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The Journal of Emergency Medicine, Vol. 44, No. 2, pp.

478–480, 2013
Copyright Ó 2013 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2012.03.026

Visual Diagnosis
in Emergency Medicine

SUPERIOR DISLOCATION OF THE PATELLA: CASE REPORT AND REVIEW


OF THE LITERATURE

Harinder Gakhar, MS, MRCS and Anil Singhal, FRCS (TR&ORTH)


Department of Orthopaedics, Prince Charles Hospital, Merthyr Tydfil, United Kingdom
Reprint Address: Harinder Gakhar, MS, MRCS, Department of Orthopaedics, Prince Charles Hospital, Flat 17, Block 4, Merthyr Tydfil
CF47 9DT, UK

CASE REPORT Plain radiographs showed that the patella was superi-
orly dislocated, with interlocking of the osteophytes
A 61-year-old man injured his right knee while opening between the inferior pole of the patella and the anterior
an up-and-over garage door. The bottom edge of the surface of the femur (Figures 1 and 2). CT scan also
door hit the knee on the way up. This was followed by clearly showed interlocked osteophytes (Figure 3).
severe pain, and he was unable to bear weight or move Closed reduction was performed under conscious seda-
his knee. On physical examination he had minimal swell- tion by hyper-extending the knee and pushing the patella
ing. There was no palpable gap in the patellar tendon. The in the proximal and lateral direction to unlock the
superior pole of the patella was prominent anteriorly and
there was a dimple visible just distal to the patella. He was
unable to perform a straight leg raise. He felt excruciating
pain on attempting to flex the knee.

Figure 1. Lateral radiograph showing interlocked osteophytes. Figure 2. Anteroposterior view of the same knee.

RECEIVED: 27 November 2011; FINAL SUBMISSION RECEIVED: 3 January 2012;


ACCEPTED: 28 March 2012

478

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Superior Dislocation of the Patella 479

Figure 3. Axial section through both knees showing the pathology.

osteophytes. The patient was delightfully relieved of pain (11). Other predisposing factors found are genu-
and had full active range of movement in the knee. recurvatum, paralytic disorders, ligamentous laxity, and
patella alta (6). Ofluoglu et al., in their report, discussed
in detail traumatic patella dislocations, and also sug-
DISCUSSION gested a new classification (12).
Usually these dislocations are easily reducible. With
Emergency Physicians frequently encounter lateral a relaxed patient who has had adequate pain relief, an up-
patella dislocations, and diagnosing them is not difficult. ward push to the patella with mediolateral pressure usu-
Superior dislocations of the patella are rare, and the diag- ally unlocks the osteophytes and brings the patella into
nosis is mainly clinical. Diagnosis in the Emergency position (1–3,8,9,13–15). This method has been
Department based on the clinical findings alone may successful in all but one case reported (16). However, 2
avoid unnecessary delays and help in prompt manage- patients underwent arthroscopic resection of the osteo-
ment. History suggests either hyperextension or a direct phytes due to recurrence of the problem (5,9). Yip et al.
blow on the knee; there is significant pain on attempting have suggested use of femoral nerve block, avoiding the
to flex the knee and straight leg raise may be performed. use of general anesthesia, particularly in the elderly (6).
There is an anterior tilting of the upper border of the After the reduction is achieved, patients can start mobili-
patella with a dimple under the lower border, and the zation of the knee under the supervision of a physiothera-
patellar tendon can be palpated without a gap. Most of pist and should avoid hyperextension of the knee.
these injuries were initially diagnosed as ruptured
patellar ligament; however, a careful examination can CONCLUSION
differentiate between the two conditions. Reviewing the
literature, it seems the extreme pain on attempting Superior dislocation of the patella is a rare injury of the
to flex the knee is a very characteristic feature of this knee joint. As osteoarthritis seems to be a predisposing
injury. factor, this condition is becoming more common, given
The first reported case of superior dislocation of the the increasing active elderly population in our society.
patella was reported by Watson-Jones (1). We could Awareness of this clinical problem would help in early ef-
find 20 cases so far reported in English literature. The fective management in the emergency setting. Initial pre-
usual mechanism of injury includes direct impact on the sentation may be confused with a patellar tendon rupture
lower aspect of the patella or hyperextension force to or a locked knee due to intra-articular causes. A careful
the knee, or a combination of both (1–6). Takai et al. clinical examination looking for the subtle signs can pro-
reported a case of voluntary superior dislocation of the vide the diagnosis.
patella in a 45-year-old woman who had undergone
arthrodesis of the superior tibiofibular joint for REFERENCES
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480 H. Gakhar and A. Singhal

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