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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 fra

In 1975, Blake and McBryde1coined

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 traction2to

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,3,4as 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

al8noted 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,927% of the patients had intracranial trauma, 15% had pelvic fractures, and 10% had chest injuries Omer et al2found 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 al8 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 stabilizafixa-tion 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 Ipsilateral Fractures of the Femur and Tibia

Douglas W Lundy, MD, and Kenneth D Johnson, MD

tery In their series of floating-knee

injuries with intra-articular

exten-sion, Adamson et al5noted 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 al9

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,817 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 al6

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 McBryde1proposed 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 Olerud7 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 al9offered 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

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

al3reported 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

al11and Johnson et al12have 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 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 McBryde1 used primary nonoperative treat-ment in 26 of the 37 femoral frac-tures and all of the 37 tibial fracfrac-tures

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 al3 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

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.

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 authors13-15have 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 al6reported 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 femfem-oral 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-trum17 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 Johnson18described 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 al21 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

al22compared 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 reducfixa-tion and inter-nal fixation of a tibial plateau fracture (B).

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 treevalu-ated 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 retroante-grade 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 anguladistrac-tion, 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.

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 fixareduc-tion.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 posteante-rior 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

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

nails are used for subtrochanteric fractures

external fixation in severe patterns

fractures

intra-articular fractures external fixator

type I injuries (diaphyseal fractures

of the femur and tibia), satisfactory

clinical outcomes can be expected as

the norm Veith et al3reported 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 al24 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 al5 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 degrees8 to as much as 131 degrees.3 Half of the patients in the study by Fraser et al9 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 al8reported 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 al5 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,37

(13%) of the 54 patients had fat embolism syndrome, 3 patients had pulmonary emboli, and 1 died Karlström and Olerud7 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 retroAnte-grade 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

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