Friday, March 2, 2012

Case 6

 A 9yr old male child was presented by his mother in our
      opd with complaints of

      pain in the right knee since two years and

      difficulty in walking since two years

    HOPI:      (Informant is mother)
        Pt was apparently alright 2 years back when the
      child injured his right knee while playing for which no
      medical advice was sought following which child developed
      limp and pain while walking
      Pain is localized to right knee which is dragging type which
      is aggravated by activity and relieved by rest. No history of
      Mother noticed limp while her child walks and has difficulty
      walking and running after the event which is non-progressive.
      No h/o similar complaints in the past.
      no h/o similar complaints in family members.
      Patient was operated at a local government hospital 4months
      back for his condition with no improvement

On General Examination:    
      A 9 yr old male child who is moderately built and moderately
      nourished who is afebrile and is otherwise healthy with
      stable vitals 

 Local examination:

      Pt is lying comfortably on couch with umbilicus central both
      ASISs at same level with both hips in neutral position with
      apparent wasting in thigh component with right patella facing
      the wall left facing the roof both knees in neutral position
      and foot plantigrade.
      On inspection a surgical healed scar of 5cms long is noted
      over the lateral aspect of right knee and a post traumatic
      healed scar of 1X1 cm noted in the supero-medial aspect of
      right knee. The medial aspect of the knee is more prominent
      in comparision to opposite knee. No swellings are noted. No
      Parapatellar fossa fullness is noted. Patella appears to be
      laterally displaced in comparision to opposite knee. No
      sinuses noted.

      No local rise of temperature
      tenderness is present in the joint line of the right knee and
      also elicited in the patellofemoral joint and lateral margin
      of patella. Patella is found to be subluxated and its more
      mobile laterally compared to opposite knee. The medial
      prominence is continuous with the femoral medial condyle
      whose size is comparable to the opposte knee. Inspectory
      findings of scars and parapatellar fossae are confirmed.

      patient is having a fixed flexion deformity of 10 degrees
      with further full range of flexion active and passive
      possible with terminal 10 degrees of flexion painful.
      Patient is flexing abducting and external rotating his right
      hip to extend the knee and dragging the foot over the crouch
      to actively extend his knee.
      The patella is dislocating laterally with every flexion of
      right knee.

          The size of the patella is comparable to opposite side. There
      is two inches wasting noted in right thigh component.

      child avoids flexion of knee while walking and running

      measured in 30deg knee flexion is 20 degrees

    Apprehension test is positive as the patient avoids flexion of kneewhen lateral
      dislocating pressure is applied over the patella.

    Patellar tilt test is positive

Radiological examination:
      x rays of right knee AP & Lat suggestive of normal sized
      patella with hypoplastic lateral condyle of rt femur. Patella
      on axial projections shows flattened lateral n medial
      articulate facets with decrease in size of lateral articular
      facet. Standing x rays suggestive of horizontal joint line
      and the decrease in size of lateral femoral condyle is
      Insall ratio is around 1.5

      Recurrent dislocation of Right patella in 9 years old pt.

      Kindly reviews the clinical pictures, videos and radiographs 
       and suggest the optimal management for the child's

AP view

Lat view shows lat condyle hypoplasia

Axial view of patella shows small lateral articular facet

X ray both knees AP in standing

Displaced patella in flexion

Lateral scar

1 comment: