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Journal of the American Academy of Orthopaedic Surgeons
238
In 1975, Blake and McBryde
1
coined
the term “floating knee” to describe
the injury pattern of ipsilateral
femoral and tibial fractures that
“disconnect” the knee from the
remainder of the extremity. This
term is usually applied to the com-
bination of diaphyseal femoral and
tibial shaft fractures, but may be
used to describe ipsilateral hip and
ankle fractures. Various methods of
treating these injuries have been
described, ranging from traction
2
to
surgical fixation.
3
Blake and Mc-
Bryde were the first to document
the results of operative treatment of
this type of injury.
This constellation of injuries is
most commonly observed in youn-
ger patients,
3,4
as is usual for major
trauma. The mechanism of injury is

generally high-energy trauma, such
as that due to motor-vehicle, vehicle-
versus-pedestrian, and motorcycle
accidents.
2,5-7
The combination of
ipsilateral femoral and tibial frac-
tures implies a more substantial
mechanism of injury that frequently
results in serious injury to other
organ systems as well as to the in-
volved extremity. Familiarity with
the critical features of the diagnosis
and management of the floating-
knee injury pattern can help the
orthopaedic surgeon maximize the
patient’s recovery.
Associated Injuries
Patients with ipsilateral femoral
and tibial fractures have often suf-
fered polytrauma and therefore
may have significant injuries of
other organ systems. They tend to
be among the more seriously in-
jured trauma patients and have a
higher incidence of associated
injuries than patients with isolated
femoral or tibial fractures. Paul et
al
8

noted that 62% of the patients in
their series had major concomitant
trauma to the head, the trunk, or
the other extremities. In the series
reported by Fraser et al,
9
27% of the
patients had intracranial trauma,
15% had pelvic fractures, and 10%
had chest injuries. Omer et al
2
found
that the most common related inju-
ries were pelvic fractures and con-
tralateral femoral fractures.
Vascular injuries are also more
common in patients with ipsilateral
femoral and tibial fractures than in
those with isolated fractures of
either bone. Paul et al
8
reported
that 6 (29%) of their 21 patients had
vascular injuries, most commonly
involving the posterior tibial ar-
Dr. Lundy is Co-Director, Orthopaedic Trauma
Service, Orthopaedic Center of the Rockies, Fort
Collins, Colo. Dr. Johnson is in private practice
with New Mexico Orthopaedics, Albuquerque,
NM.

Reprint requests: Dr. Lundy, Orthopaedic
Center of the Rockies, 2500 East Prospect Road,
Fort Collins, CO 80525.
Copyright 2001 by the American Academy of
Orthopaedic Surgeons.
Abstract
Ipsilateral fractures of the femur and tibia have been called “floating knee” injuries
and may include combinations of diaphyseal, metaphyseal, and intra-articular frac-
tures. These are often high-energy injuries and most frequently occur in the poly-
trauma patient. Many of these fractures are open, with associated vascular
injuries. Surgical stabilization of both fractures and early mobilization of the
patient and the extremity produce the best clinical outcomes. The use of a radiolu-
cent operating room table and the introduction of retrograde intramedullary fixa-
tion of femoral fractures have facilitated surgical stabilization of some floating-knee
fracture patterns. Although treatment planning for each fracture in the extremity
should be considered individually to achieve the optimal result, the effect of that
decision must be considered in light of the overall injury status of the entire
extremity. Collateral ligament and meniscal injuries may also be associated with
this fracture complex. Complications (such as compartment syndrome, loss of knee
motion, failure to diagnose knee ligament injury, and the need for amputation) are
not infrequent. Better results and fewer complications are observed when both
fractures are diaphyseal than when one or both are intra-articular.
J Am Acad Orthop Surg 2001;9:238-245
“Floating Knee” Injuries:
Ipsilateral Fractures of the Femur and Tibia
Douglas W. Lundy, MD, and Kenneth D. Johnson, MD
Douglas W. Lundy, MD, and Kenneth D. Johnson, MD
Vol 9, No 4, July/August 2001
239
tery. In their series of floating-knee

