Patellar Fractures: Difference between revisions

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== Clinically relevant anatomy  ==
== Clinically relevant anatomy  ==


The patella is a triangular bone situated on the anterior surface of the knee at the distal end of the femur. It is the largest sesamoïd bone in the body and makes part of the knee joint.<ref>Cedars-Sinai. Fractured Kneecap. Cedars Sinai organisation. https://www.cedars-sinai.org/health-library/diseases-and-conditions/f/fractured-kneecap.html (accessed 25/07/2018).</ref><ref>Schunke M. Anatomische atlas Prometheus, algemene anatomie en bewegingsapparaat. Bohn Stafieu van Loghum: 2e druk. 2010.</ref><ref>Everett L. Knee and Lower Leg. In: Marx J, Walls R, Hockberger R, editors. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia: Mosby Elsevier, 2006.</ref> Vastus medialis and lateralis, as part of the quadriceps group, control movement at the patella.<ref>Orthopaedia. Collaborative Orthopaedic Knowledgebase, http://www.orthopaedia.com/display/Main/Patella+fractures (accessed November 10, 2010).</ref> The extensor mechanism as a whole plays a major role in patella fractures. This consists of the quadriceps, quadriceps tendon, retinaculum, patella tendon, tibial tubercle and patellofemoral and patellotibial ligaments,<ref name=":11" /> See the page on the [[patella]] for more details on the anatomy.  
The patella is a triangular bone situated on the anterior surface of the knee at the distal end of the femur. It is the largest sesamoïd bone in the body and makes part of the knee joint.<ref>Cedars-Sinai. Fractured Kneecap. Cedars Sinai organisation. https://www.cedars-sinai.org/health-library/diseases-and-conditions/f/fractured-kneecap.html (accessed 25/07/2018).</ref><ref>Schunke M. Anatomische atlas Prometheus, algemene anatomie en bewegingsapparaat. Bohn Stafieu van Loghum: 2e druk. 2010.</ref><ref>Everett L. Knee and Lower Leg. In: Marx J, Walls R, Hockberger R, editors. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia: Mosby Elsevier, 2006.</ref> Vastus medialis and lateralis, as part of the quadriceps group, control movement at the patella.<ref>Orthopaedia. Collaborative Orthopaedic Knowledgebase, http://www.orthopaedia.com/display/Main/Patella+fractures (accessed November 10, 2010).</ref> The extensor mechanism as a whole plays a major role in patella fractures. This consists of the quadriceps, quadriceps tendon, retinaculum, patella tendon, tibial tubercle and patellofemoral and patellotibial ligaments.<ref name=":11" /> See the page on the [[patella]] for more details on the anatomy.  


{|  
{|  
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== Epidemiology/Etiology  ==  
== Epidemiology/Etiology  ==  


In a recent study, the average mortality rate at one year after patella fractures was 2.8%, increasing to 6.2% in the geriatric population. Patella fractures are not associated with an increased mortality rate, as the relative risk of death was 0.9.<ref>Larsen P, Elsoe R. [https://www.sciencedirect.com/science/article/pii/S0020138318303590 Patella fractures are not associated with an increased risk of mortality in elderly patients]. Injury 2018.</ref><br>  
In a recent study, the average mortality rate at one year after patella fractures was 2.8%, increasing to 6.2% in the geriatric population. Patella fractures are not associated with an increased mortality rate, as the relative risk of death was 0.9.<ref>Larsen P, Elsoe R. [https://www.sciencedirect.com/science/article/pii/S0020138318303590 Patella fractures are not associated with an increased risk of mortality in elderly patients]. Injury 2018.</ref>  


== Complications ==
== Complications ==
* Injuries (sprain/rupture) to ligaments and tendons attached to the patella:
* Injuries (sprain/rupture) to ligaments and tendons attached to the patella
** Long term complications include stiffness, extension weakness, and patellofemoral arthritis.<ref>Insall JN. Fractured kneecap: treatments. Institute for Orthopaedics and sports medicine 2007.</ref>
 
* Avascular necrosis<ref name=":4">Medscape. Patella Fracture Imaging. http://emedicine.medscape.com/article/394270-overview&amp;gt (accessed 25/07/2018).
* Avascular necrosis<ref name=":4">Medscape. Patella Fracture Imaging. http://emedicine.medscape.com/article/394270-overview&amp;gt (accessed 25/07/2018).
</ref>
</ref>
* posttraumatic arthritis.
* Post-traumatic arthritis  
* Osteochondral damage to patella-femoral joint
* Osteochondral damage to patella-femoral joint
* Stiffness
* Stiffness
* Non-union
* Non-union
* Malunion
* Malunion
* <ref name=":1" /><br>
* Concomitant injuries (e.g. injuries to the acetabulum, femur and tibia)
<br>  
* Long term complications:<ref>Insall JN. Fractured kneecap: treatments. Institute for Orthopaedics and sports medicine 2007.</ref>
** Stiffness
** Extension weakness
** Patellofemoral arthritis.
<ref name=":1" />


