Patellar Fractures: Difference between revisions

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{{Qualityalert_Injury}} '''To edit: general formatting, completion of categories''' 
<div class="editorbox"> '''Original Editor '''- [[User:Rachael Lowe|Rachael Lowe]]
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'''Editors''' ---[[User:Marie Avau|Marie Avau]] Debby Decock, Tamara Kindekens en Ellen Vandyck
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
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== Search Strategy<br>  ==
We initiated our search about ‘patellar fractures’ by putting words like patella, fracture, symptoms and diagnosis in PubMed. Secondly we went to the library to borrow books about this topic, for example: ‘practical fracture treatment’ and ‘Algemene Anatomie en bewegingsapparaat’. After this search, some parts were still incomplete so we consulted scientific databases like Pedro, Medscape, Springer Link etc.. using keywords and combi-nations of keywords like: patella, patellar fracture, fractures in the knee, treatment and care of patellar fractures, etiology of patellar fractures, diagnosis of patellar fractures and especially physical therapy treatment of a patellar fracture, to complete everything.
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== Definition/Description  ==
== Definition/Description  ==


Patellar fracture is a very common knee injury. They can be divided into three types. <br>The first type is caused by direct violence and is called comminuted (this is a bone fracture that results in more than 2 separate bone components, the bone breaks into several pieces). These type of fractures are usually associated with a blow or a fall on a flexed knee. <br>The second type is caused by muscle violence and is called transverse. These type of frac-tures are usually associated with rupture of structures at the lateral site of the knee such as the collateral ligament.<br>Finally, the third type is a minor marginal fracture, which is usually caused by a fall on the knee.&nbsp;<ref>Melvin JS. Et al, “patellar fractures in adults”, The journal of the American academy of orthopaedic surgeons, 2011. ( level of evidence 3B)</ref>  
[[Patella]] fractures are caused by direct trauma or compressive force, or as the indirect result of quadriceps contractions or excessive stress to the extensor mechanism.<ref name=":1">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. 2012; 626-683.</ref><ref name=":2">Schuett D., Hake M., Mauffrey C., Hammerberg E., Stahel P., Hak D. [https://www.researchgate.net/profile/Dustin_Schuett/publication/278788220_Current_Treatment_Strategies_for_Patella_Fractures/links/568ca26008aeb488ea2fdd6f/Current-Treatment-Strategies-for-Patella-Fractures.pdf Current treatment strategies for patella fractures.] Orthopedics. 2015;38(6):377-84.</ref><ref name=":3">Archdeacon M., Sanders R. Chapter 54 - Patella Fractures and Extensor Mechanism Injuries. In: Browner B.D., Jupiter J.B., Krettek C., Anderson P.A., (eds). Skeletal Trauma, 4th edition. Elsevier Health Sciences, 2008.</ref> Indirect injuries are commonly associated with tears of the retinaculum and [[Quadratus Femoris|quadriceps muscles]].<ref name=":1" /> Patella fractures make up about 1% of all skeletal injuries and are found in all age groups.<ref>Crowther M., Mandal A., Sarangi P. [https://bjsm.bmj.com/content/39/2/e6.full Propagation of stress fracture of the patella.] British journal of sports medicine 2005;39(2):e6.</ref><ref>Sweetnam R. [https://pmj.bmj.com/content/postgradmedj/40/467/531.full.pdf Patellectomy.] Postgraduate medical journal 1964 Sep;40(467):531.
 
</ref><ref name=":13" />
Approximately 1% of all skeletal injuries are patellar fractures. [<ref>M A A CROWTHER, A MANDAL, P P SARANGI, Propagation of stress fracture of the patella, Br J Sports Med, 2005;39</ref><ref>RODNEY SWEETNAM, Patellectomy, Postgrad Med J, 1964</ref><br>Thereby, fractures may be accompanied by a sprain or rupture of the ligaments or tendons that are attached to the patella. This injury can lead to stiffness, extension weakness, and patellofemoral arthritis.<ref>Insall, “ Fractured kneecap: treatments”, Institute for Orthopaedics and sports medi-cine, 2007. (level of evidence 5)</ref><br><br>  
== Clinically relevant anatomy  ==
 
