Patella çıkığı ve osteokondral kırık

Özet

Akut lateral patella çıkığı, patellanın troklear oluk dışına kayarken medial patella ve lateral femoral kondil arasında sıkışma veya kayma yaralanması oluşturabilir. Hasta BT çekilmeden önce redükte olmuş olsa bile karşılıklı kemik impaksiyonları, osteokondral defekt ve eklem içi mineralize fragman kalabilir. Kontrastsız ince kesit BT bu kemik yaralanmalarını ve fragmanın yerini gösterir; kıkırdak ve medial patellofemoral bağ hasarını ise sınırlı değerlendirir. Eklem içi serbest fragman veya defekt atlanırsa travmanın eklem yüzüne etkisi eksik kalır.

Faz ve pencere

Kontrastsız tanısal

Patella redükte veya lateralize konumda olabilir; medial patella faseti ile lateral femoral kondilde karşılıklı impaksiyon, osteokondral kortikal defekt ve eklem aralığında mineralize fragman aranır. Patella kırıklarında BT, özellikle alt kutup parçalı kırıklarının değerlendirilmesinde konvansiyonel radyografiden daha doğru olabilir.

Kemik algoritması tanısal

Reformatlı BT kesitleri, kırık parçalarının yer değiştirmesinin ve osteokondral defektlerin detaylı incelenmesinde konvansiyonel röntgen görüntülerine göre üstündür.

Önerilen pencereler: Kemik (G 1800 / M 400), Yumuşak doku (G 400 / M 40).

BT bulguları

• Lateral patella translasyonu veya tilt — patella troklear oluğun merkezinde değildir; olay geçiciyse inceleme sırasında redükte görünmesi çıkığı dışlamaz.
• Medial patella faseti osteokondral defekti — medial eklem korteksinde yüzeysel kopma veya impaksiyon, lateral çıkık sırasında temas alanını işaret eder.
• Lateral femoral kondil impaksiyonu — kondilin anterolateral eklem yüzünde karşılık gelen çentik veya osteokondral yüzey düzensizliği görülebilir.
• İnferomedial patella fragmanı — medial veya alt-medial fasetten kopmuş kemik-kıkırdak parçadır ve küçük boyutuna rağmen eklem içinde yer değiştirebilir.
• Eklem içi mineralize serbest cisim — patellofemoral reses, suprapatellar reses veya interkondiler alanda ana kemikten ayrıdır.
• Medial patellar kenar avulsiyonu — medial retinaküler/MPFL yapışma alanında küçük kortikal parça bulunabilir.
• Eklem efüzyonu ve medial yumuşak doku şişliği — akut çıkık sonrası hemartroz ve medial stabilizatör çevresinde ödemle uyumludur; BT bağ yırtığını doğrudan göstermez.

Normalde

Patellanın eklem kıkırdağı, medial ve lateral fasetlere ayrılır. Patellofemoral instabilite değerlendirmesinde ipsilateral ve karşı diz ölçümleri karşılaştırılabilir.

Ayırıcı tanı

Akut patella kırığı

kırık hattı patella gövdesini veya kutbunu geçer; çıkıkta daha tipik karşılıklı yüzey impaksiyonu ve medial bağ yapışma yaralanmasıdır.

Bipartit patella

superolateral parçanın kenarları düzgün kortikedir ve eklem yüzünde akut defekt oluşturması beklenmez.

Osteokondritis dissekans

medial femoral kondilde sınırlı subkondral lezyon yatağı oluşturur; akut patellar çıkıktaki karşılıklı medial patella/lateral femoral kondil impaksiyonları ve medial stabilizatör yaralanması örüntüsünü açıklamaz.

Patellar instabiliteye bağlı kronik maltracking

patella lateral tilt/translasyon gösterebilir ancak akut karşılıklı impaksiyon, kemik avulsiyonu veya eklem içi fragman bulunmayabilir.

Tuzaklar

• Çıkık inceleme sırasında kendiliğinden redükte olmuş olabilir; patellanın merkezde görünmesiyle medial faset ve lateral kondil impaksiyonlarını taramayı bırakmayın.
• Küçük eklem içi fragmanı ana defektin karşısında arayın; suprapatellar ve parapatellar reseslere göç etmiş olabilir.
• BT'de belirgin kemik parçası görülmemesi saf kıkırdak osteokondral yaralanmasını dışlamaz; klinik kuşku sürüyorsa BT'nin kıkırdak sınırlılığını raporda belirtin.
• Medial yumuşak doku şişliği MPFL'nin sağlam olduğunu kanıtlamaz; bağ bütünlüğü BT ile güvenilir biçimde dışlanamaz.

Kendini dene

1. Travma sonrası patella BT'de merkezlenmiş; medial faset ve lateral femoral kondilde karşılıklı osteokondral çentikler var. En olası açıklama nedir?

   • Redükte lateral patella çıkığı
   • İzole bipartit patella
   • Patellar tendon kopması
   • Akut patella kırığı
   Cevabı göster

   Redükte lateral patella çıkığı. Karşılıklı medial patella ve lateral kondil impaksiyonları geçici lateral çıkığın tipik kemik izlerini oluşturur; patella çekim sırasında redükte olabilir. Bipartit patella superolateral kortike varyanttır; tendon kopması ve patella kırığı bu karşılıklı eklem yüzü izlerini açıklamaz.

2. Çıkık sonrası BT'de patella medial fasetinden kopan küçük kemik parçası suprapatellar reseste izleniyor. Hangi yaralanma özellikle tanımlanmalıdır?

   • Osteokondral serbest fragman
   • Bipartit patella
   • Akut patella kırığı
   • Sinding-Larsen-Johansson değişikliği
   Cevabı göster

   Osteokondral serbest fragman. Defektten ayrılıp eklem resesine yer değiştiren parça osteokondral serbest fragmandır. Bipartit patella eklem dışı kortike aksesuar parçadır; patella kırığı gövde/kutup hattı oluşturur; Sinding-Larsen-Johansson alt kutuptaki kronik çekme değişikliğidir.

Kaynaklar

Bu sayfadaki 37 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 4 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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