Review Article

Management of the Floating Knee:

Ipsilateral Fractures of the Femur
and Tibia

Heather A. Vallier, MD
Givenchy W. Manzano, MD
Abstract
The “floating knee” is defined as fractures of the ipsilateral femur and
tibia, which consists of a spectrum of injury, and may be in isolation or
part of multiple system trauma for a given patient. A floating knee
may compromise limb viability due to severe soft-tissue and vascular
injury. Expeditious fracture reduction and patient resuscitation are
crucial, while type and timing of provisional and definitive
management is guided by the extent of injury to the involved
extremity and associated systemic injuries. Numerous surgical
techniques are available to treat the floating knee, including external
fixation and internal fixation with plates or intramedullary nails.
Fracture complexity and severity of soft-tissue injury present
challenges, with articular injuries potentially more debilitating in the
long term. Complications such as infection, deep vein thrombosis,
knee stiffness, nonunion, malunion, and posttraumatic arthrosis after
these injuries should be considered.

I psilateral fractures of the tibia and

From the Department of Orthopaedic
Surgery, MetroHealth Medical Center,
affiliated with Case Western Reserve
University (Dr. Vallier and
Dr. Manzano), and the Department of
Orthopaedic Surgery, University
Hospitals Cleveland Medical Center
(Dr. Manzano), Cleveland, OH.
Neither of the following authors nor
any immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Vallier and
Dr. Manzano.
J Am Acad Orthop Surg 2019;00:1-8
DOI: 10.5435/JAAOS-D-18-00740
Copyright 2019 by the American
Academy of Orthopaedic Surgeons.
femur, also known as the floating
knee, are rare injuries that typically
occur in the polytrauma patient.
These fractures are high-energy in-
juries and are often associated with
other severe and potentially life-
threatening injuries. Mortality has
been reported to be as high as 8.6%,1,2
with amputation rates occurring in up
to 27%.2–5 The incidence of this injury
is unknown, but it usually occurs in
patients around their third decade.6,7
The most common mechanism is a
motorized crash.6–8 Factors dictating
the management and prognosis of
these injuries include the systemic state
of the patient, fracture pattern, soft-
tissue and neurovascular injuries, and
associated injuries to other systems.9
Classification
In 1975, Blake and McBryde10 es-
tablished the concept of the “floating
knee” to describe ipsilateral fractures
of the femur and tibia. The floating
knee is a complex injury and is
typically more than a simple ipsilat-
eral fracture of the tibia and femur
and may involve both extra-articular
and intra-articular fracture patterns.
Fraser et al classified the floating
knee into three types11 (Table 1).
Type 1 includes extra-articular frac-
tures of the femur and tibia. Type 2A
refers to extra-articular fractures of
the femur and articular involvement of
the tibia. Type 2B refers to articular
fractures of the femur and extra-
articular involvement of the tibia.
Type 2C includes articular fractures of
both the femur and tibia. Ran et al12
modified Fraser’s classification, re-
porting the type 3 floating knee, which
includes injury to the extensor mech-
anism of the knee. These classification
systems serve to describe the skeletal
elements of the injury but do not
account for injuries to the soft tissues

Month 2019, Vol 00, No 00 1

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of the Floating Knee

Table 1
Surgical Options and Postoperative Rehabilitation for the Floating Knee Using the Classification System
Fraser Classification Implant Options Postoperative Rehabilitation