<br>
 
<br>


== 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 sesamoid bone in the body and makes part of the [[Knee|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> The patella 's primary role is to function as a fulcrum with the aim to increase the moment arm of the quadriceps muscle and thus, knee extensive capacity. <ref name=":14" />


The patella is the largest sesamoïd bone in the body.  
[[Vastus Medialis|Vastus medialis]] and [[Vastus Lateralis|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 medial retinaculum, formed by the vastus medialis and quadriceps aponeurosis and lateral retinaculum, formed by the vastus lateralis and the ilotibial band, all aid in the extension of the knee. <ref name=":13" /> 


The patella is a triangular bone that is situated on the anterior surface of the knee at the distal end of the femur, it's a part of the articulatio patello-femoralis. In combination with the capsuloligamentar ligaments and&nbsp;the meniscus medialis and lateralis it forms the knee joint. .<ref>Cedars-Sinai, Fractured Kneecap, Cedars Sinai organisation, 2014.</ref>[[Image:Figuur1.png]]<ref>Everett, Lyn, et al. "Knee and Lower Leg." Rosen's Emergency Medicine: Concepts and Clinical Practice. Eds. J. A. Marx, et al. 6th ed. Philadelphia: Mosby Elsevier, 2006.</ref><ref>Schunke M. et al, Anatomische atlas Prometheus, algemene anatomie en bewegingsapparaat, Bohn Stafieu van Loghum, 2e druk (juli 2010), p. 390-401</ref>[[Image:Figuur2.png]]<br>On the anterior side of the patella we can find: facies anterior, basis patellae and apex patellae. On <br>the posterior side of the patella we have: facies articularis patellae, one lateral and one me-dial separated by a ridge. On The basis patellae is the insertion of the quadriceps tendon and the apex patellae is the origin of the patellar ligament. The patella has the thickest articular cartilage of the body, it may be as thick as 1 cm. The patella is surrounded by several structures going from muscles to menisci. The two muscles that control the move-ment of the patella are the vastus medialis and the vastus lateralis. <ref>Orthopaedia, Collaborative Orthopaedic Knowledgebase, http://www.orthopaedia.com/display/Main/Patella+fractures (accessed November 10, 2010</ref><br>[[Image:Figuur3.png]]  
The extensor mechanism as a whole plays a major role in patella fractures. The extensor mechanism 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 blood supply in the patella is derived from two vessel systems, branched out of the geniculate arteries. Together, they supply the middle third and the apex of the patella. .<ref>Gary Shankman, OPA-C, PTA, ATC, CSCS, CWS, “Treating Patella Fracture”, Advanced health care network for physical therapy and rehab medicine, 1999. (level of evi-dence 5)</ref><br>
{|
|-
|[[File:658px-Knee diagram.svg.png|center|thumb]]
|[[File:Knee joint.png|center|thumb]]
|}


== Epidemiology /Etiology  ==
== Epidemiology ==  


Because of its subcutaneous location, the patella is very vulnerable to injury. Patellar frac-tures occur as a result of a compressive force, a sudden tensile force (as occurs with hyper flexion of the knee), or a combination of these two causes. <br>These fractures can be caused by direct blows to the knee in sports injuries or accidents, or from indirect stresses caused by twisting actions or violent contractions in the muscles sur-rounding the knee.<ref>Archdeacon, Michael T., and Roy W. Sanders. "Chapter 54 - Patella Fractures and Extensor Mechanism Injuries." Skeletal Trauma. Eds. Bruce D. Browner, et al. 4th ed. W.B. Saunders, 2008.</ref>  
A 2016 study found the incidence of patella fracture to be 13.1/100,000 per year with an increasing incidence with increasing age<ref name=":12">Larsen P., Court-Brown C., Vedel J., Vistrup S., Elsoe R. Incidence and Epidemiology of Patellar Fractures. Orthopedics; 2016 Nov 1;39(6):e1154-e1158.</ref>. Females accounted for 56% of patella fractures and males accounted for 44% of patella fractures. <ref name=":12" /> A newer Swedish study also found that older (>65 years old) females had a higher percentage of patellar fractures (64%) compared to males . <ref name=":15">Kruse M, Wolf O, Mukka S, Brüggemann A. [https://link.springer.com/article/10.1007/s00068-022-01993-0 Epidemiology, classification and treatment of patella fractures: an observational study of 3194 fractures from the Swedish Fracture Register]. European Journal of Trauma and Emergency Surgery. 2022 May 30:1-8.</ref> Most fractures were caused by low-energy trauma, with 70% due to simple falls, especially in the winter months. <ref name=":15" />  


