Hoffa's fracture with patellar entrapment – A rare presentation of a rare fracture

Abstract text (incl. references and figure legends)

Case History: Hoffa"s fractures are defined as coronal plane fractures of the distal femur, involving the medial, lateral or both condyles. This rare type of fracture accounts for 0.65% of all femoral fractures. It usually presents in high-energy trauma – often involving other injuries or polytrauma, making its diagnosis sometimes challenging, warranting high clinical suspicion. Associated knee joint injuries include ipsilateral femur and tibial fractures, patellar dislocation and patellar fractures. CT scan is a mandatory tool for assessment of Hoffa"s fractures, sometimes overlooked in X rays, and treatment planning. Clinical Findings: In this clinical case, a 19-year-old patient presented with a high energy monotrauma to the right knee. The knee was locked in 45º degrees flexion and very painful to mobilize. Local swelling, joint effusion and 1 centimetre wound were present. Results: X rays and CT scan demonstrated a lateral condyle Hoffa"s fracture associated with a rare injury – inferior patellar dislocation with impaction to the femur. Wound lavage, disinfection and I.V. antibiotics were administered. The patient was taken to the OR. Intraoperatively, partial quadricipital tear was also diagnosed. Therapy and Progressions: The fracture was treated with open reduction and internal fixation using two 4,5mm cancellous screws, the patella was reduced, and quadricipital tendon was reinserted using transosseous patellar tunnels. A great functional outcome was observed post-operatively after physical therapy. The patient was discharged at 3 months with full range of motion and no pain. Comments: Hoffa"s fractures treatment should be addressed with principles of articular fractures – open and anatomical reduction followed with internal stable fixation. Closed reduction of a dislocated patella with Hoffa"s fracture in an emergency room and field triage is unadvised, to prevent patellar tendon incarceration, patellar tendon rupture, and osteochondral damage.

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