injuries with intra-articular exten-
sion, Adamson et al
5
noted a 21%
incidence of vascular injuries. The
occurrence of compartment syn-
drome with this injury is not uni-
formly documented in many pub-
lished series; however, Fraser et al
9
had a 1.4% incidence.
When the ipsilateral tibia and
femur are fractured, the incidence
of open fractures is higher than
with an isolated fracture of either
bone. It is most common for there
to be an open tibial fracture and a
closed femoral fracture. In the
study by Paul et al,
8
17 of 21 pa-
tients had open fractures of one or
both bones, and 76% of these were
either grade II or grade III. Mul-
tiple procedures were required to
treat these injuries, and 5 patients
eventually required amputations.
In the 57 patients described by
Veith et al,
3

there were 17 open
femoral fractures and 29 open tibial
fractures. Both fractures were open
in 13 patients. Gregory et al
6
re-
ported 16 open fractures in their 26
patients with ipsilateral femoral
and tibial fractures. These findings
accentuate the magnitude of vio-
lent force associated with this in-
jury pattern.
Ligamentous injuries of the knee
are also commonly associated with
floating-knee injuries. In the study
by Szalay et al,
10
53% of the pa-
tients with ipsilateral femoral and
tibial fractures had knee ligament
laxity, compared with 27% of their
patients with isolated femoral frac-
tures. Eighteen percent of the pa-
tients with floating knees reported
knee instability at a mean follow-
up interval of 3.7 years. Antero-
lateral rotatory instability was the
most common instability pattern.
These findings suggest that ipsilat-
eral femoral and tibial fractures do

not provide a protective effect to
the knee ligaments, and the higher
incidence of knee ligament injuries
is demonstrative of the significant
force that these patients have sus-
tained. Although not described by
Szalay et al, the force applied to the
extremity probably first causes the
knee ligaments to rupture, and the
remaining energy is dissipated by
fracturing of the femur and tibia.
Classification
Classifying ipsilateral femoral and
tibial fractures can be especially dif-
ficult because there are so many
classification systems to define spe-
cific injury to either bone. Blake and
McBryde
1
proposed a system that
differentiated these injuries on the
basis of the presence or absence of
an intra-articular fracture. The type
I injury is the “true floating knee,”
in which neither the femoral nor the
tibial fracture extends into the knee,
ankle, or hip joint. Type II fractures
are “variant floating knees.”
Karlström and Olerud
7

described
the grading system often used to
evaluate patients with floating-knee
injuries. Their system is based on
subjective symptoms, ability to
work and play sports, shortening,
deformity, and joint stiffness.
In 1978, Fraser et al
9
offered their
classification system of ipsilateral
femoral and tibial fractures (Fig. 1).
As in Blake and McBryde’s system,
the type I fracture is extra-articular
(Fig. 2), but the type II fracture is
classified according to the nature of
the knee injury. Patients with a
type IIA injury have a tibial plateau
fracture and an ipsilateral femoral
shaft fracture (Fig. 3). The type IIB
injury is characterized by an intra-
articular distal femoral fracture and
a tibial shaft fracture. The type IIC
injury involves ipsilateral intra-
articular fractures of both the tibial
plateau and the distal femur. These
classification systems are prognos-
tic in that the patients with type I
fractures have better functional out-
comes than patients with type II

fractures.
5
Evaluation
Patients presenting with ipsilateral
femoral and tibial fractures gener-
ally have sustained severe poly-
trauma. Therefore, the advanced
trauma life support (ATLS) proto-
cols should be followed, and inju-
ries to other organ systems should
be identified and treated if neces-
sary. Anteroposterior (AP) chest,
pelvis, and lateral cervical spine
radiographs are part of the routine
evaluation. The presence of open
fractures or compartment syndrome
should be quickly determined. The
ipsilateral femoral neck, acetabu-
lum, foot, and ankle should be care-
fully examined to rule out injury.
The neurologic and vascular in-
Figure 1 Classification system of Fraser et
al.
9
Type I fractures are extra-articular.
Type II fractures are classified according to
the knee injury: type IIA injuries are char-
acterized by a tibial plateau fracture and an
ipsilateral femoral shaft fracture; type IIB,
by an intra-articular distal femoral fracture

