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10/25/2018 0 Comments

Patellar Dislocation


Background
  • Typically occurs with trauma to an extended knee with externally rotated foot (quick pivoting in basketball, football and soccer)
  • Acute dislocation occurs with traumatic injury, M=F, may see hemarthrosis
  • Chronic dislocation or patholaxity seen more commonly in women
    • Ehlers-Danlos syndrome
    • Typically, little or no swelling; painless
    • Recurrent subluxation episodes with each flexion movement
  • May occur from a direct blow (ex. helmet to knee collision in football; knee-knee collision in basketball)
    • Usually on noncontact twisting injury with the knee extended and foot externally rotated
    • Patient will usually reflexively contract quadriceps thereby reducing the patella
  • Common associated fractures
    • Medial patella facet
    • Lateral femoral condyle
 
Clinical Features
  • Patella is usually displaced laterally
  • Knee is held in flexion
  • Acute dislocation usually associated with a large hemarthrosis   
    • Absence of swelling supports ligamentous laxity and chronic dislocation mechanism
 
Evaluation
  • Clinical diagnosis
  • May consider pre-reduction x-ray if concern for fracture (not required)
 
Management
  • Reduction = Relocation with lateral pressure on dislocated patella
  • Do NOT need x-rays prior to reduction
    • Consider XR following reduction to rule out fracture or loose body
  • Rarely need any sedation (sub-dissociative dose ketamine ?)
  • Option #1:
    • Mild flexion of hip (20-30 degrees by raising head of bed, not by propping the leg up off the bed) to relax quadriceps
    • Slowly extend and slightly hyperextend the knee and slide patella back into place.
  • Option #2
    • One provider applies slow downward pressure over the quads. This stretches out the muscle and slowly straightens the leg
    • At the same time, second provider pulls gentle traction of the patella outward while rotating the patella back over from lateral to anterior

​Disposition

  • Obtain ortho consult if unable to reduce or fracture/loose bodies seen on post-reduction x-ray
  • Otherwise may be discharged with ortho follow-up in 1-2 weeks
  • Non-Operative:
    • NSAIDS, activity modification, and physical therapy
    • Knee immobilizer for comfort (short-term)
    • Quad strengthening exercises
    • Core and hip strengthening to improve limb positioning and balance (hip abductors, gluteals, and abdominals) 
  • Consider knee aspiration for tense effusion
    • Positive fat globules indicates fracture
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