hip or knee dislocations are usually treated as a surgical emergency , but ipsilateral hip and knee dislocation should be considered a dual emergency that must be addressed immediately and reduced at the earliest .
we present here the sequence of events and the final functional outcome of one such rare injury manages by us .
he presented to the emergency department in 4 h injury time with painful deformities of the right hip and knee , along with type i open wound right leg with abnormal mobility suggestive of fracture in the ipsilateral leg .
simultaneous ipsilateral hip and knee fracture - dislocation with open tibial fracture is a rare injury that should be approached as limb - threatening injury and dual orthopedic emergency .
we report this case for its rarity and to document that good results can be achieved with early appropriate treatment .
the dislocation of hip or knee is usually treated as a surgical emergency , but ipsilateral hip and knee dislocation should be considered as dual emergency that must be addressed immediately and reduced at the earliest .
when it presents along with neurovascular compromise , it threatens the limb survival and the outcome may be poor .
we report a case who presented to us with an ipsilateral hip and knee dislocation with type i open fracture distal fourth both bones of the same leg and absent pulse with common peroneal nerve palsy .
we present here the sequence of events and the final functional outcome of this rare injury .
a 22-year - old male , driver of the car was involved in a road traffic accident when his car hit against a bridge with his ipsilateral hip and knee in flexion .
he presented to the emergency department in 4 h injury time with painful deformities of the right hip and knee , along with type i open wound right leg with abnormal mobility suggestive of fracture in the ipsilateral leg . on examination
, he was drowsy and disoriented with a glasgow coma scale 8/15 and found to be hemodynamically unstable .
physical examination of the extremities revealed a flexed and adducted right hip with the right knee flexed to 30 and with posterior dislocation ( fig .
however , the doppler showed weak signals over posterior tibial and dorsalis pedis artery , and the toes were found to be warm with delayed capillary filling .
radiographs showed a posterior dislocation of the right hip and posterior dislocation of right knee with comminuted fracture right distal tibia ( fig .
the firstly , an ankle spanning exfix was applied to address the distal tibial fracture , and the knee dislocation was reduced by gentle traction given to the leg .
further traction on the right hip with the hip in 90 flexion with an assistant stabilizing the pelvis reduced the right hip dislocation , which was found to be stable after reduction .
then , ankle spanning external fixator extended to span the knee . immediately following the procedure , distal pulses were clinically not palpable but
relatively good flow was noted in the doppler both in the posterior tibial and dorsalis pedis artery .
the patient was on continued ventilator support for 48 h in intensive care unit and serial monitoring of the right lower limb vascularity was done using doppler .
post reduction ct of the pelvis showed only a minor posterior wall fracture with congruently reduced hip joint ( fig .
distal pulses were felt clinically from 4 day following which locking compression plate fixation of distal tibia was done .
postreduction computed tomography pelvis shows minor posterior wall fracture with congruent hip . at 6 weeks , external fixator was removed and bone grafting was done for the distal tibial fracture and the right knee gently manipulated . the distal tibial fracture healed in 4 months with good recovery of common peroneal nerve .
magnetic resonance imaging ( mri ) of right knee showed posterior cruciate ligament ( pcl ) avulsion fracture and lateral collateral ligament avulsion fracture ( fig .
4 ) . it was planned arthroscopic evaluation which showed a torn pcl at tibial attachment and torn anterior cruciate ligament ( acl ) at anterolateral bundle but the continuity maintained with posterolateral bundle .
arthroscopic pcl reconstruction using bio screws and open posterolateral corner repair using hamstring graft and endobutton was done .
post - operative rehabilitation included the protocol for multi - ligament instability . at 2 years follow - up , he had full range of movements at the right hip and knee .
there was complete recovery of the common peroneal nerve ( fig . 5 , 6 ) .
magnetic resonance imaging shows posterior cruciate ligament avulsion fracture at tibial attachment , posterolateral corner injury , and lateral collateral avulsion fracture .