and a tibial shaft fracture; type IIC, by ipsi-
lateral intra-articular fractures of both the
tibial plateau and the distal femur.
(Adapted with permission from Fraser RD,
Hunter GA, Waddell JP: Ipsilateral frac-
ture of the femur and tibia. J Bone Joint
Surg Br 1978;60:510-515.)
I
IIA IIB IIC
Floating Knee
Journal of the American Academy of Orthopaedic Surgeons
240
tegrity of the affected extremity
should also be carefully examined
and documented.
Radiographs should be obtained
in two planes to include the joint
above and below the fracture (i.e.,
views of the entire lower extremity
from the hip to the ankle). Veith et
al
3
reported 12 ipsilateral foot and
ankle injuries and 3 hip fractures in
their series of 53 floating knees.
Adequate radiographs of the fem-
oral neck and acetabulum are es-
sential to rule out fractures affect-
ing the hip.
Timing of Intervention

Patients with ipsilateral femoral and
tibial fractures often require aggres-
sive hemodynamic resuscitation;
therefore, the timing of fracture sta-
bilization must be integrated into
the optimal management of the
traumatized patient. Patients whose
fractures are associated with com-
partment syndromes, open frac-
tures, or vascular injuries should be
treated surgically on an emergent
basis as soon as practical. Bone et
al
11
and Johnson et al
12
have shown
that early stabilization of femoral
fractures decreases the incidence of
pulmonary complications in multi-
ply injured patients. Early fixation
may be defined as fracture stabiliza-
tion within the initial 24 hours after
the injury or when the patient’s con-
dition has stabilized after resuscita-
tion. Urgent stabilization of these
fractures is imperative to maximize
the patient’s overall condition, espe-
cially the ability to mobilize the pa-
tient.

Stabilization of intra-articular
fractures may be delayed until soft-
tissue swelling has decreased or the
appropriate surgical team is avail-
able. Tibial plateau and plafond
fractures are often associated with
compromised skin and soft tissues,
and a delayed approach may yield
fewer complications and a better re-
sult. Similarly, knee ligament re-
construction can be delayed until
after adequate rehabilitation of the
patient’s skeletal injuries. Although
technically more difficult, anterior
cruciate ligament reconstruction may
be performed without removing ret-
rograde femoral nails, as the bone
plug can be placed posterior and lat-
eral to the retrograde femoral nail.
Nonoperative Management
Nonoperative management of ipsi-
lateral femoral and tibial fractures
was common in the 1960s and
1970s, but yielded less than satisfac-
tory outcomes. Blake and McBryde
1
used primary nonoperative treat-
ment in 26 of the 37 femoral frac-
tures and all of the 37 tibial fractures
in their series. Half of the extremi-

ties initially treated nonoperatively
eventually required surgery. More
than half of the patients had perma-
nent functional impairment, includ-
ing activity compromise and limp.
After intramedullary fixation of
the femur became more widely
accepted in the late 1970s, the man-
agement of ipsilateral femoral and
tibial fractures evolved to femoral
nailing and casting of the tibial frac-
ture.
3
With the advances in surgical
treatment of tibial fractures, both the
femur and tibia are now routinely
treated operatively. Veith et al
3
re-
ported on 57 ipsilateral fractures of
the femur and tibia. All but 1 of the
femoral fractures and about half of
the tibial fractures were internally
fixed. Good or excellent results
were achieved in about 80% of the
patients, with an average knee
range of motion of 129 degrees.
Nonoperative management of se-
lected tibial fractures may be accept-
able in patients with nondisplaced

tibial fractures. If the patient is un-
able to participate in early knee
range-of-motion activities and
weight bearing, the tibial fracture
should be surgically stabilized.
A B
Figure 2 AP radiographs of the femur (A)
and tibia (B) of a patient who sustained a
type I floating-knee injury. Note that the
femoral and tibial fractures are both extra-
articular.
Figure 3 AP radiographs of a patient who
sustained a type IIA floating-knee injury in
a motor vehicle accident. Her injuries
included ipsilateral femoral neck and seg-
mental femoral shaft fractures (A), a
Schatzker VI tibial plateau fracture (B), and
a contralateral tibial shaft fracture.
A B
Douglas W. Lundy, MD, and Kenneth D. Johnson, MD
Vol 9, No 4, July/August 2001
241
Operative Management
The current recommended treat-
ment for the floating knee consists
of surgical fixation of both the fem-
oral and the tibial fracture (Fig. 4).
There is no single ideal method of
treating the patient with a floating
knee; rather, there are a number of

