What is the appropriate management for a patient with lateral subluxation of the patella, a slight depressed fracture of the lateral femoral condyle, moderate joint effusion with hemarthrosis, and a Grade 1 medial collateral ligament injury?

Management of Lateral Patellar Subluxation with Lateral Femoral Condyle Fracture

The appropriate management for a patient with lateral subluxation of the patella with kissing contusions, slight depressed lateral femoral condyle fracture, moderate joint effusion with hemarthrosis, and Grade 1 MCL injury requires immediate immobilization, multimodal analgesia, and a staged approach to treatment with early mobilization when stable.

Initial Management

Pain Control and Immobilization

• Implement multimodal analgesia immediately:

  • Regular paracetamol/acetaminophen
  • Cautious use of opioids (especially with potential renal dysfunction)
  • Consider regional nerve block (femoral or fascia iliaca) 1
  • Apply cold therapy (ice) for 20-30 minutes, 3-4 times daily 2

• Immobilize the knee:

  • Posterior splint initially to prevent further injury while allowing for swelling 2
  • This approach provides good stability with lower redislocation rates and less joint movement restriction than braces 3

Diagnostic Imaging

• Initial radiographs should include:

  • Anteroposterior and lateral views
  • Patellofemoral view to assess patellar alignment and fracture 1
  • Cross-table lateral view to visualize lipohemarthrosis 1

• Consider advanced imaging:

  • MRI to fully assess soft tissue injuries (MCL, patellar stabilizers) and confirm extent of bone contusions 1
  • CT may be helpful to better characterize the depressed lateral femoral condyle fracture 1

Definitive Management

For the Lateral Femoral Condyle Fracture

• For a slight depressed fracture without intra-articular extension:

  • Non-operative management is appropriate if alignment is acceptable 1
  • Temporary immobilization followed by early protected mobilization

• If the fracture is unstable or significantly depressed:

  • Consider delayed definitive osteosynthesis after initial stabilization 1
  • Timing should be based on patient's overall clinical status and resolution of swelling 1

For Patellar Subluxation/Dislocation

• Initial non-operative approach:

  • Immobilization for 3-5 weeks to allow soft tissue healing 3
  • Transition to hinged knee brace after initial immobilization period 4

• Consider patellar stabilizing brace after acute phase:

  • Dynamic braces that apply medially displacing force to lateral border of patella can be effective 5
  • May help prevent recurrent subluxation during rehabilitation

For Grade 1 MCL Injury

• Non-operative management:
  • Protected weight-bearing with brace support
  • MCL injuries typically heal well with conservative management

Rehabilitation Protocol

Early Phase (0-2 weeks)

• Protected weight-bearing as tolerated with immobilization
• Gentle isometric quadriceps exercises
• Elevation and ice to control swelling

Intermediate Phase (2-6 weeks)

• Transition from splint to hinged knee brace
• Begin progressive range of motion exercises
• Initiate quadriceps and hamstring strengthening
• Focus on vastus medialis obliquus strengthening to improve patellar tracking

Late Phase (6+ weeks)

• Progress to full weight-bearing
• Advance strengthening exercises
• Begin proprioceptive training
• Gradual return to activities based on functional progress

Monitoring and Follow-up

• Regular radiographic assessment to monitor fracture healing
• Evaluate for patellar tracking and stability
• Watch for common complications:
  • Recurrent patellar instability
  • Post-traumatic arthritis
  • Persistent pain or mechanical symptoms

Special Considerations

• For young, active patients with recurrent instability after rehabilitation, surgical options may include:

  • Medial patellofemoral ligament reconstruction
  • Lateral retinacular release
  • Tibial tubercle osteotomy if indicated 1, 6

• For older patients with pre-existing degenerative changes:

  • Focus on non-surgical management with activity modification 1
  • Supervised rehabilitation program 1

Prognosis

• Most patients with this injury pattern can expect good outcomes with appropriate conservative management
• Risk factors for recurrent instability include young age and high activity level
• The depressed lateral femoral condyle fracture may increase risk of post-traumatic arthritis, requiring longer-term monitoring

This management approach prioritizes early stabilization followed by progressive rehabilitation to optimize functional outcomes while minimizing complications.