CASE REPORT

Patella Dislocation Association with Drop Foot

Aamir H. Shaikh1, Ashraf Dawood2, G. Eswara Murthy2 and Andrew C. Macey2

ABSTRACT
All limb injuries should be examined with complete documentation of neurovascular assessment as they are often ignored
in the busy emergency department setup. This may lead to delay in such diagnosis during the treatment of limb injuries at
a follow-up in orthopaedic clinics. Early diagnosis can help orthopaedic team to investigate and start treatment which may
help in the recovery of such neurovascular injuries. We report a case of missed neurovascular assessment in the
emergency department on a patellar dislocation of a young person leading to foot drop and sensory numbness in the deep
peroneal nerve distribution, which improved completely within three and a half months with conservative treatment. This
is also the first reported case of foot drop in association with patellar dislocation.

Key words: Foot drop. Patella dislocation. Neurovascular examination. Transient peroneal neuropathy.

INTRODUCTION
Nerves injuries of different types may arise after
fractures and dislocations.1 Knee injuries of varying
severity have been linked to involvement of peroneal
nerve leading to foot drop condition. A report of non-
contact knee dislocation in a female basketball player
involving the peroneal nerve has been made which
resolved in 42 weeks.2 So far, no report of peroneal
nerve injury has been made for patella dislocation and
subluxation. The only report of transient neuropraxia of
the saphenous nerve in patella dislocation was reported
by Glesson et al.3
We report a transient case of deep peroneal neuropathy
leading to foot drop condition in young male after patella
dislocation treated conservatively with full recovery.
CASE REPORT
A 16-years-old male suddenly twisted his right knee
during dancing with foot being fixed and therefore,
leading to a fall. He arrived in the emergency
department with an inability to bear weight on his right
leg. On examination, swelling and deformity of his knee
noted. X-ray revealed lateral patella dislocation with no
associated fracture (Figure 1), which was reduced under
sedation. There were no clinical features of ligamentous
knee injury except tenderness at the medial side of
quadriceps. This patient was initially managed by the
emergency doctor and there was no record of neuro-
1 Department of Orthopaedic Surgery, Royal College of Surgeons,
Ireland.
2 Department of Orthopaedic Surgery, Sligo General Hospital,
Sligo Eire, Ireland.
Correspondence: Dr. Aamir H. Shaikh, 23 Hayworth Mews,
Ongar Park, Dublin 15, Ireland.
E-mail: draamir@ireland.com
Received February 08, 2011; accepted October 21, 2011
Figure 1: Patellar dislocation.
vascular involvement of the limb as this was missed in
the emergency department. After splinting his knee in
the back slab, he was referred to fracture clinic. Two
days later in the clinic he was identified with foot drop
along with swelling on his right knee and sensory deficit
in the first web space between the first and the second
toe in the deep peroneal nerve distribution. There was
no power (grade 0) in tibialis anterior and extensor
hallucis longus (EHL) as detected on modified MRC
scale.4 Although, patella apprehension test was positive,
rest of the ligamentous knee examination was normal
apart from generalized knee swelling. He was continued
in the knee cast. Later, he was reviewed after 10 days
with noted improvement in tibialis anterior and EHL
power as the knee swelling started to settle. He received
cast treatment for a total of 3 weeks and thereafter,
changed to a foot drop splint which allowed him to start
with his physiotherapy regime. He showed remarkable
improvement and his motor weakness completely
resolved (grade 5) in three and half months of
conservative treatment. He did not require a nerve
conduction study as he started to show clinical signs of
improvement in both sensation and power of his right
lower limb as early as first 10 days of injury.

182 Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (3): 182-183
Patella dislocation association with drop foot
DISCUSSION
Deep peroneal nerve arises from common peroneal
nerve, which innervate short head of biceps femoris
muscle in thigh and lies laterally in the common neural
sheath with tibial nerve until proximally in the popliteal
fossa where this division is encountered. Exceptions in
this anatomical course have been documented.5
The common peroneal nerve then travels across the
lateral head of gastrocnemius muscle giving out lateral
cutaneous nerve of the calf supplying lateral aspect of
the leg below the knee. At about the neck of fibula the
nerve becomes subcutaneous and divides into deep
mainly muscular branch so called deep peroneal nerve
and superficial branch mainly sensory to lower lateral
aspect of leg and dorsum of feet and toes. It is motor to
the muscles of peroneal (lateral) compartment of the
leg. The small area of foot in between the first two toes
is supplied by cutaneous branch from the deep peroneal
nerve.
Deep peroneal nerve innervates anterior compartment
muscles of the leg by travelling deep to the peroneus
longus. This nerve supplies tibialis anterior, extensor
hallucis longus, extensor digitorm longus, and peroneus
tertius. These muscles control ankle dorsiflexion and
toes extension. In this case, there was a typical
involvement of deep peroneal nerve as sensation of
touch, pin prick and temperature were involved in this
nerve distribution along with loss of power of ankle
dorsi-flexors and big toe extensor.
Superficial peroneal nerve on the other hand travels
between the peroneal longus and brevis, the primary
ankle evertors and innervates them.
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Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (3): 182-183
There are reports of knee dislocation leading to
temporary foot drop as trauma to the knee joint leads to
soft tissue compromise at the level of fibular neck
causing injury to common peroneal nerve.2 We report
isolated deep peroneal nerve neuropathy following
trivial twisting injury of the leg leading to lateral patellar
dislocation which was initially missed and subsequently
discovered after 2 days at follow-up in the outpatient
fracture clinic run by orthopaedic team. This neuropathy
recovered fully on modified MRC scale4 with power of
5/5 without consequences in three and half month of
conservative treatment.
We recommend that an assessment of the complete
neurovascular examination should be warranted to
identify such type of remote injuries after patellar dis-
location in the emergency department.
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3. Gleeson AP, Kerr JG. Patella dislocation neurapraxia: a report of
two cases. Injury 1996; 27:519-20.
4. Bhardwaj P, Bhardwaj N. Motor grading of elbow flexion: is
Medical Research Council grading good enough? J Brachial Plex
Peripher Nerve Inj 2009; 4:3.
5. Prakash, Bhardwaj AK, Devi MN, Sridevi NS, Rao PK, Singh G.
Sciatic nerve division: a cadaver study in the Indian population
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