Type 1 Intramedullary nail or plating for extra-articular Weight bearing as tolerated after nail fixation.
femur and tibia fractures. Staged with an Non–weight bearing after plate fixation.
external fixator if severe soft tissue injury.
Type 2A Intramedullary nail for extra-articular femur Non–weight bearing due to intra-articular
fracture. Plating and/or intramedullary nail for involvement. Hinged knee brace with progres-
articular tibia fracture. Staged with an external sive range of motion based on integrity of knee
fixator if severe soft tissue injury. ligaments.
Type 2B Non–weight bearing due to intra-articular
Intramedullary nail for extra-articular tibia fracture.
Plating and/or intramedullary nail for articular involvement. Hinged knee brace with progres-
femur fracture. Staged with an external fixator if sive range of motion based on integrity of knee
severe soft tissue injury. ligaments.
Type 2C Plating and/or nailing for articular femur and tibia Non–weight bearing due to intra-articular
fractures. Staged with an external fixator if involvement. Hinged knee brace with progres-
severe soft tissue injury. sive range of motion based on integrity of knee
ligaments.
Type 3 Intramedullary nail and/or plating for the femur Weight bearing as tolerated after nail fixation.
and tibia. Fixation or partial patellectomy for the Non–weight bearing after plate fixation. Hinged
patellar fracture. Transosseous fixation of the knee brace locked in extension with transition
ruptured quadriceps or patellar tendon. Staged to progressive range of motion based on injury
with an external fixator if severe soft-tissue to the extensor mechanism.
injury.

or knee ligamentous complex. Fur-
thermore, they do not guide treat-
ment principles or provide prognostic
information.
Initial Assessment
A floating knee after high-energy
mechanism may be associated with
massive hemorrhage, particularly if
the fractures are open and/or if an
associated arterial injury is present.
Most patients with a floating knee
also have concurrent injuries, which
may be life threatening. Some patients
present in critical condition.6
Advanced Trauma Life Support prin-
ciples of airway, breathing, and cir-
culation are initiated on presentation,
followed by the stepwise Advanced
Trauma Life Support algorithm for
evaluation and care after trauma.13
After the patient is clinically stabilized,
a secondary and tertiary evaluation is
undertaken to assess for other injuries.
Feron et al6 reviewed 172 cases of
floating knee in a multicenter setting
and reported 38% with severe head
injury, 25% with combined head-
thorax injury, and 68% with other
limb fractures. Associated injuries in
the polytrauma patient affect man-
agement and prognosis. In particular,
floating knee patients with vascular
injuries have worse Karlstrom func-
tional outcomes than patients without
vascular injuries.14 Furthermore, pa-
tients with concurrent head injuries
have higher risk of pulmonary com-
plications, and early stabilization of
lower extremity long bone fractures
has been shown to mitigate these
adverse events.15,16
A systematic approach is needed to
evaluate the floating knee, which
should start with a thorough history
of the mechanism of injury. Radio-
graphs of the involved extremity
from the hip to the ankle should be
ordered to characterize the fracture
and to assess for subluxation or dis-
location of the knee, which occurs
infrequently17,18 (Figure 1). Mor-
bidly obese patients are at higher risk
of dislocation.17 Clinical examina-
tion includes evaluation of any
wounds and documentation of
motor and sensory neurologic func-
tion and vascular status.19 Up to
80% of these injuries may be open.20
Feron et al6 reported 38% with an
open femur fracture and 57% with
an open tibia fracture. Appropriate
antibiotic coverage for open wounds
should be based on the energy of
injury, complexity of wounds, degree
of contamination, and setting where
the injury occurred.21
Vascular compromise has been
reported in up to 29% of patients
with a floating knee.6,13,22 If no
extremity pulses are initially appre-
ciated on initial evaluation, ensure
that the fracture and any associated
knee dislocation are reduced and
then reassess the pulses by palpation
and with Doppler if needed. Absent
pulses warrant emergent vascular
consultation. In the presence of an
asymmetrical pulse (compared with
the contralateral extremity), the ankle-
brachial index should be obtained to
evaluate for possible vascular injury. If

2 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Heather A. Vallier, MD and Givenchy W. Manzano, MD

Figure 1

AP radiographs of a 25-year-old woman who sustained ipsilateral open fractures of the femur and tibia and a knee
dislocation with vascular injury and common peroneal nerve palsy in a motorcycle crash (A and B). She underwent
emergent closed reduction of the dislocation followed by débridement and fixation of the femur and tibia, with plating through
the open fracture wounds. External fixation of the knee and a lateral four-compartment fasciotomy were performed after
revascularization (C). She then had delayed knee repair of the knee ligaments, lateral meniscus, and posterolateral corner.

