eMedicine Specialties > Sports Medicine > Knee

Patellar Injury and Dislocation: Differential Diagnoses & Workup

Author: Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Coauthor(s): Brian F White, DO, Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey; Wah Sang Lee, DO, MS, Staff Physician, Department of Physical Medicine and Rehabilitation, New Jersey Medical School/Kessler Institute of Rehabilitation; Thomas Agesen, MD, Assistant Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ, New Jersey Medical School; Consulting Staff, Mountainside Hospital, Summit Overlook Hospital
Contributor Information and Disclosures

Updated: Sep 8, 2008

Differential Diagnoses

Anterior Cruciate Ligament Injury
Medial Collateral Knee Ligament Injury
Meniscus Injuries
Patellar Injury and Dislocation
Patellofemoral Joint Syndromes

Other Problems to Be Considered

Bipartite patella
Chondromalacia
Osteochondritis dissecans
Patella fracture
Patellofemoral arthritis
Soft tissue and capsular injury

Workup

Imaging Studies

  • Plain radiography
    • Plain radiography is the most common diagnostic imaging study performed for patellofemoral dysfunction, and it is the least costly.
    • A standard radiographic protocol for the screening for patellar dislocation includes anteroposterior, true lateral, and axial or sunrise views.
    • Several variations of the axial view radiograph can be used, but the most widely accepted techniques are taken with the patient supine and the knee at 20-45° of flexion with and/or without external rotation of the tibia.
    • A true lateral view can be used to assess for several possible problems. First, with a vertical position of the knee, it can be used to evaluate for patella alta or baja. Second, it can be used for a measurement of patella tilt. Some authors find this view provides more sensitivity for patellofemoral pain and previous subluxation than a measurement of tilt on an axial view. Third, it can help evaluate trochlear depth. In this view, examination of the proximal portion of the trochlear groove for dysplasia is possible. This area is especially important in patella motion in early flexion; this evaluation is not possible on an axial view.
    • A Merchant view can be used to determine the severity of patellar subluxation and the presence of a maintained dislocation, although this second condition is not very common because most acute dislocations spontaneously reduce.
    • Plain radiography is also very effective for identifying patellar, tibial, and femoral fractures. In a study of 214 patients with acute knee trauma, a single lateral view radiograph had 100% sensitivity in detecting fractures.14 Overall, plain radiography is an effective and inexpensive screening tool that is particularly useful in diagnosing fractures. However, radiography has limited value in assessing soft-tissue structures.
  • CT scanning
    • When CT scanning was tested against standard radiography for determining patellar subluxation, CT scanning was found to be significantly more sensitive.
    • Stanciu et al found that CT scanning was roughly 1.5 times more sensitive in detecting patellar tracking anomalies than standard radiography.15 In Shea and Fulkerson also found that CT scanning was highly effective for detecting patellar subluxation.16 Using CT scanning, the authors accurately determined the severity of patellar tilt versus subluxation. In addition, based on CT scan findings, Shea and Fulkerson selected the patients for lateral retinacular release procedures (ie, patients in whom conservative treatment was unsuccessful). Finally, based on CT scan findings, they predicted the prognosis for patients undergoing surgery.
    • CT scanning may also be performed as a dynamic study. This study is performed using a helical CT scanning process and a continuous 10-second exposure through the midtrochlea level; patellofemoral dynamics may be evaluated for their in vivo physiologic relationships.
    • CT scanning has advantages over plain radiography because it is capable of imaging patellar cartilage.
    • A disadvantage of CT scanning is that it is less sensitive than magnetic resonance imaging (MRI) in detecting lesions in cartilage. CT scanning often requires contrast medium for certain studies, and it also exposes patients to radiation.
  • MRI
    • MRI is extremely sensitive for identifying soft-tissue anomalies of the knee. In one study, MRI helped physicians identify MPFL injuries occurring secondary to acute patellar dislocation. MRI can also be used to help determine if joint laxity is present in the absence of bony deformities. MRI can be very helpful in assessing the extensor mechanism and its relationship to the patellofemoral apparatus.17
    • Although far more expensive, MRI is more effective than CT scanning in determining if patellar chondral lesions are present and for determining cartilage thickness and volume. Assessment of patellar cartilage thickness and volume is important to evaluate for osteoarthritis, and it is useful to preoperatively calculate the effect of joint contact and load transmission after surgical procedures.
    • T1-weighted images are not as sensitive as T2-weighted images. However, T2 imaging yields a high number of false-positive results, which may be due to the detection of very early cartilaginous lesions. Further tests need to be performed.
    • The kinematic MRI method is quite suitable to determine patellar tracking and other functional aspects of the patellofemoral joint. Brossmann et al found kinematic MRI findings correlated well with arthroscopic findings in patellofemoral pathology.18 The clinical value of kinematic MRI is questionable for most patients, and these studies are not available at most centers.
    • Axial views on MRI or CT scans may be used to evaluate the trochlea-tubercle distance. This is the horizontal distance in a vertical plane between the intercondylar notch and the tibial tubercle. Similar to the Q-angle, this evaluates the potential laterally directed vectors on the patella. Some authors suggest that a distance of 2 cm is specific, but not sensitive, for maltracking.
  • Ultrasonography
    • Ultrasonography is not typically used in the assessment of patellar injury and dislocation.
    • Ultrasonography is better than CT scanning for distinguishing between cysts, granulation tissue, metaplasia, mucinoid degeneration, and congenial defects of the patellar ligament. Knowing that ultrasonography is available to help determine the cause of anterior knee pain is important.

More on Patellar Injury and Dislocation

Overview: Patellar Injury and Dislocation
Differential Diagnoses & Workup: Patellar Injury and Dislocation
Treatment & Medication: Patellar Injury and Dislocation
Follow-up: Patellar Injury and Dislocation
Multimedia: Patellar Injury and Dislocation
References
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Further Reading

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Keywords

patellar injury and dislocation, patellofemoral dysfunction, patellofemoral dislocation, patella subluxation, patellofemoral joint dysfunction, patellofemoral joint syndrome, patellofemoral pain, patellofemoral pain syndrome, PFPS, patellofemoral stress syndrome, PFSS, kneecap injury, dislocated kneecap, knee pain, knee injury, knee dislocation, dislocated knee, patella fracture, knee fracture

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Contributor Information and Disclosures

Author

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Brian F White, DO, Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey
Brian F White, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Wah Sang Lee, DO, MS, Staff Physician, Department of Physical Medicine and Rehabilitation, New Jersey Medical School/Kessler Institute of Rehabilitation
Wah Sang Lee, DO, MS is a member of the following medical societies: American Osteopathic Association
Disclosure: Nothing to disclose.

Thomas Agesen, MD, Assistant Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ, New Jersey Medical School; Consulting Staff, Mountainside Hospital, Summit Overlook Hospital
Thomas Agesen, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Andrew L Sherman, MD, MS, Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, Leonard A Miller School of Medicine, University of Miami
Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Paraplegia Society, American Spinal Injury Association, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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