The dislocation of the hip, knee, and/or ankle joint typically necessitates prompt surgical intervention, yet the co-occurrence of ipsilateral hip, knee, and ankle fracture-dislocation demands heightened urgency, constituting an emergency warranting immediate attention and expeditious care ^[1]. Such injuries are predominantly resulting from high-velocity motor vehicle collisions ^[2]. When associated with neurovascular compromise, these injuries are further complicated by the challenges of limb viability, and the prognosis is unfavorable if not properly managed. We document a case presented in the emergency department with ipsilateral hip fracture-dislocation, knee fracture-dislocation, and bimalleolar ankle fracture with ankle subluxation. In this discourse, we delineate the chronological events of management and elucidate the ultimate functional outcome of this infrequent injury.

A 41-year-old male motorcyclist sustained a road traffic accident (2 weeks vs. 4 weeks) presented to the 41-year-old male motorcyclist sustained a road traffic accident (2 weeks vs. 4 weeks) and presented to the emergency department of the tertiary care center, presenting his left hip in an attitude of flexion, adduction, and internal rotation, left knee swollen and posterior dislocated and left ankle swollen and valgus deformity, along with a lacerated wound of 3 cm over the right mid-leg (Fig. 1). The advanced trauma life support protocol was followed, and initial management was started. The range of movements at the hip, knee, and ankle joints was painful and restricted. After initial stabilization, radiographs were done and a diagnosis of the left-sided posterior hip dislocation with posterior wall rim fracture with knee fracture-dislocation with bimalleolar ankle fracture (Lauge-Hansen type Supination External Rotation) with ankle subluxation which was established on X-rays (Fig. 2).

Closed reduction of the left hip and left knee was done under mild sedation anesthesia in the emergency department, and calcaneal skeletal pin traction with an above-knee slab was applied to maintain the reduction. The knee dislocation was reduced by gentle traction applied to the leg. Further traction on the left hip with the hip in 90° flexion with an assistant stabilizing the pelvis, Allis 90/90 hip reduction maneuver, reduced the left hip dislocation which was stable post-reduction. During the procedure, anterior tibial artery, dorsalis pedis artery, and posterior tibial artery pulses were clinically checked regularly and were palpable. Post-reduction X-rays confirmed the reduction (Fig. 3). A computed tomography (CT) scan of the pelvis showed only a small posterior wall fracture fragment (Thompson-Ebstein type-1) with a congruently reduced hip joint, without any intra-articular loose body (Fig. 4). Magnetic resonance imaging (MRI) with CT scan was performed for the left knee was suggestive of tibial avulsion of the anterior cruciate ligament (ACL) (Mayer-Mckeever type 2) and lateral collateral ligament grade I tear at the femoral insertion along with proximal tibia fracture (Fig. 5 and 6).

The patient was transferred to the ward and after 4 days when the swelling subsided, shifted to operation theater, and given combined spinal epidural and positioned supine. He underwent open reduction internal fixation (ORIF) with raft plate (7H) for the proximal tibia fracture (Hohl and Moore type 2) and 2 Herbert screws for the tibial spine fracture (3.5 mm, 40 mm × 2) for the knee. ORIF with 2 CC screw for medial malleolus and ORIF with 1 CC screw for lateral malleolus was done to fix ankle fracture subluxation. No surgical intervention was required for hip fracture-dislocation (Fig. 7).

Below knee slab and knee range of motion (ROM) brace were applied postoperatively. The post-operative period was uneventful and no complication was noted; suture removal was done at 2 weeks. After 2 weeks, slab and brace were removed and, ROM exercises and non-weight-bearing mobilization were started. Rehabilitation protocol for multi-ligament injury of the knee was started. (Table 1).  Functional outcome was measured using Harris Hip Score for hip joint, Lysholm Knee Score for knee joint, American Orthopedic Foot and Ankle Society–Ankle-Hindfoot Scale for foot joint (Table 2). At 6 weeks, partial weight-bearing and strength training was started.

The patient was followed up in the outpatient department routinely, and subsequent radiographs were taken (Fig. 8). Six months post-surgery, the patient was able to achieve adequate hip, knee, and ankle ROM and walked unassisted with full weight bearing. He was also able to do squatting and sitting cross-legged comfortably at the end of 6 months postoperatively (Fig. 9).

