A 27-year-old woman who suffered a high-energy trauma after being hit by a car presents herself to the Emergency Department of a trauma hospital level III with multiple trauma. After initial ABDCE by ATLS, she was suffering from pain in the pelvis, left arm, and both knees. On physical examination, there was deformity and edema in the left arm with functional disability, but without neurovascular changes. The pelvis presented with pain on palpation, but without instability. The knees were quite edematous without blisters and apparent varus deformity bilaterally. Varus stress was positive grade III. She had a negative anterior and posterior drawer exam. Dorsalis pedis and posterior tibial pulses were normal, as well as the neurological examination of the normal lower limb. The skin was intact for all injuries.
Left arm radiographic examination showed a distal third left diaphyseal humerus's fracture that was classified as AO/ASIF (Arbeitsgemeinschaft Osteosynthesefragen/Association for the Study of Internal Fixation) 12 B2C. Radiography of the pelvis showed right pubic branch fracture with minimal deviation (Tile/AO A1). Radiographic examination of the knees showed bilateral avulsion fractures of the fibular head associated with the arcuate signal, being classified as AO/ASIF 41 A19 (Figure 1). For a better definition of the fracture pattern, fragment size, and surgical planning, a CT (Computerized Tomography) scan of both knees was performed (Figure 1). The pelvis fracture was treated nonsurgically. The humerus fracture was initially immobilized, and surgical treatment was performed later with open anatomical reduction and fixation with a dynamic compression plate associated with an interfragmentary screw. Bilateral immobilization on the knees was performed temporarily, and surgical treatment was performed seven days after hospitalization because it was the time needed for edema regression.
The procedure was performed on a radiolucent operating table in a horizontal supine position with spinal anesthesia associated with a regional ultrasound-guided femoral nerve block (LOGIQ S8, GE Healthcare , USA) with a high-frequency linear transducer (8-15 MHz). It was performed pneumatic tourniquet with pressure 100 mmHG above the systolic pressure first on the right side. After the first procedure was finished, the pneumatic tourniquet was deflated and the contralateral side surgical procedure was begun. The posterolateral rotatory drawer maneuver and dial test were performed under anesthesia at this time, which were positive lesion of the posterolateral corner. The first knee to be operated (right knee) was placed at 70  of flexion, while the other (left knee) was in full extension on the radiolucent surgical table. A lateral curvilinear hockey stick incision was made parallel to the posterior aspect of the ITB, curving over the lateral femoral condyle towards distally to the area between Gerdy's tubercle and the anterior aspect of the fibular head. An excessively anterior incision in the skin makes access and dissection of the common fibular nerve difficult. Initially, the common fibular nerve was dissected and isolated, leaving it marked with a cardiac tape without any traction.
Fibular head's comminuted fracture with the conjoint tendon (biceps femoris long head and lateral collateral ligament) inserted without injury was identified. Also, it was observed a single large fragment of the lateral edge of the tibia with an ALL complex inserted without injury. Krackow suture was performed with No. 5 ethibond thread in the conjoint tendon together with the posterolateral ligament complex (Figure 2(a)). The tibial fragment was provisionally fixed with three 2.0 Kirschner wire and, after checking the reduction, definitively fixed with two 4.5 mm cannulated screws and two washers (Medtronic Sofamor Danek Inc., Memphis, TN, USA). Transosseous tunnels were performed in the fibular head (10 mm distal to the fracture line and were 15 mm away from each other) to fix the posterolateral ligament complex (Figure 2(b)). On the left knee, the exact same access was used. Isolation of the fibular nerve and cardiac tape marking was performed. Multifragmentary fracture of the lateral edge of the tibia with the insertion of the integral ALL complex was observed, as well as fibular head avulsion fracture with multiple microfragments with an intact conjoint tendon. Krackow suture was performed in the conjoint tendon together with the posterolateral ligament complex (PLC) and another suture, separately, in the iliotibial band (Figure 2(c)). Transosseous PLC fixation was performed on the fibular head, and the main fragments were fixed on the lateral margin of the tibia with 1.5 Kirschner wires. The ALL complex was fixed by a pull-out technique, creating a transtibial tunnel and tied to a 3.5 DCP plate (Medtronic Sofamor Danek Inc., Memphis, TN, USA) in an anterior cortex placed through anterior mini access (Figure 2(d)). Control radiography was performed intraoperatively on both knees (Figure 3).
The postoperative period was performed with a specific physiotherapy protocol similar to that used for PLC ligament injuries. In the immediate postoperative period, the knees were kept in an articulated brace with a range of motion (ROM) gradually allowed (1-2 weeks: 0 -60 ; 3-4 weeks: 0-90 ). After the 5th week, progression occurred to complete ROM in order to avoid arthrofibrosis. Isometric exercises of quadriceps, hamstrings, sural triceps, and anterior tibialis, as well as active and passive range of motion of the hip, knee, and ankle, were performed from the first postoperative day. In relation to the other lesions, she developed a slight superficial infection of the surgical wound on his left arm in the immediate postoperative period, which was treated only with serial dressings and an oral antibiotic for 5 days. Pubic branch fracture remained well throughout the follow-up, with no deviation. Weightbearing was not allowed in the first four weeks. The brace was discontinued after the first month, being used only during weight-bearing which was started after thirty days of surgery with two axillary crutches. Full weight-bearing was allowed only after two months of surgery. Outpatient returns were performed 15, 30, 60, 120, and 180 days after surgery.
The patient evolved well in the late postoperative period, showing fracture consolidation after three months of surgery. She had normal walking with a full range of motion of the hip, knee, and ankle (Figure 4). She did not present anteroposterior instability to the stress tests (Lachman, anterior drawer, posterior drawer, and pivot shift), nor valgus and varus instability. She felt no pain after 3 months. She returned to his usual sport (volleyball) after 180 days with a Lysholm functional score 15/95 points (excellent).