methods of surgical stabilization,
which should be individualized for
the specific type of femoral and tib-
ial fracture. The optimal method of
fixation of each fracture depends on
the fracture pattern, soft-tissue in-
jury, associated injuries, and prefer-
ences of the surgeon. When stabi-
lizing ipsilateral femoral and tibial
fractures, each injury should be
regarded separately, but the effect
that each of the treatments will
have on the other injuries must also
be considered.
For type I injuries, intramedul-
lary nailing of both the femoral and
the tibial fracture is often the opti-
mal form of fixation (Fig. 5). The
technique of antegrade intramedul-
lary nailing of both the femur and
the tibia has been well described.
This method can provide stable fix-
ation of both fractures and fre-
quently allows rapid progression of
activity and knee function.
Advances in surgical techniques
have influenced the care of these frac-
tures. The utilization of retrograde
femoral nails and the technique of
operating on a radiolucent table

rather than a fracture table, allowing
simultaneous surgical setup for both
the femoral and the tibial fracture,
have facilitated treatment of some
floating-knee injury variants.
Several authors
13-15
have reported
good results with retrograde fem-
oral nailing and use of the intra-
articular starting point described by
Iannacone et al.
16
Most of the pa-
tients in these series had isolated
femoral fractures. The patients had
few complaints of knee pain, and
knee motion in excess of 120 degrees
was reported.
Gregory et al
6
reported a series of
26 ipsilateral femoral and tibial frac-
tures treated with retrograde fem-
oral nailing and antegrade non-
reamed tibial nailing through one
incision. They reported 13 good or
excellent and 7 acceptable results,
and knee range of motion averaged
120 degrees.

With the use of retrograde fem-
oral nails, certain types of femoral
fractures can be stabilized through
a single incision that can then be
used to operatively stabilize an
ipsilateral tibial shaft or a tibial
plateau fracture. Depending on
the skin condition, fracture pat-
tern, and overall patient status,
this approach may decrease opera-
tive time and surgical trauma. Os-
trum
17
recently reported good
results in patients with type I frac-
tures treated with retrograde fem-
oral nails and small-diameter tibial
nails placed through a single knee
incision.
Treatment of a floating knee is
one of several situations in which it
is advantageous to nail femoral frac-
tures on a radiolucent table rather
than on a fracture table. McFerran
and Johnson
18
described a technique
of femoral nailing with use of a
femoral distractor to maintain
reduction. The distractor has also

been applied to tibial fractures to
hold reduction during intramedul-
lary fixation.
19,20
Karpos et al
21
re-
ported femoral nailing utilizing
manual traction alone without the
use of a fracture table. They asserted
that this technique allows quicker
and more efficient treatment of the
polytraumatized patient. Wolinsky et
al
22
compared the times required for
nailing of femoral fractures on and
off the fracture table. Using the
fracture table resulted in longer
anesthesia durations and operative
times than performing antegrade
reamed intramedullary nailing on a
radiolucent table.
Figure 4 AP radiographs of the same patient as in Figure 3 after reconstruction-nail fixa-
tion of the femoral neck and segmental femoral fractures (A) and open reduction and inter-
nal fixation of a tibial plateau fracture (B).
A B
Floating Knee
Journal of the American Academy of Orthopaedic Surgeons
242

