Close Calls: Posterior Knee Dislocation in Football

I have been a certified athletic trainer for over 20 years. Fortunately we have not experienced a truly life threatening incident at our school. I do feel confident that we are properly equipped and trained to manage serious incidents. We were hosting a varsity football game against a neighboring school. The visiting team traveled with their athletic trainer and orthopedist. We also had our two athletic trainers, two physicians, and an ALS EMS unit on site. During the first period, one of their players ran back a punt and was tackled along the visiting team sidelines. After the pile of players stood up, it was obvious that one player was on the ground and injured. Their medical staff was right on the spot. As our medical team came across the field to assist, I observed their team orthopedist holding his lower leg. I could sense from the look on the faces of players from both teams, coaches and officials that this was a serious injury. The young man was conscious but in extreme pain. For the first time in my career, I saw what appeared to be a total posterior dislocation of his lower leg at the knee. The doctor advised to the rest of the combined medical staffs that he could feel any distal pulses past the knee.

Our on-site EMS unit had been utilized to transport another athlete to the local hospital emergency department with a possible concussion. A police officer came onto the field and immediately requested a second ambulance to the stadium. They have a 6-8 minute response time to reach us. The police officer remained with us to relay medical information to the responding unit on their side city radio channel. We use an electrical Cushman cart at the stadium. It has a backboard and collars, splint bag, AED with oxygen, and blankets. With their Orthopedist in charge, it was decided that we would package the patient on the field while awaiting the squad. A vacuum splint was applied around the leg. The orthopedist’s hands remained inside the conforming splint. As the splint was carefully applied, others checked his vital signs. Their athletic trainer provided psychological first aid by continuing to talk to him and explain what everyone was doing. He was covered with a blanket due to cool night air. An IV was established by an off duty paramedic in his arm so that pain meds could be administered once the squad arrived. Our protocol at the time, included in the use IV saline under the direction of a physician. He was placed on a backboard and secured. He was then lifted onto the cart. The second EMS unit had arrived.

They had been told to stage at the nearest stadium gate and that we would slowly transport him to their location. We crossed the field with him properly packaged but still lacking distal pulses. Upon reaching the ambulance, the crew was given an update by their orthopedist. He determined that he needed to be in the operating room. Everyone agreed that he would not go to the nearest hospital but be transported to the Level 1 trauma center downtown. This would be a 20 minute trip instead of 10. His parents were not at the game, but their athletic director and other school administrators continued to make telephone calls. Their orthopedist rode with the patient to the hospital and assisted in the OR with the vascular surgeon. Pulses were returned and he faced many months of post op rehab. His limb was saved but he continues to have partial foot drop. Perhaps his rehabilitation process can be described in another post.

Lessons learned from this incident

From my prospective, we did manage the patient well. The cooperation between the home and visiting medical staffs allowed for his overall well being.

Both schools had the necessary emergency supplies on hand. We did not rely on using the EMS unit’s equipment. In this case, they were not on site at the time of the emergency. Having our own equipment allowed for us to stabilize and package the injured player without delay. The senior medical person took charge calmly and directed everyone’s actions. I noted that that his athletic trainer and doctor were expectedly more psychologically connected with their own player. Our staff was there to both treat the patient but also take some of burden off their staff whenever possible. A later example of this was to relieve their athletic trainer of covering the JV game the next morning at 10 am. I knew that he would be at the hospital all night and would have his hands full and exhausted. He did arrive later that morning to give me an update. He did a great job and would later provide excellent personal assistance to the athlete in his long recovery. The police officer knew his role would be to keep communication open between the on field medical team and responding EMS unit.

The EMS crew alerted the receiving trauma center while en route to their facility. We were truly dealing with the “Golden Hour” of trauma protocol. One consideration discussed was the possibility of calling in the trauma service helicopter. Fortunately, our stadium is located close to the interstate, and traffic was light. Landing a helicopter around a crowded football stadium isn’t always the easiest and safest thing to do. In this case, ground transportation worked out fine. From this incident, we did not make any major changes. An established emergency action plan is always encouraged. Cooperation between everyone on site is vital. This includes the maintenance staff that controls parking lot access, to school administrators dealing with parents and the news media. Surviving the “big one” only solidified the professional relationship between the schools’ medical staff and local police and fire departments. The young man truly had the best team assembled to come to his aid.