A 19-Year-Old Man

and Iain McNamara1



(1)
Trauma & Orthopaedics, Norfolk & Norwich University Hospital, Norwich, United Kingdom

 



A 19-year-old man presented with problems with his right knee that began at the age of 15 years. At that time he was playing soccer when he was struck on the lateral side of the knee. He fell to the ground and at point of contact felt a “pop” in his knee. The knee swelled slowly over the course of approximately 2 h. He went to the Emergency Department and then returned the following day, but no diagnosis was made. Since then he had had approximately five episodes where his knee gave way and he felt the kneecap move out of joint and return spontaneously. All these episodes occurred either during sports or after jumping when dancing. His knee would then take about 4 weeks to return to normal, until the last episode since when he had great difficulty trusting his knee, particularly on the stairs. He wanted to get back to soccer or running.


Past Medical History


None significant


Family History


His sister had recently had a patellar dislocation getting out of the shower.


Examination


His Beighton score was 4 out of 9. He stood with slight valgus alignment. He had mild retroversion of the hips but normal tibial torsion. He had diminished quadriceps bulk on the right-hand side, with an absent VMO. He had no patellar apprehension, and the mediolateral glide was 2+ on the right and 1+ on the left. His knee range of movement was −10 to 135°. He had a palpable trochlear boss. His tibiofemoral ligaments were intact with a negative Lachman’s and jerk test. His patella tracked straight. His balance on his right leg was very poor, and he was unable to squat.


Scores





















BMI

23

Beighton

4 out of 9

Kujala

88

NPI

32 %


Question 1

How would you describe the clinical presentation to a colleague in one sentence?


Question 2

What is the importance of a history of trauma in a first-time dislocator?


Question 3

What is normal hip version and normal tibial torsion?


Question 4

What is the definition of hypermobility?


Question 5

What is the significance of the positive family history?


Imaging




A429080_1_En_4_Figa_HTML.jpg


A429080_1_En_4_Figb_HTML.jpg


Question 6

What Dejour type would you classify these images and why?

The images showed a trochlear boss of 8 mm on the plain radiograph and 7 mm on MRI. The MRI also showed a tibial tubercle-trochlear groove (TTTG) distance of 18 mm and a patellar tilt angle (PTA) of 16°.


Question 7

What management advice would you give to the patient?


Question 8

What is the risk of further patellar dislocations?

Sep 26, 2017 | Posted by in ORTHOPEDIC | Comments Off on A 19-Year-Old Man

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