The technique of stabilizing both
the femoral and the tibial shaft frac-
ture with the patient in the supine
position offers advantages whether
the femur is nailed antegrade or ret-
rograde. When the radiolucent table
is used, the patient does not need to
be moved to the fracture table after
a general surgical procedure, and
the time required for setup of the
fracture table is eliminated. There-
fore, the patient can be more quickly
stabilized, and the operative time
may be reduced. The correct length
of the fractured femur and tibia can
be approximated by measuring the
noninjured extremity with fluo-
roscopy before draping the patient.
When there are bilateral femoral or
tibial fractures, the side that is more
easily reconstructed is used as a
guide for length. Rotation is deter-
mined by palpation of the greater
trochanter, the epicondyles, and the
malleoli.
Recommendations and
Surgical Technique
The different varieties of floating
knee injuries necessitate individual
consideration of the fracture type

and the overall status of the soft tis-
sues of the extremity. The preferred
order for femoral and tibial fixation
and the suggested techniques for the
various injury patterns are shown in
Table 1. Regardless of displacement,
an optimal outcome after intra-
articular fractures is dependent on
early range-of-motion activities and
protected weight bearing.
The patient is usually placed in
the supine position on the radiolu-
cent table with a bump of two rolled
sheets placed under the pelvis on
the affected side. The lateral posi-
tion is used for intramedullary fixa-
tion of subtrochanteric fractures
with reconstruction nails. The pa-
tient is prepared and draped from
the iliac crest to the foot. Open frac-
ture wounds and areas of potential
compartment syndromes are evalu-
ated and treated before proceeding
with fracture fixation.
The femoral fracture is usually
stabilized first. If the patient is
hemodynamically unstable after the
femur is nailed, the tibial fracture
can be stabilized with a splint, and
the patient can then return to the

intensive care unit without the need
of femoral traction. Another advan-
tage of primarily stabilizing the
femur is the avoidance of inadver-
tent displacement of the femoral
fracture that would occur with tibial
nailing before femoral stabilization.
Deformation of the tibial fracture
can be controlled with manual re-
duction during stabilization of the
femur. However, an unstable fem-
oral fracture might displace and
cause more soft-tissue injury when
the knee is flexed for nailing of the
tibia. If the tibia is very commi-
nuted, or if femoral nailing is ex-
pected to be difficult, the tibial frac-
ture should be stabilized with an
external fixator before nailing the
femur. Depending on the location
and nature of the fracture, ante-
grade or retrograde intramedullary
fixation is utilized. Retrograde nails
are preferred if the femoral fracture
does not extend proximally into the
subtrochanteric area.
If there is an open knee injury,
the femur and tibia can be nailed
through the knee laceration after
thorough irrigation and debride-

ment. If there is gross contamina-
tion that cannot be adequately
debrided, antegrade femoral nailing
and tibial external fixation can be
considered. In floating knees with
an open tibial fracture, the lower leg
should be irrigated and debrided
before stabilizing the femur. The
open tibial fracture can be secured
with an external fixator or distractor
to minimize additional soft-tissue
injury while the femur is being
nailed.
19,20
This fixator can then be
changed to an intramedullary nail
or left as definitive fixation based on
the severity of the soft-tissue injury.
When nailing the femoral frac-
ture, the leg is carefully protected
from undue deformation through
the tibial fracture. The femoral frac-
ture is reduced with manual distrac-
tion without causing angulation,
which would increase the soft-tissue
injury. Applying manual traction
may be difficult in patients with
proximal tibial fractures. In this sit-
uation, the surgeon should insert a
distal femoral or proximal tibial

traction pin that allows femoral
traction without displacing the tibial
fracture. If the tibial fracture will be
treated with an external fixator, the
tibial fixator should be quickly
applied before femoral fixation.
Distal femoral fractures can also
be treated by utilizing a radiolucent
table. The incision for this procedure
can be extended distally to allow
treatment of either a proximal or a
shaft fracture of the tibia. A midline
incision from the proximal patella
extending down over the anterior
Figure 5 AP radiographs after antegrade
intramedullary fixation of both a femoral
(A) and a tibial (B) fracture.
A B
Douglas W. Lundy, MD, and Kenneth D. Johnson, MD
Vol 9, No 4, July/August 2001
243
portion of the tibia can accommodate
retrograde fixation of a femoral shaft
or supracondylar fracture, as well as
internal fixation or intramedullary
fixation of a tibial fracture. The lat-
eral incision used in the approach for
condylar blade-plate fixation of dis-
tal femoral fractures can be extended
distally and anteriorly to incorporate

