age was 23.3 years (range 16-41.3 years). Average
follow-up was 3.7 years (range 6 months-10 years). The
cause of injury in both groups is shown in Table I. In the
group with femoral fracture alone, an equal number were
injured in motor car and motorcycle accidents. Of those
sustaining
ipsilateral femoral and tibial fractures, the
majority were injured in motorcycle accidents.
The methods of treatment in both groups are shown in
TableII and Table III. The incidence of knee laxity in the 17
patients treated with tibial traction was not significantly
different to the incidence in the ,group treated with internal
fixation.

Table I. Mode of injury

lpsilateral femoral fracture

alone
Motor car
Motorcycle
Fall
Athletics
Total

Ipsilateral
fracture
of femur and
tibia

48
48
10
4

10
23

110

33

Table II. Treatment of femoral fractures

71
23
2
14
4

Intramedullary nail
Plate
External fixator
Non-operative
Combination

Table III. Treatment of kachre of femur and tibia

17
8
6
3

Internal fixation both fractures

Fixation of femur with splintage of tibia
Fixation of femur with external fixator tibia
Non-operative treatment of both fractures

399

At follow-up, 31 of the group with femoral fractures

alone (27 per cent) had demonstrable laxity in the ipsilateral
knee while 13 (11 per cent) were classified as having
important instability. AU patients with important instability
showed anterior rotary laxity. There were no patients with
isolated collateral laxity. In the group with ipsilateral
fractures of both femur and tibia, 18 (53 per cent) of the 34
knees had clinicaIly detectable knee laxity and in six (18 per
cent) this was graded as important. Laxity of ihe posterior
structures was more common in this group than in patients
with femoral fracture alone. The type of ligament laxity in
both groups is summarized in TableN. Of the patients
classified as having unimportant
laxity, five were functionally limited due to other complications of the fractures.
These were ankle equinus and stiffness, foot drop and
malunion.
The difference in incidence of ligament laxity between the
group with fractures of the femur and tibia and those with
femoral fracture alone was found to be shtistically significant (PC 0.01). The incidence of important instability was
not found to be significantly different in the two groups.

Discussion
Knee ligament injury occurring in association with ipsilateral
femoral shaft fracture is well documented.
Pedersen and
Serra (1968) first reported this combination of injuries in a
series of six cases. Dunbar and Coleman (1978) prospectively examined 20 patients and noted a 25 per cent
incidence of important instability, while 70 per cent of knees
showed detectable laxity at the time of injury. Walling et al.
(1982) assessed knee stability at the time of injury in 24
patients by inserting a pin through the distal femur. Eight
patients showed ligament laxity, all but two having anterior
cruciate ligament rupture, with or without laxity of other
ligaments. Walker and Kennedy (1980) reviewed 54 patients
retrospectively
and found laxity in 26 knees (48 per cent).
Of these, 16 showed damage to the anterior cruciate
ligament; 30 per cent of the knees were classified as being
significantly unstable.
Fraser et al. (1978) reviewed 63 patients with fracture of
the femur and tibia and found that 39 per cent showed
laxity, with one-third of these having important symptoms.
Some of the patients had intra-articular fractures involving
the knee and the type of ligament laxity was not specified.
To our knowledge, there has been only one published

TabIe IV. Types of knee laxity

Femur fracture only
(N=114)
Important
ALRI
AMRI
PLRI
ALRI and AMRI
ALRI and PLRI
PLRI and posterior
AMRI, ALRI and PLRI
Lateral
Posterior
Total

6
1
4
2

Unimpoflant
7
2
1
6

Femur and tibia

fracture (N = 34)
Important

Unimportant

3
3
1
1

2
13

ALRI =Anterolateral rotary instability

AMRI =Anteromedial rotary instability
PLRI = Posterolateral rotary instability

18

12

400

Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No.

study comparing the incidence of knee ligament injury in

patients sustaining ipsilateral fracture of the femur with
those suffering ipsilateral fracture of femur and tibia.
Lakshman and Scotland (1985) found demonstrable laxity
in II of 21 patients with a fracture of the femur alone, of
whom five were symptomatic.
Of seven patients with
ipsilateral fracture of femur and tibia, all showed laxity but
only three were symptomatic. Medial ligament and posterior capsule tears were the most common injuries detected.
The rate of knee ligament laxity associated with fractures
of the femur in our series is lower than most of the previous
studies. Important instability, also, was less common than
has been previously reported. All but three patients with
detectable laxity in the femoral fracture group showed
anterior rotary laxity alone or in combination
with other
laxity patterns. This is in agreement with previous studies
which have shown a high incidence of anterior cruciate
ligament injury.
Detectable
ligament
laxity was significantly
more
common in patients with ipsilateral fracture of the femur and
tibia than with fracture of the ipsilateral femur alone. The
difference in incidence of symptomatic instability between
the two groups was not significant. However, six of the 12
patients in the group classified as having unimportant
instability were restricted by other complications of their
fractures. It may be that they would have had a symptomatically unstable knee with normal use of the limb.
Only one case of isolated collateral laxity was identified
in the whole series. In several previous reports (Pedersen and
Serra, 1968; Walling et al., 1982) collateral laxity was
common. There is evidence that collateral ligament tears
heal without surgical repair (Hastings, 1980; Sandberg et al.,
1987). Our patients may have suffered collateral injury
which healed spontaneously.
On the other hand, knees with
rupture of the anterior cruciate ligament and rotary instability rarely stabilize with time (Fetto and Marshall, 1980).
Whilst the treatment of anterior cruciate ligament injuries
is controversial,
we believe it is important to diagnose
ligament injuries associated with femoral fracture early to
allow an appropriate rehabilitation programme to be instituted. The presence of an effusion should alert the clinician
to the possibility of knee ligament injury. The Lachmann test
has been shown to be almost 100 per cent diagnostic of
anterior cruciate ligament tear when performed under
anaesthesia (Jonsson et al., 1982). Rigid fixation of fractures
allows more accurate assessment of the knee.
In conclusion, this study revealed that 27 per cent of
patients with femoral shaft fractures showed detectable knee
laxity at long-term follow-up, while II per cent showed
important instability. Following ipsilateral fracture of the
femur and tibia, 53 per cent had detectable knee laxity and
18 per cent showed important
instability. Most of the

patients with important instability showed anterior rotary

laxity. We advocate examination of the knee under anaesthesia in all patients with fracture of the shaft of the femur.

Acknowledgement
The authors would like to thank Mr Alan Skirving for his
assistance in the preparation of the manuscript.

References
Dunbar W. H. and Coleman

S. S. (1978) Occult knee injuries

associated with ipsilateral femoral fractures. A prospective
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Fetto S. J. and Marshall J. L. (1980) The natural history and
diagnosis of anterior cruciate ligament insufficiency. Clin.
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Fraser R. D., Hunter G. A. and Waddell J. P. (1978) Ipsilateral
fracture of the femur and tibia. 1. Bone anAjoint Sung. 60B, 510.
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Hughston J. C. and Norwood L. A. (1980) The posterolateral

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Paper accepted 29 January 1990.

Requestsforreprints shouM be aailressed to: Dr M. Szalay, Orthopaedic
Registrar, Royal Perth Hospital, PO Box x2213, GPO Perth WA
6001.