Hip, knee, and ankle fracture-dislocation is a rare clinical occurrence and when present simultaneously, they should be approached as a limb-threatening emergency. A general physical examination with appropriate X-rays of the injured part should be performed on arrival at the emergency room. The neurovascular status of the injured lower limb should be well performed and 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 ^[3]. Posterior dislocation of the hip has been classified by Thompson and Epstein ^[4]. In our case, it was a Type 1 posterior dislocation of the hip, which is also the most common type. Treatment for this dislocation consists of closed reduction as soon as possible followed by immobilization in Buck’s traction, a cast, or a Thomas splint or skeletal traction for 2 weeks ^[5]. The extent of acetabular involvement and the stability of the hip post-reduction are pivotal factors influencing the course of the treatment. When the involvement surpasses 65% of the posterior wall, reconstruction of the acetabular wall becomes imperative to ensure hip stability ^[1]; however, irreducible or unstable hips post-reduction may necessitate resorting to open reduction. The complications of knee dislocation may be disastrous and must be anticipated. The incidence of vascular injuries in knee dislocations was around 18% in a study conducted by Medina et al. ^[6]. The popliteal artery is vulnerable to such trauma due to its unique fixation and anatomic relationships; intima disruption, dissection, thrombosis, pseudoaneurysm, and partial or complete transection. In our case, we used Doppler along with a pulse oximeter waveform for monitoring, and the Doppler signals were compared to the uninjured side. The peroneal nerve is injured most often, and the prognosis for return of function after injury is guarded. In a systematic review of Woodmass et al., ^[7] the majority of patients achieved complete recovery in incomplete palsy, and recovery was seen in <40% of patients with complete peroneal nerve palsy. Knee dislocations can be classified according to the Kennedy position or the Schenck anatomic classification system ^[8]. Knee dislocations can be reduced satisfactorily by closed methods. Immediate surgical intervention is indicated for an irreducible knee by closed reduction or an unstable knee, which requires a vascular repair and open knee dislocation. Circulation should be assessed periodically for 5–7 days. Once it is certain that the circulation is not impaired, treatment may be done for injured ligaments. MRI provides critical information regarding ligament injuries, meniscal injuries, chondral injuries, and fractures to guide treatment, particularly after an acute knee dislocation. Approximately 50% of knee dislocations are associated with tears of the ACL, whereas 75% are associated with tears of the posterior cruciate ligament ^[9]. Avulsion fractures of cruciate and collateral ligaments can be fixed with non-absorbable sutures or screws in isolation or while fixation of associated fractures around the knee. Whereas Jlidi et al. reported a case of a 35-year man in a road traffic accident with ipsilateral hip fracture-dislocation and a knee dislocated with patella fracture, the hip was closed reduced, and managed conservatively and the knee was reduced and stabilized with the external fixator ^[10]. Sharma et al. ^[11] mentioned 23-year-old male with ipsilateral hip fracture-dislocation and knee dislocation with a ligament injury. In the latter case, both joints were reduced in an emergency, and posterior wall acetabulum was fixed urgently and the delayed knee ligament was reconstructed. Falgons and Warner ^[12], in their study, reported 40-year-old male with ipsilateral posterior hip and anterior knee dislocation (Schenck type V) with ipsilateral femoral head fracture and incomplete femoral neck fracture. Three CC screws for the femoral neck and three cortical screws for the femur head was used to fix the fracture. Three months after injury, he underwent open treatment for osteochondral fracture medial condyle distal femur, ACL reconstruction with quadricep tendon autograft, and arthroscopic medial and lateral meniscus repair. Khan et al. reported a case of ipsilateral central hip and knee fracture-dislocation but even after fixing all the fractures, the patient later developed avascular necrosis and underwent total hip replacement ^[13]. Waterman and Banerjee ^[14], in their report, mentioned that in their case, a 25-year-old man presented with hip and knee dislocation which was closed reduced, an open tibia fracture was debrided, and intramedullary tibia nail was done and in the diastasis in the ankle was stabilized using syndesmotic screw. Salaria et al. ^[15] mentioned in their report a case of 37-year-old male farmer with the right knee lateral dislocation and ipsilateral ankle fracture-dislocation. Both were reduced initially in emergency and external fixator was applied to stabilize and later definitive fixation was done once swelling subsided. The ipsilateral hip, knee, and ankle fracture-dislocation is an uncommon phenomenon with various surgeon-related factors that could improve outcomes including emergent reduction of the knee joint, assessment of neurovascular injury, reduction of the hip joint as soon as possible, preferably in the emergency room with the knee stabilized, stabilization of the ankle joint and management of the multi-ligament knee injury on an elective basis.

Review of literature of reported cases of multiple joint fracture-dislocation in ipsilateral lower limb (Table 3).

Simultaneous ipsilateral hip, knee, and ankle fracture-dislocation is rare condition with limited reports reported in literature that should be approached as a limb-threatening injury and orthopedics emergency. We report this case for its rarity and to document that achieving good results is possible with early appropriate treatment.

Simultaneous ipsilateral hip, knee, and ankle fracture-dislocation is an extremely rare and severe high-energy injury. Early recognition, prompt radiographic assessment, staged surgical intervention, and a coordinated multidisciplinary approach are crucial in achieving optimal functional outcomes and limb salvage in such complex presentations.