the exposure of the proximal tibia. If
necessary, the incision used for the
retrograde femoral nail may be
extended distally and incorporated
into the approach for the tibial
plateau fracture.
Nondisplaced fractures extending
into the knee may be best treated
with percutaneous fixation and early
range-of-motion activities. These
injuries have fewer complications
than displaced intra-articular frac-
tures that require open reduction
and internal fixation. Early weight
bearing on diaphyseal fractures
should be delayed if the patient has
an ipsilateral intra-articular fracture.
Pain associated with the diaphyseal
fracture may also hinder the rehabil-
itation of the knee.
The femoral neck fracture should
be stabilized before addressing the
tibial fracture. Although many sur-
geons fix these fractures on a frac-
ture table, some prefer the standard
radiolucent table. Femoral neck
fractures in young adults should be
reduced and fixed in a timely fash-
ion. In these situations, the femoral
fracture should be stabilized first,

and the patient should then be repo-
sitioned before addressing the tibial
fracture.
Tibial plafond fractures likewise
should be treated after the femoral
fracture. Treatment of this injury
should be selected without regard
for the fracture of the femur. Tibial
plafond fractures are often best
treated with primary closed reduc-
tion and external fixation.
23
After surgical stabilization of the
femoral and tibial fractures, the knee
is examined for range of motion and
stability. If there is valgus instability
indicative of a medial collateral liga-
ment injury, the knee is treated with a
brace for 6 weeks. Injuries to the ante-
rior or posterior collateral ligament
are rehabilitated and reconstructed
in a delayed fashion if appropriate.
Lateral and posterolateral corner
injuries are repaired in the early post-
operative period, but are not ad-
dressed at the time of initial frac-
ture stabilization. Meniscal tears are
resected or repaired in the early post-
operative period. Early identification
of meniscal tears may be difficult be-

cause patients with ipsilateral femoral
and tibial fractures have adequate
reason to have knee pain and swell-
ing. Magnetic resonance images of
the knee may be difficult to interpret
when fixation devices made of mate-
rials other than titanium are used.
Results
When current treatment modalities
are used to stabilize and rehabilitate
Table 1
Recommendations for Fixation of Floating-Knee Injuries
Injury
Type Description Recommendations Femoral Technique Tibial Technique
I Femoral and tibial Protect tibial fracture Retrograde nails are often Intramedullary nails
diaphyseal fractures during femoral stabilization; preferred; antegrade nails preferred; consider
consider temporary are used for high femoral external fixator for
two-pin fixator fractures; reconstruction severe fractures
nails are used for
subtrochanteric fractures
IIA Diaphyseal femoral Stabilize femur first; Same as for type I Cannulated screws;
and intra-articular stabilize proximal tibial open reduction and
tibial fractures fractures through approach internal fixation
used for retrograde nailing (plates and screws);
external fixation in
severe patterns
IIB Intra-articular femoral Stabilize femur first Angled plate and Same as for type I
and diaphyseal tibial retrograde nails
fractures
IIC Femoral and tibial Consider spanning Depends on pattern Depends on pattern

intra-articular fractures external fixator
Floating Knee
Journal of the American Academy of Orthopaedic Surgeons
244
type I injuries (diaphyseal fractures
of the femur and tibia), satisfactory
clinical outcomes can be expected as
the norm. Veith et al
3
reported the
first series of ipsilateral femoral and
tibial fractures that were treated
with primary surgical stabilization.
Nearly all of the femoral fractures
were treated with antegrade intra-
medullary nails, and the tibial frac-
tures were fixed with intramedul-
lary nails, plates, external fixators,
or casts. In contrast to the findings
in previous studies, they reported
dramatically improved functional
outcomes, with 92% good or excel-
lent results in patients who under-
went surgical stabilization of both
fractures. Of the 57 patients, 46
(81%) regained full range of motion
of the knee. In their series of chil-
dren with ipsilateral femoral and
tibial fractures, Yue et al
24