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
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** Most common type
** Most common type
** Proximal blood supply may be compromised
** Proximal blood supply may be compromised
** Usually as a result of hyper flexion of the knee
** Usually as a result of hyper-flexion of the knee
* Marginal:  As a result of a fall on the knee
* Marginal:  As a result of a fall on the knee
* Vertical
* Vertical/longitudinal
* Lower/upper pole
* Lower/upper pole
* Osteochondral
* Osteochondral
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<ref name=":2" /><ref name=":3" /><ref name=":4" /><ref name=":5">Whittle PA. Fractures of the Lower Extremity. In: Canale ST, Beaty JH, editors. Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier, 2008.</ref><ref>Melvin SJ, Mehta S. [https://journals.lww.com/jaaos/Abstract/2011/04000/Patellar_Fractures_in_Adults.4.aspx Patellar fractures in adults.] Journal of the American Academy of Orthopaedic Surgeons 2011;19(4):198-207.</ref><ref name=":7">Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.</ref>
<ref name=":2" /><ref name=":3" /><ref name=":4" /><ref name=":5">Whittle PA. Fractures of the Lower Extremity. In: Canale ST, Beaty JH, editors. Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier, 2008.</ref><ref>Melvin SJ, Mehta S. [https://journals.lww.com/jaaos/Abstract/2011/04000/Patellar_Fractures_in_Adults.4.aspx Patellar fractures in adults.] Journal of the American Academy of Orthopaedic Surgeons 2011;19(4):198-207.</ref><ref name=":7">Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.</ref>


The prognosis of the injury depends on the amount of chondral damage at the time of injury. Functional outcome depends on the ability to achieve pain-free and stabile range of motion in an early stage. <ref name=":6">Mehling I, Mehling A, Rommens PM. [https://www.sciencedirect.com/science/article/pii/S026808900600168X Comminuted patellar fractures.] Current Orthopaedics 2006;20(6):397-404.</ref><br>
The prognosis of the injury depends on the amount of chondral damage at the time of injury. Functional outcome depends on the ability to achieve pain-free and stable range of motion in an early stage. <ref name=":6">Mehling I, Mehling A, Rommens PM. [https://www.sciencedirect.com/science/article/pii/S026808900600168X Comminuted patellar fractures.] Current Orthopaedics 2006;20(6):397-404.</ref>


== Differential diagnosis ==
== Differential diagnosis ==
* Bipartite patella<ref name=":1" />
* Bipartite patella<ref name=":1" />
* [[Multiligament Injured Knee Dislocation|Knee dislocation]]
* Patella dislocation


== Diagnosis  ==
== Diagnosis  ==
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=== Special investigations ===
=== Special investigations ===
* X-rays:   
* [[X-Rays|X-rays]]:   
** AP view:
** AP view:
*** May be difficult to see patella
*** May be difficult to see patella
** Lateral view:
** Lateral view:
*** Undisplaced - < 2mm separation
*** Undisplaced - < 2mm separation
*** Displaced - > 2mm separation
*** Displaced - > 2mm separation, step deformity noted
** Sky view
** Sky view
** Regular monitoring of healing process and any possible complications
** Used for regular monitoring of healing process and any possible complications


* CT scan:  Usually not needed
* [[CT Scans|CT scan]]:  Usually not needed
* MRI:  Diagnosis of associated injuries to nearby tendons and ligaments
* [[MRI Scans|MRI]]:  Diagnosis of associated injuries to nearby tendons and ligaments
* Bone scans:  To identify stress fractures
* Bone scans:  To identify stress fractures
<ref name=":7" /><ref name=":8" /><ref name=":9" /><ref name=":11" />
<ref name=":7" /><ref name=":8" /><ref name=":9" /><ref name=":11" />
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* [http://www.physio-pedia.com/McGill_Pain_Questionnaire McGill pain questionnaire]
* [http://www.physio-pedia.com/McGill_Pain_Questionnaire McGill pain questionnaire]
== Medical management    ==
== Medical management    ==
 
* In acute cases, local anesthetics can be given to eliminate pain.<ref name="p4" /> This helps to aid in the assessment and diagnosis of the patella fracture.
In acute cases, local anesthetics can be given to eliminate pain.<ref name="p4" /> This helps to aid in the assessment and diagnosis of the patella fracture.


