The Knee 18 (2011) 512–513

Contents lists available at ScienceDirect

The Knee

Case Report

Extra-articular patellar dislocation with vertical axis rotation

Chen Yang, Yubao Gong, Xiaoyu Wen, Jianguo Liu, Xin Qi ⁎
Department of Orthopedic Surgery, The First Hospital of Jilin University, Xinmin Str 71, Changchun 130021, Jilin, China

a r t i c l e i n f o a b s t r a c t

Article history: Extra-articular vertical dislocation is very rare. It occurs when the patella is forced crossing the lateral femoral
Received 11 June 2010 trochlear surface, and rotated simultaneously along its longitudinal axis at about 90°, resulting in a wedged
Received in revised form 1 November 2010 dislocation against lateral condyle. Reduction has been reported to require general anesthesia and an open
Accepted 2 November 2010
procedure. We report a 19-year-old boy with extra-articular patellar dislocation, and a successful reduction
was done by manipulation under local anesthesia. We believe that the mechanism of lateral vertical
Keywords:
Extra-articular
dislocation is the fulcrum mechanism.
Patellar dislocation firms © 2010 Elsevier B.V. All rights reserved.

1. Introduction
Vertical dislocation of the patella indicates that the patella rotates
along its longitudinal axis, with the articular surface facing laterally or
medially. The dislocation can be intra-articular when the rotated
patella is locked within the femoral groove, or can be extra-articular
when the dislocated patella is wedged against the condyle, usually the
lateral side of the lateral condyle. Extra-articular patellar vertical
dislocation is not common. Reduction has been reported to done by
open procedure with general anesthesia [2–4,6,7]. We report a unique
case of successful reduction by manipulation under local anesthesia,
and describe the mechanism by which this was achieved.
in the lateral aspect of the lateral femoral condyle. Gross osteochon-
dral fracture was not observed.
Two closed reductions were performed while the patient was
sedated with 10 mg of intravenous diazepam and 40 ml of intra-
articular lidocaine (concentration: 1:100). The patella was success-
fully reduced by hyperextending the knee and rotating the patella,
then pushing it superomedially. Postreduction radiographs showed
that the position of the patella had been restored, and the contour of
the knee recovered.
The knee was immobilized in full extension within a cylinder cast
for a period of 6 weeks. Quadriceps exercises started thereafter. Two
months later, his knee had regained a full range of motion.

2. Case report
A 19-year-old boy presented to the emergency room complaining
of right knee pain and deformity. He stated that a friend fell on his left
knee when he was lying on the right side. The left knee directly
impacted the medial aspect of the right one. He was subsequently
unable to flex the right knee, stand or walk. He denied any prior injury
to the knee.
Examination revealed that the right knee was fixed in full
extension with the patella tenting the intact skin anterolaterally
(Fig. 1a and b). The patella was visibly and palpably rotated 90°
around its vertical axis with the articular surface facing laterally. Distal
neurovascular examination was normal. Radiographs confirmed that
the patella rotated 90° around the vertical axis with the articular
surface facing laterally. The medial edge of the patella was embedded
⁎ Corresponding author. Xinmin Str 71#, Changchun 130021, Jilin, China. Tel.: + 86
15043031980; fax: + 86 431 88782473.
E-mail addresses: yangchen1115@yahoo.com.cn, Dr.qixin@jlu.edu.cn,
imokol@hotmail.com (X. Qi).
3. Discussion
Patellar dislocation with vertical axis rotation was first described
by Cooper in 1844 [1]. This type of patellar dislocation is rare and most
cases were intercondylar. Only four cases have been described as
lateral vertical dislocations that were extra-articular, in which the
medial edge of the vertical patella was wedged against the lateral
femoral condyle or lateral to the lateral femoral condyle [2–5].
Reduction has been reported to always require general anesthesia and
an open procedure [2–4,6,7]. We report a unique case of successful
reduction by manipulation without general anesthesia. We recom-
mended 40 ml analgesic of articular cavity injection before reduction.
The local anesthesia relieved pain during and after reduction, and
absorbed some energy during patellar restoration.
The mechanism of vertical dislocation was considered to be a
laterally directed blow to the medial aspect of the knee. By reviewing
the literature, we found that intra-articular vertical dislocations
always resulted from severe force, such as a kick in soccer or football
playing [6–8]. However, as to extra-articular dislocations, they follow
minor force and occur when the knee hits the ground. Therefore, we
believe that the mechanism of lateral vertical dislocation is that a

0968-0160/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2010.11.003

Downloaded for Anonymous User (n/a) at Universitas Muslim Indonesia from ClinicalKey.com by Elsevier on May 07, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
 C. Yang et al. / The Knee 18 (2011) 512–513
Fig. 1. a, b: Photographs illustrating the appearance of the right knee in the
anteroposterior and lateral view. The patella tent the skin anterolaterally.
direct or indirect blow pushes the patella to the opposite femoral
condyle, with the effect of a ground fulcrum, and rotates the patella on
its vertical axis. Without the fulcrum, this would be merely a simply
lateral dislocation.
Downloaded for Anonymous User (n/a) at Universitas Muslim Indonesia from ClinicalKey.com by Elsevier on May 07, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
513
The presented case was unique in that closed reduction was
achieved under local anesthesia, while open reductions were reported
in the literature. Since this patient was not physically muscular, closed
reduction under local anesthesia was carried out. When the
quadriceps was squeezed toward the knee, the extensor was relaxed.
With the knee in hyperextension, the patellar was elevated and
pushed cranial-medially, thus the prominent part of the lateral
condyle could be avoided. It is suggested that closed reduction with
local anesthesia could be attempted in similar cases.
The patient was followed up for 26 months. The apprehension test
was negative. The lateral structures were not tight and the patella
could be lifted. Mal-tracking the patella was not observed. The knee
was graded as satisfactory according to the rating system of Crosby
and Insall [9].
Conflict of interest
There are no conflicts of interest at all.
References
[1] Cooper A. A treatise on dislocations and fractures of the joints. Philadelphia: Lea &
Febiger; 1844. p. 178.
[2] Carragher A, Todd A, Blake G. Acute traumatic lateral patellar dislocation. Ann
Emerg Med 1989;18:149–50.
[3] Corso SJ, Thal R, Forman D. Locked patellar dislocation with vertical axis rotation. A
case report. Clin Orthop Relat Res 1992;6(279):190–3.
[4] ElMaraghy AW, Berry GK, Kreder HJ. Irreducible lateral patellar dislocation with
vertical axis rotation: case report and review of the literature. J Trauma 2002;53(1):
131–2.
[5] Sherman SC, Yu A. Patellar dislocation with vertical axis rotation. J Emerg Med
2004;26(2):219–20.
[6] Rollinson PD. Vertical intercondylar dislocation of the patella. Injury 1988;19(4):
281–2.
[7] Alioto RJ, Kates S. Intra-articular vertical dislocation of the patella: a case report of
an irreducible patellar dislocation and unique surgical technique. J Trauma 1994;36
(2):282–4.
[8] Singletary EM, Dobson J. Intercondylar dislocation of the patella with vertical axis
rotation. Am J Emerg Med 1999;17(1):76–7.
[9] Crosby EB, Insall J. Recurrent dislocation of the patella. Relation of treatment to
osteoarthritis. J Bone Joint Surg Am 1976;58(1):9–13.