found
that children, like adults, had far
better results after operative treat-
ment of their injuries.
Type II injuries often have worse
outcomes than type I injuries. The
severity of this injury pattern was
illustrated by Adamson et al
5
in
their series of 34 patients with type
II (intra-articular) ipsilateral femoral
and tibial fractures. Nearly one
third of these patients had sustained
intra-articular fractures of both the
femur and the tibia. The fractures
were open in 21 (62%) of the ex-
tremities, and 7 fractures (21%) were
associated with vascular injuries.
Three (9%) of the injuries necessi-
tated above-knee amputation. Knee
range of motion averaged only 96
degrees, and 26 (76%) of the patients
had fair or poor outcomes. The au-
thors noted that the type II floating-
knee injuries had a much worse
prognosis than type I fractures.
Complications
Loss of knee motion and knee pain
are both common complications

after ipsilateral femoral and tibial
fractures. In reported series, the
average knee motion has varied
from as low as 92 degrees
8
to as
much as 131 degrees.
3
Half of the
patients in the study by Fraser et al
9
had chronic knee pain. This high
incidence of knee problems accen-
tuates the severity of these injuries.
Awareness of this problem, com-
bined with early knee motion, may
help to decrease the occurrence of
this complication.
Additional orthopaedic proce-
dures are frequently required in the
treatment of patients with ipsilateral
femoral and tibial fractures. Bone
grafting, exchange nailing, and
dynamization may be necessary to
encourage union of both the tibial
and the femoral fracture. Delayed
union may often be due to severe
soft-tissue injuries and open frac-
tures with segmental bone loss.
Amputation after ipsilateral

femoral and tibial fractures was
considered unavoidable in many se-
ries. Paul et al
8
reported that 5 of
their 21 patients required ampu-
tation. These amputations were
thought to be the direct result of the
catastrophic trauma that the patients
had sustained. Most amputations
were the result of severe open tibial
fractures that could not be recon-
structed even without the presence
of an ipsilateral femoral fracture.
Adamson et al
5
reported a 32%
incidence of infection in their series
of 34 patients with ipsilateral fem-
oral and tibial fractures. The high
infection rate reflects the magnitude
of this injury pattern. Of the 11
patients with infections, 1 had a fair
result, and 10 had poor results. In-
fection necessitated above-knee
amputation in 3 of the 34 patients.
Adult respiratory distress syn-
drome is a frequent complication in
patients with polytrauma and long-
bone fractures and most certainly in

patients with ipsilateral femoral and
tibial fractures. Pulmonary embo-
lism and death also occur occasion-
ally. In the study by Veith et al,
3
7
(13%) of the 54 patients had fat
embolism syndrome, 3 patients had
pulmonary emboli, and 1 died.
Karlström and Olerud
7
reported on
31 patients whose ipsilateral fem-
oral and tibial fractures were treated
with a variety of methods. Many of
their patients displayed characteris-
tics of multiply injured patients; 6
had fat embolism syndrome, and 4
patients died of their injuries.
Rapid stabilization of ipsilateral
femoral and tibial fractures has been
shown to decrease the incidence of
the systemic problems common to
the multiply injured patient.
11,12
When treating critically ill patients,
the femoral and tibial fractures may
need to be provisionally stabilized,
as the initial focus must be on emer-
gent resuscitation. External fixation

spanning the knee may be the most
appropriate form of treatment for
patients in extremely unstable con-
dition.
Summary
Ipsilateral femoral and tibial frac-
tures are severe injuries that are fre-
quently associated with other ex-
tremity and organ-system injuries.
These fractures are best treated
with early surgical stabilization,
and the decision as to which tech-
nique and type of fixation to utilize
should be made with consideration
of the other injuries to the extremi-
ty. There are numerous advantages
to use of a radiolucent table. Ante-
grade or retrograde nailing of the
femur and antegrade nailing or
osteosynthesis of the tibia allow
rapid stabilization of the fractures
and early mobilization. Due to
positioning problems, femoral neck
and subtrochanteric femoral frac-
tures should be addressed primari-
ly without including the tibial frac-
ture in the procedure. Attention
should be given to the high inci-
dence of knee ligament injuries
found with this injury pattern.

Douglas W. Lundy, MD, and Kenneth D. Johnson, MD
Vol 9, No 4, July/August 2001
245
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