the ankle-brachial index is less than
0.9, CT angiography should be or-
dered and vascular surgery consulted.19
Initial Management
Initial assessment and resuscitation
of the patient with a floating knee
occur concurrently in a multidisci-
plinary fashion.23 Figure 2 is a sug-
gested algorithm for managing the
patient with a floating knee. Intra-
venous antibiotics are administered
for open fractures. Patients with
pulseless extremities are emergently
revascularized when their injuries
and systemic status permit. Those
with nonreconstructable injuries are
treated with primary amputation, and
those with massive life-threatening
hemorrhage may also be indicated
for amputation, if attempted salvage is
deemed by the treating surgeons to be
acutely incompatible with survival.
Numerous lower limb extremity
severity scores have been proposed to
guide clinical decision making on
whether amputation is the most suit-
able treatment. These scoring systems
include the Mangled Extremity Sever-
ity Score, Limb Salvage Index, Predic-
tive Salvage Index, and Hannover
Fracture Scale-97 for ischemic and
nonischemic limbs. In addition, an
insensate plantar foot was previously
considered an absolute indication for
amputation.24,25 However, the Lower
Extremity Assessment Project study
demonstrated that an insensate plan-
tar foot on presentation did not prove
to be predictive of eventual plantar
sensation or functional outcome.26 In
addition, the Lower Extremity
Assessment Project study did not show
utility of any of the above lower
extremity severity scores for deter-
mining limbs that require amputation
or those likely to be successfully sal-
vaged.27 Amputation has been sug-
gested when limb salvage poses
notable risk to patient survival, when
functional result would be superior,
and when duration and course of

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Management of the Floating Knee
Figure 2
Suggested algorithm of managing the floating knee patient. ABI = ankle-brachial
index
salvage would cause intolerable psy-
chological disturbance, depending on
the baseline psychosocial patient state.
After resuscitation, patients may
become stable enough to undergo
definitive management; however,
soft-tissue considerations and frac-
ture complexity may warrant staged
management. In a community practice
setting, a damage control approach
with application of an external fixator
may be reasonable followed by transfer
to a trauma center. Patients are con-
sidered adequately resuscitated for
surgical intervention when hemody-
namically stable without pressor sup-
port and when initial metabolic
acidosis has improved to venous
4 Journal of the American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
lactate ,4.0 mmol/L, pH $ 7.25, or
base excess $ 25.5 mmol/L.28 Pa-
tients who are insufficiently resusci-
tated may be indicated for provisional
external fixation, skeletal traction,
or continued splinting, depending on
their injuries. Rarely, severe head
injury or progressive cardiac defi-
ciency may also warrant surgical
delay.
Definitive Management
Nonsurgical management is rarely
indicated for the floating knee. Aki-
nyoola et al29 reported high rates
of malunion and dysfunction after
nonsurgical care. Surgical manage-
ment has progressed over the years
because of improvements in both
fixation strategies and systemic
management of multiply injured
patients. Early stabilization of femur
and tibia fractures promotes upright
posture and mobility from bed,
reducing pulmonary and thrombotic
complications.28 Accurate reduction
and stable internal fixation to restore
articular and mechanical alignment
are the goals of orthopaedic man-
agement to optimize later function.
The characteristics of the Fraser type
1 through 3 floating knee can be
used to guide surgical implant choice
(Table 1). Nevertheless, owing to the
variability of pattern among these
injuries, a combination of plates and
nails are used for approximately
40% of floating knees.30 Each frac-
ture is unique, and treatment should
be decided based on patient factors,
fracture pattern, and the extent of
soft tissue injury.
Type 1 Floating Knee
The purely extra-articular pattern of
these fractures makes intramedullary
nailing an appealing treatment
option for these injuries, which al-
lows for load sharing and earlier
weight bearing. The femur should
be stabilized first, as the tibia can
be reliably splinted on a temporary
basis, while not relegating the patient
to further skeletal traction and
recumbency.31 Nailing of the femur
can be performed either antegrade or
retrograde depending on the fracture
and on the surgeon’s experience.
Antegrade nailing may be beneficial
in the presence of open wounds
about the knee, as such injuries could
further contaminate the femoral
medullary canal if a retrograde
technique is used. However, numer-
ous studies have demonstrated that a
single-incision technique (for retro-
grade femoral nail and infrapatellar
tibial nail) has shorter setup and
 Heather A. Vallier, MD and Givenchy W. Manzano, MD