As a result of these forces, various fracture patterns result, which depend on the mechanism of the injury. <br>The most common pattern is often described as transverse or stellate. (in this case the prox-imal blood supply may be compromised leading to avascular necrosis of the proximal seg-ment.)<ref>Lamoureux, Christine. "Patellar Fractures." eMedicine. Eds. David S. Levey, et al. 24 May. 2007. Medscape. 23 Dec. 2009 &amp;lt;http://emedicine.medscape.com/article/394270-overview&amp;gt;.</ref><br>Less common patterns include vertical, marginal, osteochondral, and sleeve fractures (exclu-sively seen in the pediatric 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; 49(10):1901-1904.</ref> 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.


Causes of fractures:<br>A direct blow to the patella: most often results in a stellate fracture. The compressive forces applied to the patella result in a comminuted pattern. The energy of the blow is absorbed by the fracture and causes damage to the articular cartilage of both the patella and the femoral condyles. <br>Another mechanism is a tensile force: this is sustained with hyper flexion of the knee, this is equal to an eccentric contraction of the quadriceps. <br>A combination of these two mechanisms: leads to a variety of other fracture patterns. A dis-placed transverse fracture can have “comminution”(see figure 3).<br><br>  
== Complications ==
 
* Injuries (sprain/rupture) to ligaments and tendons attached to the patella
<br>  
* [[Avascular Necrosis|Avascular necrosis]]<ref name=":4">Medscape. Patella Fracture Imaging. http://emedicine.medscape.com/article/394270-overview&amp;gt (accessed 25/07/2018).
</ref>
* [[Post-traumatic arthritis]]
* Osteochondral damage to [[Patellofemoral Joint|patellofemoral joint]]
* Stiffness
* Non-union
* Malunion
* Concomitant injuries (e.g. injuries to the [[Hip Anatomy|acetabulum]], [[femur]] and [[tibia]])
* 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  ==


Patellar fractures are classified in two groups: displaced or non-displaced, these 2 groups consist of several types.<br>Non- displaced fractures can be recognized when the broken bone is stable and has re-mained in place.<br>Displaced fractures, in which the pieces of broken bone have shifted out of position, logically these fractures are unstable.(transverse, vertical, comminuted or lower/upper pole)<ref>Whittle, Paige A. "Fractures of the Lower Extremity." Campbell's Operative Ortho-paedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Else-vier, 2008.</ref><br>[[Image:Figuur 4.png]]<br><br>
=== Types of fractures ===
 
Patella fractures are classified as either displaced or non-displaced. Displaced fractures are unstable and can be further classified as:<ref name=":5" />
== Differential Diagnosis ==
* 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.
A doctor can diagnose a fracture of the patella by asking you about the details of your acci-dent and by examining you. He will inspect your knee, focusing on where it is tender, swol-len or misshapen. Then, he may also ask you to raise your leg or extend your knee, possibly after giving you a local anesthetic to eliminate pain. This helps the doctor to see if there are other injuries in and around your knee. <ref name="24">Günal L. et al, Patellectomy : an overview with reconstructive procedures, Clinical Orthopeadics and Related Research, 2001.</ref><br>Most of the times the individual reports pain during this examination of the affected knee.<br>Common causes that the patients may report for this pain are: an accident, a fall from height or a direct blow to the knee.
* Transverse/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<ref name=":12" />
The best way to exclude or include a patellar fracture is an X-ray, taken from several angles, to determine the extent of a fractured kneecap and to check for other injuries. If other inju-ries are suspected, a computer tomography (CT) or magnetic resonance imaging (MRI) scan may also be done.<br>  
** Proximal blood supply may be compromised
 
** Usually as a result of hyper-flexion of the knee
== Diagnostic Procedures  ==
* Marginal: As a result of a fall on the knee
 