=== Conservative management ===
=== Conservative management ===
Indication:  Undisplaced fracture (mostly vertical and horizontal fractures) with extensor mechanism in place <ref name=":1" /><ref name=":6" />
Indication:  Undisplaced fracture (mostly vertical, horizontal and comminuted fractures) with extensor mechanism in place <ref name=":1" /><ref name=":6" />


Management: <ref name=":6" /><ref name=":11">Duke Orthopaedics. Wheeless’ textbook of Orthopaedics. Fractures of the patella.http://www.wheelessonline.com/ortho/fractures_of_the_patella (accessed November 10 2010).</ref><ref name=":10">American Academy Of Orthopaedic Surgeons. Diseases and conditions - Patellar (Kneecap) Fractures. http://orthoinfo.aaos.org/topic.cfm?topic=A00523 (accessed November 10, 2010).</ref>
Management:<ref name=":7" /><ref name=":6" /><ref name=":11">Duke Orthopaedics. Wheeless’ textbook of Orthopaedics. Fractures of the patella.http://www.wheelessonline.com/ortho/fractures_of_the_patella (accessed November 10 2010).</ref><ref name=":10">American Academy of Orthopaedic Surgeons. Diseases and conditions - Patellar (Kneecap) Fractures. http://orthoinfo.aaos.org/topic.cfm?topic=A00523 (accessed November 10 2010).</ref>
* Fracture immobilized with cast or splint (start off in full extension):
* Fracture immobilized with POP cylinder cast or range of motion brace locked in extension (4-6 weeks):
** As healing takes place, knee flexion can gradually be increased
** As healing takes place, knee flexion can gradually be increased
** Must be worn until union (on X-rays) and clinical signs of healing (not tender on palpation) are present
** Range of motion brace must be worn until union (on X-rays) and clinical signs of healing (not tender on palpation) are present
* Crutch walking 6-8 weeks
* Crutch walking 6-8 weeks
* Rehabilitation  
* Rehabilitation  
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Indication:  Significant displacement with extensor mechanism not intact.<ref name=":1" />
Indication:  Significant displacement with extensor mechanism not intact.<ref name=":1" />


Aim:  Restore extensor function, align articular incongruities, and allow early motion<ref name=":6" /><ref name=":9" /><ref>Shang ZG. Patellar fractures treatment and management. Unbound medline 2013;26(6):445-8.</ref><ref>Strauss J. ORIF Patella Fracture Post-Operative Rehabilitation Protocol, Hospital for Joint Diseases, 2008.</ref>
Aim:  Restore extensor function, align articular incongruities, and allow early motion<ref name=":6" /><ref name=":9" /><ref>Shang ZG. Patellar fractures treatment and management. Unbound medline 2013;26(6):445-8.</ref><ref name=":0">Strauss J. ORIF Patella Fracture Post-Operative Rehabilitation Protocol, Hospital for Joint Diseases, 2008.</ref>
 
Management:<ref name=":1" /><ref name=":7" />
* Transverse/simple, comminuted mid-patella fracture:  Open reduction and internal fixation using tension band wire technique using pins and wires and 'a figure of eight' to press the pieces together
** POP cast in extension for 6 weeks
 
* Proximal/distal <1/3 - simple or comminuted:  Excision of small piece & tendon repair
** POP cast for 6 weeks
 
* Longitudinal (uncommon):  Interfragmentary screw fixation
* Comminuted fracture/irreducible or irreparable fracture or when cartilage too badly damaged:  Partial vs complete patellectomy:<ref name="p4" />
** Quadriceps muscles is is attached to the patellar ligament to ensure function of the extensor apparatus during a complete patellectomy<ref name="p4" />
** Patellectomy: Relatively old procedure, <u>last treatment of choice</u>


Management:<ref name=":1" />
* Open reduction and internal fixation using tension band wire technique
** Transverse fracture:  Open reduction and internal fixation using tension band wire technique using pins and wires and 'a figure of eight' to press the pieces together
** Comminuted fracture:  Partial vs complete patellectomy:<ref name="p4" />
*** Quadriceps muscles is is attached to the patellar ligament to ensure function of the extensor apparatus during a complete patellectomy<ref name="p4" />
*** Patellectomy: Relatively old procedure, last treatment of choice
* Repair of bilateral vastus muscles
* Repair of bilateral vastus muscles
* Rehabilitation same as with conservative management<br>
* Rehabilitation same as with conservative management<br>
Line 145: Line 154:


== Physiotherapy management  ==
== Physiotherapy management  ==
Extensor mechanism in place
As clinical healing phases do not always correlate with theoretical healing, the surgeon will guide rehabilitation taking X-ray findings into consideration. The following is a guide to be used in the rehabilitation of a patient after a patella fracture, but it is always good to discuss treatment plans with your orthopaedic surgeons.
 
