What are the treatment options for a patellar dislocation relocation injury with an impaction fracture of the lateral femoral condyle and a kissing contusion of the medial patellar facet?

Treatment Options for Patellar Dislocation with Lateral Femoral Condyle Impaction Fracture and Medial Patellar Facet Contusion

Surgical management is indicated for patellar dislocation with an impaction fracture of the lateral femoral condyle and kissing contusion of the medial patellar facet due to the presence of osteochondral injury. 1

Initial Evaluation

• Radiographs should be the first imaging study obtained for acute knee trauma with patellar dislocation 1
• MRI without IV contrast is the recommended next imaging study to:
  • Assess the integrity of the medial patellofemoral ligament and medial patellar retinaculum
  • Define the extent of cartilage injury
  • Identify loose bodies 1
  • Evaluate the impaction fracture of the lateral femoral condyle and kissing contusion of the medial patellar facet

Treatment Algorithm

Surgical Management (Recommended)

The presence of an osteochondral fracture (impaction fracture of lateral femoral condyle) is a specific indication for surgical intervention, even in first-time patellar dislocations 2, 3.

Surgical options include:

1. Arthroscopic assessment and treatment:

   • Evaluation of the osteochondral impaction fracture
   • Assessment of the medial patellar stabilizers
   • Removal or fixation of loose bodies if present 1

2. Osteochondral fracture management:

   • For fixable fragments: Open reduction and internal fixation
   • For non-fixable fragments: Debridement and microfracture of the lateral femoral condyle 3

3. Medial patellofemoral ligament (MPFL) repair or reconstruction:

   • Indicated when there is substantial disruption of the medial patellar stabilizers 2
   • Typically injured at its femoral attachment in acute patellar dislocations 4

Post-Surgical Rehabilitation

• Initial phase (0-4 weeks): Pain control and protected range of motion
• Intermediate phase (4-8 weeks): Progressive strengthening exercises and eccentric training
• Advanced phase (8-12 weeks): Occupation-specific training and functional exercises 5

Non-Surgical Management (Not Recommended for This Case)

While non-operative management is typically recommended for first-time traumatic patellar dislocations without osteochondral injury 2, the presence of an impaction fracture of the lateral femoral condyle in this case necessitates surgical intervention.

If non-surgical management were pursued (not recommended), it would include:

• Activity modification
• Bracing
• Physical therapy focusing on quadriceps strengthening
• NSAIDs for pain management

Follow-up and Return to Activity

• Regular assessment at 2,6, and 12 weeks to evaluate:

  • Pain levels
  • Range of motion
  • Functional improvement
  • Signs of recurrent instability 5

• Return to full activity permitted when:

  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to uninjured side
  • Successful completion of functional tests 5

Potential Complications and Pitfalls

• Recurrent patellar instability (up to 44% after first-time dislocation) 4
• Patellofemoral arthritis due to cartilage damage 2
• Decreased level of sporting activity 2
• Persistent pain 2

Key Considerations

• Osteochondral injury to the weight-bearing portion of the lateral femoral condyle is an uncommon but important lesion that requires recognition and appropriate treatment 3
• MRI is crucial for identifying cartilage damage, loose bodies, and the extent of soft tissue injury 1, 6
• Delayed treatment of osteochondral injuries can lead to long-term complications including arthritis 2

The presence of an impaction fracture of the lateral femoral condyle is a clear indication for surgical intervention rather than conservative management, as it represents significant osteochondral injury that requires repair or debridement to prevent long-term complications.