* Vertical/longitudinal
A patellar fracture is suspected when there is a history of direct violence, when there are difficulties in standing or when there is a snapping sensation. In most cases there is straight leg raise inability and the inability to extend the knee.<br>Bruising and abrasion, the presence and site of tenderness, any palpable gap above or be-neath the patella as well as any obvious proximal displacement of the patella can indicate a patellar fracture.<br>Radiographs are necessary to clarify because there isn't some kind of specific test to identify a patellar fracture. Standard x-rays with special views of the patella are usually sufficient to diagnose a patellar fracture. However in more difficult cases where x-rays are not decisive, CT scan may be necessary. Associated injuries to nearby tendons and ligaments may need to be evaluated by MRI studies.<ref>McRae et al, “Practical fracture treatment” , Churchill Livingstone/ Elsevier, Editie 2002. (level 2a: levels of evidence)</ref><ref>Fourati M.K., "reeducation du genou après fracture de la rotule", Ann. Kinésitherapie, 1986. (Level 2b: levels of evidence)</ref><br><br>
* Lower/upper pole
 
* Osteochondral
== Outcome Measures  ==
* Sleeve (only in paediatric patients)
 
<ref name=":2" /><ref name=":3" /><ref name=":4" /><ref name=":5">Whittle P. Fractures of the Lower Extremity. In: Canale S., Beaty J., (eds). Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier, 2008.</ref><ref name=":14">Melvin S.J., 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. (ed). Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.</ref>
The outcome depends primarily on the quality of articular restoration. Any intra-articular incongruities lead to the development of posttraumatic arthritis. <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 stabile range of motion in an early stage. <br>Manipulation under anesthesia or the arthroscopic releasing of adhesions is required when athrofibrosis occurs. <br>Future treatment options may include osteochondral allograft reconstructions of the patella, for posttraumatic arthritis. Currently, several fixation methods of patellar fractures includes modified tension band wiring, Circumferential cerculage wires, and screw fixation and re-cently bioabsorbable fixation which may reduce the frequency of hardware symptoms.<ref>Mehling, I. et al, « Comminuted patellar fractures », Current Orthopaedics, volume 20 p.397-404, 2006.</ref>  
 
These outcomes can be measured by the following measures:
 
- [http://www.physio-pedia.com/Knee_Injury_and_Osteoarthritis_Outcome_Score Knee injury and osteoarthritis outcome score]


- [http://www.physio-pedia.com/Knee_outcome_survey Knee outcome survey]  
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 P. [https://www.sciencedirect.com/science/article/pii/S026808900600168X Comminuted patellar fractures.] Current Orthopaedics 2006;20(6):397-404.</ref>


- [http://www.physio-pedia.com/Lower_Extremity_Functional_Scale_%28LEFS%29 Lower extrimity function scale]  
== Differential diagnosis ==
* Bipartite patella<ref name=":1" />
* [[Multiligament Injured Knee Dislocation|Knee dislocation]]
* [[Patellar dislocation|Patella dislocation]]


-[http://www.physio-pedia.com/McGill_Pain_Questionnaire McGill pain questionnaire]
== Diagnosis  ==


== Examination  ==
=== Interview ===
* Details regarding accident
* Mechanism of injury
* Pain at knee
* Complaints of difficulty standing or snapping sensation at knee
<ref name="p4">Günal I., Karatosun V. [https://journals.lww.com/clinorthop/Fulltext/2001/08000/Patellectomy__An_Overview_With_Reconstructive.12.aspx Patellectomy: an overview with reconstructive procedures.] Clinical Orthopaedics and Related Research 2001;389:74-8.</ref><ref name=":8">McRae R., Esser M. Practical fracture treatment E-book. Churchill Livingstone/ Elsevier; 2002.</ref><ref name=":9">Fourati MK. Reeducation du genou après fracture de la rotule. Ann. Kinésitherapie 1986.</ref>


The clinical examination should include an inspection of the whole extremity. Clinical signs of a patellar fracture are swelling and pain in the knee joint. Wounds should be checked to con-firm whether the fracture is open or closed. <br>In displaced patellar fractures, a defect zone between the fragments may be palpable. Often there is a haemarthrosis of the knee. Flexion and extension in the knee joint is limited and painful. Active extension and lifting of the leg is usually impossible. <br>However, the ability to extend the knee does not rule out a patellar fracture, because the medial and lateral retinacula may be still intact.<br>Of course a check of the peripheral pulses, the compartments of the leg, and a neurological examination should always be performed. Special interest should be paid to potential ipsi-lateral concomitant injuries (e.g. acetabular fractures, femoral fractures or tibial fractures) which are signs of serious trauma.<ref>Scolaro, J. et al, « In brief : patellar fracture », For the association of bone and joint surgeons, 2010. (level of evidence 5)</ref><br><br>
=== Physical examination ===
* 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