=== Conservative management ===
Conservative management are used when the extensor mechanism is still intact.<ref name=":1" />
 
==== Phase 1: 0-6 weeks ====
* Range of motion (as per surgeon):
** Range of motion brace locked in extension 2-3 weeks
** Controlled motion brace at 2-3 weeks
** Exercises:
*** Open kinetic chain strengthening and knee range of motion at 3-4 weeks - focus on active flexion & extension in inner ranges
*** Quadriceps
*** Hamstring
*** Gluts sets
*** SLR
*** Open and closed kinetic chains hip strengthening exercises
*** Circulatory drills
* Weight-bearing:
** Partial weight-bearing in brace
** May stand tandem
** Weight-bearing restrictions normally apply for 6-8 weeks<ref name=":11" /><ref name=":10" />
** Duration of crutches/weight-bearing restrictions as per surgeon
 
* Patella mobilization
* Pain & oedema management using [[cryotherapy]]
<ref name=":1" /><ref name=":0" />
 
==== Phase II: 6-12 weeks ====
* Range of motion knee brace as per surgeon
* Range of motion:
** Progress to full knee flexion & extension


Extension splint. as fracture heals, gradulally increase knee flexion. quads strengthening in inner ranges. -SPORT
* Exercises:
** Stationary bike with seat elevated and no resistance
** Progress closed kinetic chain exercises: Mini squats, step up, retro step, etc
** Progress resistance on hip exercises
** Proprioception
** Lunges from weeks 8-10
<ref name=":0" />


cons mx Crutches will be used during the 6 to 8 week healing process.<ref name=":10" /><ref name=":11" />
=== Post-operative rehabilitation ===
Surgical intervention are done in cases where there are significant displacement and the extensor mechanism is not intact. Open reduction and internal fixation using the tension band wire technique is normally the treatment of choice.<ref name=":1" />


Treatment with cold can be used to control pain and oedema. During the immobilization of the knee the patient is encouraged to train other leg muscles. After removing the cast or splint, and the fracture is considered healed, the therapy to regain range of motion starts.<br>There are instructions to prevent loss of motion and strength in adjacent joints. Ankle exer-cises are taught to promote circulation. <br>The range of motion, strengthening, and proprioceptive exercises of the involved joint should be initiated and progressed as indicated and tolerated by the individual. <ref>Medical Disability Guidelines , http://www.mdguidelines.com/fracture-patella (ac-cessed December 26, 2010)</ref><br>  
==== Phase I:  0-2 weeks ====
* Range of motion brace set at 0-30°
** Only to be taken off for physiotherapy sessions
* <br>  


ignificant displacement, extensor mechanism not intact. ORIF tension band wire technique. Repari or bilater. vastus. same rehab as with no-operative-SPORT<br>  
ignificant displacement, extensor mechanism not intact. ORIF tension band wire technique. Repari or bilater. vastus. same rehab as with no-operative-SPORT<br>  
Line 194: Line 243:
(Strauss J. (MD)(level of evidence&nbsp;: 5), Elizabeth Arendt(MD) ( level of evidence: 5) )  
(Strauss J. (MD)(level of evidence&nbsp;: 5), Elizabeth Arendt(MD) ( level of evidence: 5) )  


<br>'''Treatment procedure Non-Operative&nbsp;:'''
<br>
 
<u>Phase
 I:
0-­6 
Weeks</u><br>• Knee
Brace:
 Brace locked in extension 2-3 weeks, controlled motion brace at 2-3 weeks<br>o Weightbearing: <br>• PWB in brace and on crutches. <br>• May stand tandem. <br>• Duration of crutches as per surgeon<br>o Range
of
Motion:

 ROM as per surgeon<br>o Therapeutic
Exercises:
<br>• Start open kinetic chain strengthening and ROM of knee at 3-4 weeks or per surgeon order. <br>• Quadriceps<br>• Hamstring <br>• Glutei sets <br>• SLR <br>Open and close kinetic chains hip strengthening exercises. <br>• Patellar mobilization<br>
 
<br>
 
Examples of a knee braces after a patellar fracture:
 
