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 References 1. Blake R, McBryde A Jr: The floating knee: Ipsilateral fractures of the tibia and femur. South Med J 1975;68:13-16. 2. 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Yue JJ, Churchill RS, Cooperman DR, Yasko AW, Wilber JH, Thompson GH: The floating knee in the pediatric patient: Nonoperative versus opera- tive stabilization. Clin Orthop 2000; 376:124-136. . 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