== Medical Management <br> ==
* Distal pulses
* Assess compartment of the leg
* Neurological assessment
<ref name=":7" /><ref name="p4" /><ref>Scolaro J, Bernstein J, Ahn J. [https://link.springer.com/article/10.1007/s11999-010-1537-8 In brief: patellar fractures]. Clinical Orthopaedics and Related Research®. 2011 Apr;469(4):1213-5.</ref>


<u>Surgical treatment</u> is usually performed in patients with a displaced fracture and is carried out on an emergency basis if the fracture is open or if an associated traumatic arthrotomy is present.Sometimes surgery is necessary because the strong M. Quadriceps can pull the broken pieces out of place and apart from each other so callus cannot form. When this occurs, healing with ossification is im-possible. <br>  
=== Special investigations ===
[[X-Rays|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
{|
|-
|[[File:Patella fracture.JPG|thumb|AP view]]
|[[File:Patella fracture latview.jpg|thumb|Lateral view]]
|}
* [[CT Scans|CT scan]]:  Usually not needed
* [[MRI Scans|MRI]]:  Diagnosis of associated injuries to nearby tendons and ligaments
* Bone scans: To identify stress fractures
<ref name=":7" /><ref name=":8" /><ref name=":9" /><ref name=":11" />


[[Image:Figuur 5.png]]  
== Outcome measures  ==
* [http://www.physio-pedia.com/Knee_Injury_and_Osteoarthritis_Outcome_Score Knee injury and osteoarthritis outcome score]
* [http://www.physio-pedia.com/Knee_outcome_survey Knee outcome survey]
* [http://www.physio-pedia.com/Lower_Extremity_Functional_Scale_%28LEFS%29 Lower extremity function scale]
* [http://www.physio-pedia.com/McGill_Pain_Questionnaire McGill pain questionnaire]
== 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.


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


The therapy procedure variates with the characteristics of the patella fracture. If you have a transverse fracture If the fracture is transverse, the most common procedure is to use pins and wires and 'a figure of eight' to press the pieces together (AO tension band wiring). A comminuted fracture is usually associated with a blow or a fall on a flexed knee, and causes the patella to break in several pieces. In this case, the small crushed pieces of the patella will be re-moved.(partial patellectomy). In addition, there is also a procedure called ‘complete pallac-tomy’. In this case the whole patella is removed and the tendon of the M. Quadriceps is at-tached to the ligamentum patellae, to ensure the function of the extensor apparatus. But, this is a relatively old procedure and its effects are controversial. (Günal L. et al ) <br>A break in the center of the kneecap can be fixed using wires and screws. Note that a patellec-tomy is the last treatment for a comminuted fracture.<br>Operative treatment aims to restore extensor function, align articular incongruities, and al-low early motion (Fourati M.K. Level 2b: levels of evidence, Mehling, I. et al, Scolaro, J. et al. level of evidence 5, Zhongguo Gu Shang et al. level 2b: levels of evidence, Strauss J. MD Lev-el 5&nbsp;:levels of evidence) <ref>Zhongguo Gu Shang et al, “patellar fractures treatment and management”, Unbound medline 2013 Jun;26(6):445-8. (level 2b: levels of evidence)</ref><ref>Strauss J. (MD), ORIF Patella Fracture Post-Operative Rehabilitation Protocol, Hospi-tal for Joint Diseases, 2008 (Level 5 :levels of evidence)</ref><br>
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 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 to restore full range of motion, strength, and return to function