Figure 3

AP radiographs of a 34-year-old woman who sustained left femoral and tibial fractures in a motor vehicle collision (A and B).
The femoral fracture included an intercondylar injury, which was treated with open reduction and screw fixation, before a
retrograde intramedullary nail of the femur and intramedullary nail of the tibia (C and D).

surgical times and less bleeding, but
mixed functional outcomes.6,32 In-
tramedullary nailing of ipsilateral
femur and tibia fractures may be
at risk of malunion and possibly
rotational deformity where sub-
stantial bone loss and shortening is
found.31
Despite the appeal of intramedullary
nailing, Fraser type 1 fractures can
also be treated with plates, which
may be particularly helpful when
poor bone stock exists and a short
distal segment is found. Plating may
also be preferable for patients with
underlying genetic or metabolic
bone diseases, which alter the shape
of the femur and tibia. Finally,
plating may be expeditious for pa-
tients with large adjacent open
wounds conducive to implant place-
ment and for patients with multiple
long bone fractures, where canal
reaming and instrumentation pro-
duces substantial pulmonary em-
bolic burden.12 Such patients often
have associated chest injury, which
further compromises their ability to
withstand a large embolic inflam-
matory load.
Type 2 Floating Knee
The combination of extra-articular
and articular fractures makes this
injury amenable to treatment with a
combination of intramedullary nail-
ing of the extra-articular fracture
and open reduction and internal
fixation with plates for the articular
fracture. Extreme nailing of the
tibia and femur can also be per-
formed with extra-articular frac-
tures with simple intra-articular
extension patterns. In this situa-
tion, the articular surface is first
reduced and fixed followed by in-
tramedullary nailing (Figure 3).
Although open direct reduction
and internal fixation in the type 2
floating knee addresses the intra-
articular fractures, the exposure
also allows the surgeon to address
potential concomitant intra-articular
soft-tissue pathology such as a lateral
meniscus tear, more easily.
Type 3 Floating Knee
The involvement of the extensor
mechanism adds to the complexity
and challenge of treating the type 3
floating knee. The femur and tibia
fractures should be managed simi-
lar to the type 1 and type 2 floating
knees. If the patella is fractured,
multiple options exist, including
tension band wiring, plating, or
partial patellectomy with tendon
advancement in cases with sub-
stantial bone loss or when a patient
has low functional demands. In
the presence of disruption of the
quadriceps or patellar tendon,
transosseous repair should be
performed.
Additional Considerations
Knee Ligament Injuries
The incidence of knee ligament in-
juries in the floating knee has been
reported to be as high as 53%.33
An anterior cruciate ligament in-
jury is the most common associated
ligament injury followed by the
posterior cruciate ligament, menis-
cus, and collateral ligaments.33
Early identification of these injuries
is important, as cruciate repair may
be a challenge after placement of a
retrograde femoral nail.