<br>
 
<br>
 
<br>
 
<br>
 
Open kinetic chain strengthening and ROM of knee:
 
<br>
 
<br>
 
<br>
 
<br>
 
<br><u>Phase II: 6-12 Weeks</u><br>• Knee Brace: Discharge per surgeon order<br>o Range of Motion: Progress toward full knee flexion, extension<br>o Therapeutic Exercises:<br>▪ Stationary biking with seat elevated and no resistance for ROM <br>▪ Progress close kinetic chain exercise: mini squats, step up, retro step, etc <br>▪ Progress resistance on hip exercise. <br>▪ Advance proprioceptive exercise <br>▪ Begin lunges 8-10 weeks
 
(Strauss J. (MD)(level of evidence&nbsp;: 5), Elizabeth Arendt(MD) ( level of evidence: 5), Kathryn E. Cramer, MD et al (level of evidence 5 )
 
<br>
 
Examples of exercices:
 
Quadriceps: The patient sits on the floor with his injured leg straight and his other leg bent. He presses the back of the knee of his injured leg against the floor by tightening the muscles on the top of his thigh. He has to hold this position 10 seconds and then re-lax, the patient does 2 sets of 15seconds. (Bhave A et al. (Level of evidence&nbsp;:5), Creighton AR et al. (level of evidence&nbsp;: 5))
 
<br>SLR&nbsp;: The patient has to lie on his back with his legs straight. Then he has to bend the knee on his uninjured side and place his foot flat on the floor. Once this is done, he has to tighten the thigh muscle on his injured side and lift his leg about 8 inches off the floor. The patient keeps his leg straight and his thigh muscle tight and then he brings his leg slowly back down to the floor. This exercise is also done in 2 sets of 15 seconds. Bhave A et al. (Level of evidence&nbsp;:5), Creighton AR et al. (level of evidence&nbsp;: 5)
 
Patellar mobilisation&nbsp;:
 
o Patient sits with his injured leg in front of him. His leg should be completely straight and relaxed. Patient has to use his hands to move the patella sideways toward the inside of his leg. Then he has to move it sideways toward the inside of his leg. Each position has to be hold for 15 to 30 seconds.<br>Fourati M.K. (level of evidence:2b), Elizabeth Arendt(MD) (level of evidence: 5),Bhave A et al. (Level of evidence&nbsp;:5), Creighton AR et al. (level of evidence&nbsp;: 5)
 
o Patient has to use his hands to move his patella toward him and then away from him for 15 to 30 seconds in each direction. Then he has to compare the movement of the injur<br>ed patellla with the movement of the uninjured patella. The main goal is to have the same amount of movement for bouth kneekaps. 
 
== Resources <br>  ==
== Resources <br>  ==


Revision as of 22:12, 29 July 2018

Original Editor - Rachael Lowe Top Contributors - Marie Avau, Leana Louw, Lise De Wael, Admin, Angeliki Chorti, Rachael Lowe, Debby Decock, Kim Jackson, Patti Cavaleri, Aminat Abolade, Evan Thomas, Scott Buxton, Oyemi Sillo, WikiSysop, Karen Wilson, Claire Knott, Manisha Shrestha and 127.0.0.1


***Editing in process***

Definition/Description[edit | edit source]

Patella fractures are caused by directly by trauma or a compressive force, or indirectly as the result of quadriceps contractions or excessive stress to the extensor mechanism.[1][2][3] Indirect injuries are commonly associated with tears of the retinaculum and vastus muscles.[1] Patella fractures make up about 1% of all skeletal injuries.[4][5]

Clinically relevant anatomy[edit | edit source]

The patella is a triangular bone situated on the anterior surface of the knee at the distal end of the femur. It is the largest sesamoïd bone in the body and makes part of the knee joint.[6][7][8] Vastus medialis and lateralis, as part of the quadriceps group, control movement at the patella.[9] The extensor mechanism as a whole plays a major role in patella fractures. This consists of the quadriceps, quadriceps tendon, retinaculum, patella tendon, tibial tubercle and patellofemoral and patellotibial ligaments.[10] See the page on the patella for more details on the anatomy.

658px-Knee diagram.svg.png
Knee joint.png


Epidemiology/Etiology[edit | edit source]

In a recent study, the average mortality rate at one year after patella fractures was 2.8%, increasing to 6.2% in the geriatric population. Patella fractures are not associated with an increased mortality rate, as the relative risk of death was 0.9.[11]

Complications[edit | edit source]

  • Injuries (sprain/rupture) to ligaments and tendons attached to the patella
  • Avascular necrosis[12]
  • Post-traumatic arthritis
  • Osteochondral damage to patella-femoral joint
  • Stiffness
  • Non-union
  • Malunion
  • Concomitant injuries (e.g. injuries to the acetabulum, femur and tibia)
  • Long term complications:[13]
    • Stiffness
    • Extension weakness
    • Patellofemoral arthritis.