- ray pelvis shows viable femoral head , and x - ray of knee and leg shows stable knee and healed tibial fracture . good range of movements at right hip and knee .
the patients presenting with hip or knee dislocation are usually treated as true orthopedic emergencies , as they usually occur following very high energy violence .
when hip and knee dislocation presents simultaneously , it should be approached as dual emergency as other associated systemic injuries may be present .
the general physical examination with appropriate x - rays of the injured part should be performed on the arrival to the emergency room .
the neurovascular status of the injured lower limb should be documented and it should be serially monitored .
hip dislocations in these injuries occur following axial forces acting on the flexed hip and are often associated with acetabular fractures , particularly posterior wall .
hip dislocations should be reduced as early as possible to decrease the incidence of avascular necrosis of the femoral head , secondary arthritis of hip and nerve injury .
the extent of acetabular involvement and the stability of hip following reduction determines the management .
when it involves > 65% of the posterior wall reconstruction of the acetabular wall is essential for the stable hip .
post reduction ct scan is sensitive in planning the post reduction management . in our case ,
post reduction ct showed a posterior wall rim fracture involving < 10% with congruent containment of hip .
but in some cases of irreducible or unstable hip following closed reduction may require open reduction [ 1 , 2 , 3 , 4 ] .
some authors have used schanz screws in the proximal femur in aid reduction of hip to minimize further injury to neurovascular injury at knee [ 1 , 5 ] . a knee dislocation can be accompanied by popliteal artery injury .
of these three studies had no surgical requirement for patients with normal pulses [ 7 , 8 , 9 ] .
the investigation modalities have been followed with different opinion are ankle - brachial index , angiography , color duplex scan , ct angiography , and recently mri angiography .
the most appropriate vascular evaluation for a patient with a knee dislocation without signs of ischemia and palpable or weak pulses continues to be controversial . in our case , we used serial doppler along with pulse oximeter waveform for monitoring and the doppler signals were compared to the uninjured side .
mri provides critical information regarding ligament injuries , meniscal injuries , chondral injuries , and fractures to guide treatment , particularly after an acute knee dislocation . in patients
who present 6 weeks or later , mri may not provide as clear of a picture of the injury pattern .
therefore , in chronic injuries , it is important to rely on the clinical examination findings in addition to the mri findings to determine the pattern of injury .
approximately , 50% of knee dislocations are associated with tears of the acl , whereas 75% are associated with tears of the pcl .
many authors have debated about the timing of intervention , the type of reconstruction and operative versus nonoperative treatment .
however , recent studies have shown that improved functional and clinical outcomes in operative treatment compared with nonoperative treatment .
immediate surgical intervention is absolutely indicated for irreducible knee by closed reduction or an unstable knee , which requires a vascular repair and open knee dislocation . in these instances , avulsion fractures or cruciate and collaterals
can be fixed with nonabsorbable sutures . if there are no injuries that need to be addressed acutely , the timing of surgery is largely dependent on the patient general condition , the condition of the knee and surgeon preference .
analyzed five studies that compared early versus delayed surgery . among them , two studies showed no statistical difference in outcome scores and found a statistical difference in higher sports activities in another three studies . in our case , because of head injury and open tibial fracture on the same leg , it was planned for late reconstruction .
however , the functional outcome was excellent at final follow - up . neurological involvement in hip dislocations occurs in approximately 10% and partial recovery can be expected in 60 - 70% cases .
the peroneal branch is most commonly involved . in knee dislocations , nearly 20 - 40% is complicated by common peroneal nerve palsy and prognosis is fairly poor as recovery is incomplete in 50% of the patients . in our case ,
common peroneal nerve was injured at the level of the knee and full recovery was observed in 6 months .
simultaneous ipsilateral hip and knee fracture - dislocation with open tibial fracture is a rare injury that should be approached as limb - threatening injury and dual orthopedic emergency .
we report this case for its rarity and to document that good results can be achieved with early appropriate treatment .
hip and knee dislocations are emergencies which should be treated immediately . in this case report
, we have discussed the technique for reduction of ipsilateral hip and knee dislocations with ipsilateral open both bones fracture leg .
when you are unable to feel distal pulses clinically , we can use doppler for vascularity monitoring .
ligament injury of the knee also should be addressed , and acl can also be intact in knee dislocations .
 introduction : hip or knee dislocations are usually treated as a surgical emergency , but ipsilateral hip and knee dislocation should be considered a dual emergency that must be addressed immediately and reduced at the earliest . 
 we present here the sequence of events and the final functional outcome of one such rare injury manages by us.case report : a 22-year - old male was involved in a road traffic accident . 
 he presented to the emergency department in 4 h injury time with painful deformities of the right hip and knee , along with type i open wound right leg with abnormal mobility suggestive of fracture in the ipsilateral leg.conclusion:simultaneous ipsilateral hip and knee fracture - dislocation with open tibial fracture is a rare injury that should be approached as limb - threatening injury and dual orthopedic emergency . 
 we report this case for its rarity and to document that good results can be achieved with early appropriate treatment . 
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Introduction
Case Report
Discussion
Conclusion