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Management of the Floating Knee
Fat Embolism Syndrome
Fat embolism syndrome is very rare
now that long bones are nailed so
soon after the injury, in contrast to
the past when fractures were not
stabilized acutely. Nevertheless, fat
embolism presents a common threat
in the patient with a floating
knee.4,10,34 Therefore, checking the
fraction of inspired oxygen (FiO2)
after each nail is placed is important
to decide whether to proceed with
fixing subsequent bones. A decrease
in the FiO2 value after nailing can be
suggestive of an intraoperative
embolic event. For example, if the
FiO2 value is decreased after nailing
the femur, plans for nailing the tibia
may be deferred. The tibia may be
stabilized with a plate or provision-
ally with an external fixator, with
plans to return for definitive, med-
ullary fixation at a later date. In a
patient with multiple, midshaft long
bone injuries, as is the case with
bilateral floating knees, the pulmo-
nary burden caused by instrument-
ing all four canals to place
intramedullary nails is very high,
especially in people with a small
femoral canal and a simple fracture
pattern.
Bone and Soft-Tissue Defects
The high-energy nature of the float-
ing knee can result in substantial soft-
tissue injury and bone loss. When
soft-tissue loss that cannot be closed
primarily is found, negative-pressure
wound therapy (NPWT) may be
helpful to reduce edema and micro-
scopic contamination and to promote
circulation and oxygenation. No
studies have evaluated the utility of
NPWT, specifically in the floating
knee. However, Dedmond and col-
leagues demonstrated that NPWT
reduces the frequency of muscle flap
coverage for open tibial shaft frac-
tures,35 although infections are still
common after Gustillo 3B open
fractures.36 In cases with severe bony
defects, options for staged manage-
6 Journal of the American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
ment include antibiotic cement in the
form of a bead pouch or solid spacer
with delayed definitive management
with a bone graft.37
Early and Late
Complications
Many of the complications associ-
ated with the floating knee are also
seen in polytrauma patients with
long bone injuries. However, owing
to the high-energy nature of the
floating knee, associated injuries,
and combination of complex bony,
ligamentous, and other soft tissue
injuries, patients are at greater risk
of complications.23 Complications
related to the floating knee include
superficial and deep infection,
excessive blood loss, fat embolism,
malunion, delayed union or non-
union, knee stiffness, and prominent
implants. These complications may
lead to unplanned procedures, longer
hospital stay, and prolonged immo-
bility, all of which ultimately may lead
to worse functional outcomes.23 These
complications can be categorized as
early or late.
Early Complications
Many of the early complications
associated with the floating knee
are those of other high-energy poly-
trauma patients with long bone
fractures and include pneumonia,
acute respiratory distress syn-
drome, multiple organ failure,
infection, deep vein thrombosis
(DVT), and pulmonary embolism.
As a result of possible prolonged
immobilization, the floating knee
patient may be more likely to
develop DVT. DVT has been
reported in up to 25% after a
floating knee injury.6,38 Expedi-
tious resuscitation, early fixation,
and mobilization to an upright
posture are key in minimizing
early pulmonary and thrombotic
complications.
Late Complications
Late complications after the floating
knee include stiffness, nonunion,
malunion, heterotopic ossification,
prominent implants, and posttrau-
matic arthrosis. The rates of non-
union in the literature are 4% to 11%
for the femur and 3% to 30% for the
tibia.5–8,14,29,39–42 According to
Feron et al,6 risk factors for non-
union in the floating knee are age,
sex (24.3% women versus 16.2%
men), and segmental pattern (AO
type 32-C [50%] or 42-C [44%]).
Fraser type did not influence the risk
of nonunion (type 1-22%, type 2A-
7.1%, type 2B-20%, and type 2C-
3%).6 However, Dahmani et al43 did
find that Fraser type was a risk factor
for nonunion. Malunions are rela-
tively common in this injury and
have been reported to occur in 3% to
33% of patients with a floating
knee.43,44 This variability suggests
the difficulty in obtaining the correct
axis in case of the floating knee.43
Regarding heterotopic ossification,
Kent et al45 reported more hetero-
topic ossification around the knee in
floating knee patients treated with a
retrograde femoral nail when com-
pared with treatment with the ante-
grade femoral nail group (90%
versus 43%). They also found more
heterotopic ossification in the patel-
lar tendon in the retrograde group
when compared with the antegrade
group (74% versus 29%).45 How-
ever, no association was found
between the severity of heterotopic
ossification and knee range of
motion.45 Stiffness after manage-
ment of the floating knee has been
shown to be associated with a his-
tory of tobacco smoking, higher
Injury Severity Score, and open
fractures.39
Functional Outcomes
Functional results of the floating knee
are difficult to assess because of