[1]

Characteristics/Clinical Presentation[edit | edit source]

Types of fractures[edit | edit source]

Patella fractures are classified as either displaced or non-displaced. Displaced fractures are unstable and can be further classified as:[14]

  • Comminuted: As a result of direct trauma (mostly due to blows or falls on flexed knee)
    • Can cause damage to the articular cartilage of patella and femoral condyles.
  • Tansverse/stellate: As a result of muscle contraction/extensive stress on the extensor mechanism, e.g. explosive quadriceps contraction after jumping from height.
    • Most common type
    • Proximal blood supply may be compromised
    • Usually as a result of hyper-flexion of the knee
  • Marginal: As a result of a fall on the knee
  • Vertical/longitudinal
  • Lower/upper pole
  • Osteochondral
  • Sleeve (only in paediatric patients)

[2][3][12][14][15][16]

The prognosis of the injury depends on the amount of chondral damage at the time of injury. Functional outcome depends on the ability to achieve pain-free and stable range of motion in an early stage. [17]

Differential diagnosis[edit | edit source]

Diagnosis[edit | edit source]

Interview[edit | edit source]

  • Details regarding accident
  • Mechanism of injury
  • Pain at knee
  • Complaints of difficulty standing or snapping sensation at knee

[18][19][20]

Physical examination[edit | edit source]

  • Observation:
    • Whole extremity
    • Swollen, bruised knee
    • Deformity around knee
    • Possible wounds (open fracture)
  • Palpation (often done after local anesthetics to eliminate pain):
    • Tenderness around patella
    • Palpable gap (for displaced fractures)
  • Rule out concomitant injuries:
    • e.g. fractures of the acetabulum, femur and tibia
  • Haemarthrosis
  • Range of motion:
    • Acute:
      • Limited knee and painful knee flexion and extension
      • Often unable to do straight leg raise
    • Chronic:
      • Full knee flexion with extension lag
  • Distal pulses
  • Assess compartment of the leg
  • Neurological assessment

[16][18][21]

Special investigations[edit | edit source]

  • X-rays:
    • AP view:
      • May be difficult to see patella
    • Lateral view:
      • Undisplaced - < 2mm separation
      • Displaced - > 2mm separation, step deformity noted
    • Sky view
    • Used for regular monitoring of healing process and any possible complications
  • CT scan: Usually not needed
  • MRI: Diagnosis of associated injuries to nearby tendons and ligaments
  • Bone scans: To identify stress fractures

[16][19][20][10]

Outcome measures[edit | edit source]

Medical management[edit | edit source]

  • In acute cases, local anesthetics can be given to eliminate pain.[18] This helps to aid in the assessment and diagnosis of the patella fracture.

Conservative management[edit | edit source]

Indication: Undisplaced fracture (mostly vertical, horizontal and comminuted fractures) with extensor mechanism in place [1][17]

Management:[16][17][10][22]

  • Fracture immobilized with POP cylinder cast or range of motion brace locked in extension (4-6 weeks):
    • As healing takes place, knee flexion can gradually be increased
    • Range of motion brace must be worn until union (on X-rays) and clinical signs of healing (not tender on palpation) are present
  • Crutch walking 6-8 weeks
  • Rehabilitation

Surgical intervention[edit | edit source]

Indication: Significant displacement with extensor mechanism not intact.[1]

Aim: Restore extensor function, align articular incongruities, and allow early motion[17][20][23][24]

Management:[1][16]

  • Transverse/simple, comminuted mid-patella fracture: Open reduction and internal fixation using tension band wire technique using pins and wires and 'a figure of eight' to press the pieces together
    • POP cast in extension for 6 weeks
  • Proximal/distal <1/3 - simple or comminuted: Excision of small piece & tendon repair
    • POP cast for 6 weeks
  • Longitudinal (uncommon): Interfragmentary screw fixation
  • Comminuted fracture/irreducible or irreparable fracture or when cartilage too badly damaged: Partial vs complete patellectomy:[18]
    • Quadriceps muscles is is attached to the patellar ligament to ensure function of the extensor apparatus during a complete patellectomy[18]
    • Patellectomy: Relatively old procedure, last treatment of choice
  • Repair of bilateral vastus muscles
  • Rehabilitation same as with conservative management

Later stages:

Manipulation under anesthesia or the arthroscopic releasing of adhesions is required when athrofibrosis occurs.[17]

Physiotherapy management[edit | edit source]

As clinical healing phases do not always correlate with theoretical healing, the surgeon will guide rehabilitation taking X-ray findings into consideration. The following is a guide to be used in the rehabilitation of a patient after a patella fracture, but it is always good to discuss treatment plans with your orthopaedic surgeons.

Conservative management[edit | edit source]

Conservative management are used when the extensor mechanism is still intact.[1]

Phase 1: 0-6 weeks[edit | edit source]

  • Range of motion (as per surgeon):
    • Range of motion brace locked in extension 2-3 weeks
    • Controlled motion brace at 2-3 weeks
    • Exercises:
      • Open kinetic chain strengthening and knee range of motion at 3-4 weeks - focus on active flexion & extension in inner ranges
      • Quadriceps
      • Hamstring
      • Gluts sets
      • SLR
      • Open and closed kinetic chains hip strengthening exercises
      • Circulatory drills
  • Weight-bearing:
    • Partial weight-bearing in brace
    • May stand tandem
    • Weight-bearing restrictions normally apply for 6-8 weeks[10][22]
    • Duration of crutches/weight-bearing restrictions as per surgeon
  • Patella mobilization
  • Pain & oedema management using cryotherapy

[1][24]

Phase II: 6-12 weeks[edit | edit source]

  • Range of motion knee brace as per surgeon
  • Range of motion:
    • Progress to full knee flexion & extension
  • Exercises:
    • Stationary bike with seat elevated and no resistance
    • Progress closed kinetic chain exercises: Mini squats, step up, retro step, etc
    • Progress resistance on hip exercises
    • Proprioception
    • Lunges from weeks 8-10

[24]

Post-operative rehabilitation[edit | edit source]

Surgical intervention are done in cases where there are significant displacement and the extensor mechanism is not intact. Open reduction and internal fixation using the tension band wire technique is normally the treatment of choice.[1]

Phase I: 0-2 weeks[edit | edit source]

  • Range of motion brace set at 0-30°
    • Only to be taken off for physiotherapy sessions

ignificant displacement, extensor mechanism not intact. ORIF tension band wire technique. Repari or bilater. vastus. same rehab as with no-operative-SPORT

Treatment procedure Post-Operative :

Phase
 I:
0­-2 
Weeks
Knee
Immobilizer:
Worn
at
all
times
(taken
off
only
for
physical
therapy
sessions
converted
to
hinged
knee)
brace is worn
at
first
post‐op
visit

  • Weight bearing: with
the
knee
locked
in
extension
  • Range
 of 
Motion:
 0‐30
degrees
  • Therapeutic 
Exercises:


• 
Isometric
quadriceps/hamstring/adductor/abductor
strengthening,

• Ankle
theraband exercises


Phase
 II:
2-­6
 Weeks
Knee 
Brace:
 Worn
 with 
weight bearing
 activities 
still 
locked 
in 
full 
extension,
may
be
 removed 
at 
night

  • Weightbearing:
  • Range
of
Motion:

 add
15
degrees
of
flexion
each
week
–

  • Goal
is
90
degrees
by
post‐op
week
6

  • Therapeutic
Exercises:


• Isometric
quadriceps/hamstring/adductor/abductor
strengthening,

• Ankle
theraband
exercises,

• Initiate
straight
leg
raises

Phase
 III:
 6-­10 
Weeks
Knee
 Brace:
Unlocked,
worn 
with 
weight bearing
 activities

  • Weightbearing:
Full
  • Range
of
Motion:
 progress
to
full
ROM
by
post‐operative
week
10
  • Therapeutic
Exercises:
Isometric
quadriceps/hamstring/adductor/abductor
 strengthening,
Ankle
theraband
exercises,
Initiate
straight
leg
raises




Phase
 IV:
10­-12 
Weeks
Knee
Brace:
Discontinue

  • Weightbearing:
Full
  • Range
of
Motion:
Full
  • Therapeutic
 Exercises:
Isometric
 quadriceps/hamstring/adductor/abductor
 strengthening, Ankle 
theraband
exercises,
Initiate
 straight
leg
raises,
Start
 stationary 
bicycle


Phase
V:
3­6
 Months: return 
to 
full 
activities
 as
 tolerated

(Strauss J. (MD)(level of evidence : 5), Elizabeth Arendt(MD) ( level of evidence: 5) )