variability of evaluation criteria.
The functional assessment after
management of the floating knee is
evaluated by most authors using the
Karlstrom and Olerud44 grading
system (Table 2, Supplemental Dig-
ital Content 2, http://links.lww.com/
JAAOS/A382). Satisfactory results
range from 28% to 90% in previous
reports.1,3,6,11,43,44 A major limita-
tion of this grading system is that
a poor score in one factor will
generate a poor global score, but no
other scoring systems are presently
available. Furthermore, no studies
exist using modern patient-reported,
validated functional outcome scores
in the floating knee patient.
Numerous factors have been
shown to influence functional out-
come after the floating knee. Func-
tional outcomes have been associated
with age,39 vascular involvement,
articular involvement,41 and open
fractures. The Injury Severity Score
has not been shown to influence
functional outcomes.6 However,
from our experience, fractures that
are open with severe intra-articular
comminution, along with severe soft-
tissue injuries, portend poor func-
tional outcomes. Yokoyama et al41
also found that the severity of dam-
age to the knee joint, open tibial
fractures, and time delay before
definitive fixation were all notable
factors contributing to functional
outcome after floating knee injuries.
Hee et al39 found that open fractures
predicted the likelihood of knee
stiffness and delayed full weight-
bearing ability. An overall trend is
that Fraser type 1 floating knees
have better outcomes compared with
type 2,6,43 but data in studies may
be skewed because type 1 floating
knees are more common. However,
a few series have focused purely on
Fraser type 2 floating knees.4,22,46
Adamson et al reported only 24% of
type 2 floating knees to have satis-
factory outcomes according to the
Karlstrom-Olerud criteria. Jain et al22
Month 2019, Vol 00, No 00
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Heather A. Vallier, MD and Givenchy W. Manzano, MD
evaluated type 2A fractures consist-
ing of a tibial shaft fracture and
ipsilateral Hoffa fracture and re-
ported an average knee society score
of 163 (range 127 to 182). Hung
et al5 compared type 2A and 2B
floating knees with type 1 and type 3
floating knees. They reported that
type 2A has similar outcomes to type
1, but type 2B and type 3 have worse
prognosis. The type of surgical
treatment has also been shown to
influence outcome. Rios et al32 sug-
gested that placing a retrograde
femoral nail and antegrade tibial nail
through a single incision is associ-
ated with better outcomes for type 1
injuries. However, whether to
perform a single-incision technique
or a dual-incision technique con-
sisting of an antegrade femoral nail
and tibial nail remains a controver-
sial topic.30,32,43
Postoperative Care
Early mobilization is critical for pa-
tients with a floating knee. Patients
should be involved in a rigorous
physical therapy program with a
focus on progressive weight bearing
and knee range of motion. Weight-
bearing status should be determined
on an individualized basis and de-
pending on the presence of articular
fractures and other lower extremity
injuries. The complexity of the frac-
ture and the integrity of the knee lig-
amentous complex may prescribe the
postoperative rehabilitation course
for weight bearing and knee range of
motion (Table 1).
Summary
The floating knee is a devastating
injury that often results from a high-
energy mechanism. Patients may
present in critical condition with
other associated injuries. Type 1
floating knees typically do well
from a functional perspective and are
best treated with intramedullary
nailing. Type 2 floating knee out-
comes are related to articular
involvement and associated liga-
mentous injuries. The floating knee
continues to be challenging to treat.
Expeditious initial assessment and
resuscitation followed by the appro-
priate method and timing for defini-
tive management that incorporates
systemic, soft tissue, and fracture
considerations will mitigate the risk
of complications. Further study
regarding features affecting validated
patient-reported functional out-
comes appears indicated.
References
References printed in bold type are
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