Resources
[edit | edit source]

http://www.physioroom.com/injuries/knee/patella_fracture_full.php
http://www.summitmedicalgroup.com/library/adult_health/smapatellarfractureexecises_references/
http://www.mdguidelines.com/fracture-patella
http://www.ncbi.nlm.nih.gov/pubmed/?term=patellar%20fracture
http://www.healthline.com/human-body-maps/knee

References
[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Frobell R, Cooper R, Morris H, Arendt, H. Acute knee injuries. In: Brukner P, Bahr R, Blair S, Cook J, Crossley K, McConnell J, McCrory P, Noakes T, Khan K. Clinical Sports Medicine: 4th edition. Sydney: McGraw-Hill. p.626-683
  2. ↑ 2.0 2.1 Schuett DJ, Hake ME, Mauffrey C, Hammerberg EM, Stahel PF, Hak DJ. Current treatment strategies for patella fractures. Orthopedics. 2015;38(6):377-84.
  3. ↑ 3.0 3.1 Archdeacon, Michael T., and Roy W. Sanders. Chapter 54 - Patella Fractures and Extensor Mechanism Injuries. In: Browner BD, Jupiter JB, Krettek C, Anderson PA, editors. Skeletal Trauma, 4th edition. Elsevier Health Sciences, 2008.
  4. ↑ Crowther MA, Mandal A, Sarangi PP. Propagation of stress fracture of the patella. British journal of sports medicine 2005;39(2):e6.
  5. ↑ Sweetnam R. Patellectomy. Postgraduate medical journal 1964 Sep;40(467):531.
  6. ↑ Cedars-Sinai. Fractured Kneecap. Cedars Sinai organisation. https://www.cedars-sinai.org/health-library/diseases-and-conditions/f/fractured-kneecap.html (accessed 25/07/2018).
  7. ↑ Schunke M. Anatomische atlas Prometheus, algemene anatomie en bewegingsapparaat. Bohn Stafieu van Loghum: 2e druk. 2010.
  8. ↑ Everett L. Knee and Lower Leg. In: Marx J, Walls R, Hockberger R, editors. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia: Mosby Elsevier, 2006.
  9. ↑ Orthopaedia. Collaborative Orthopaedic Knowledgebase, http://www.orthopaedia.com/display/Main/Patella+fractures (accessed November 10, 2010).
  10. ↑ 10.0 10.1 10.2 10.3 Duke Orthopaedics. Wheeless’ textbook of Orthopaedics. Fractures of the patella.http://www.wheelessonline.com/ortho/fractures_of_the_patella (accessed November 10 2010).
  11. ↑ Larsen P, Elsoe R. Patella fractures are not associated with an increased risk of mortality in elderly patients. Injury 2018.
  12. ↑ 12.0 12.1 Medscape. Patella Fracture Imaging. http://emedicine.medscape.com/article/394270-overview&gt (accessed 25/07/2018).
  13. ↑ Insall JN. Fractured kneecap: treatments. Institute for Orthopaedics and sports medicine 2007.
  14. ↑ 14.0 14.1 Whittle PA. Fractures of the Lower Extremity. In: Canale ST, Beaty JH, editors. Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier, 2008.
  15. ↑ Melvin SJ, Mehta S. Patellar fractures in adults. Journal of the American Academy of Orthopaedic Surgeons 2011;19(4):198-207.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Mehling I, Mehling A, Rommens PM. Comminuted patellar fractures. Current Orthopaedics 2006;20(6):397-404.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 Günal I, Karatosun V. Patellectomy: an overview with reconstructive procedures. Clinical Orthopaedics and Related Research 2001;389:74-8.
  19. ↑ 19.0 19.1 McRae R, Esser M. Practical fracture treatment E-book. Churchill Livingstone/ Elsevier; 2002.
  20. ↑ 20.0 20.1 20.2 Fourati MK. Reeducation du genou après fracture de la rotule. Ann. Kinésitherapie 1986.
  21. ↑ Scolaro J, Bernstein J, Ahn J. In brief: patellar fractures. 2011;1213-1215.
  22. ↑ 22.0 22.1 American Academy of Orthopaedic Surgeons. Diseases and conditions - Patellar (Kneecap) Fractures. http://orthoinfo.aaos.org/topic.cfm?topic=A00523 (accessed November 10 2010).
  23. ↑ Shang ZG. Patellar fractures treatment and management. Unbound medline 2013;26(6):445-8.
  24. ↑ 24.0 24.1 24.2 Strauss J. ORIF Patella Fracture Post-Operative Rehabilitation Protocol, Hospital for Joint Diseases, 2008.



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