<u>Nonsurgical treatment</u> (Orthopeadic) is indicated when the broken pieces of the patella aren't displaced. The patient needs a casts or splints to immobilize the fractured pieces, this is done in vertical and horizontal fractures. In horizontal fractures, radiographs are taken at weekly intervals to exclude late separation of the pieces. so callus formation can take place. In this way the callus can form. Crutches will be used during the 6 to 8 week healing process.<ref>AAOS, American Academy Of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=A00523 (accessed November 10, 2010)</ref><ref>Duke Orthopaedics, Wheeless’ textbook of Orthopaedics, http://www.wheelessonline.com/ortho/fractures_of_the_patella (accessed Novem-ber 10, 2010)</ref><br>Once radiographic evidence indicates union and clinical signs of healing (nontender to palpa-tion) are present, the patient is changed to a removable brace.( Mehling, I. et al )<br><br>  
=== Surgical intervention ===
Indication:  Significant displacement with extensor mechanism not intact<ref name=":1" />or articular step off >2-3mm or fracture displacement >1-4 mm. <ref name=":13">Posner A., Zimmerman J. [https://www.scientificarchives.com/admin/assets/articles/pdf/surgical-management-of-patella-fractures-a-review-20220302120317.pdf Surgical management of patella fractures: a review.] Archives of Orthopaedics 2022; 3(1):17-21. </ref>


== Physical Therapy Management <br> ==
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>


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>
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
[[File:Patella ORIF.png|center|thumb|Tension band wire ORIF]]
* Proximal/distal <1/3 - simple or comminuted:  Excision of small piece & tendon repair
** POP cast for 6 weeks


<br>  
* 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> due to significant loss of extension


'''Treatment procedure Post-Operative&nbsp;:'''  
* Repair of bilateral vastus muscles
* Rehabilitation same as with conservative management<br>
'''Later stages''':


<u>Phase
 I:
0­-2 
Weeks</u><br>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
Manipulation under anesthesia or the arthroscopic releasing of adhesions is required when athrofibrosis occurs.<ref name=":6" />  


*Weight bearing: with
the
knee
locked
in
extension
== Physiotherapy management  ==
*Range
 of 
Motion:
 0‐30
degrees
As clinical healing phases do not always correlate with theoretical healing, the surgeon will guide rehabilitation while 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 the referring orthopaedic surgeons.
*Therapeutic 
Exercises:



• 
Isometric
quadriceps/hamstring/adductor/abductor
strengthening,
<br>• Ankle
theraband exercises
=== Conservative management ===
Conservative management are used when the extensor mechanism is still intact.<ref name=":1" />


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


*Weightbearing:
* Patella mobilization
*Range
of
Motion:

 add
15
degrees
of
flexion
each
week
–

* Pain & oedema management using [[cryotherapy]]
*Goal
is
90
degrees
by
post‐op
week
6

<ref name=":1" /><ref name=":0" />
*Therapeutic
Exercises:



• Isometric
quadriceps/hamstring/adductor/abductor
strengthening,
<br>• Ankle
theraband
exercises,
<br>• Initiate
straight
leg
raises
==== Phase II: 6-12 weeks ====
* Range of motion knee brace as per surgeon
* Range of motion:
** Progress to full knee flexion & extension


Phase
 III:
 6-­10 
Weeks<br>Knee
 Brace:
Unlocked,
worn 
with 
weight bearing
 activities
* 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" />  


*Weightbearing:
Full
=== Post-operative rehabilitation ===
*Range
of
Motion:
 progress
to
full
ROM
by
post‐operative
week
10
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" />
*Therapeutic
Exercises:
Isometric
quadriceps/hamstring/adductor/abductor
&nbsp;strengthening,
Ankle
theraband
exercises,
Initiate
straight
leg
raises


<br>
==== Phase I:  0-2 weeks ====
* Range of motion brace:
** Locked in extension (if POP cast not used)
** Only to be taken off for physiotherapy sessions, 0-30° knee flexion range of motion allowed at first.
* Mobilization:
** Knee locked in extension with range of motion brace
* Exercises:
** Isometric quadriceps/hamstring/adductor/abductor strengthening
** Resisted ankle exercises (e.g. with theraband)


<br>
==== Phase II: 2-6 weeks ====
* Range of motion brace (if applicable):
** To be worn for weight-bearing activities, locked in extension
** May be removed at night
* Range of motion:
** 5° of flexion can be added each week to achieve 90° by week 6
* Exercises:
** Isometric quadriceps/hamstring/adductor/abductor strengthening
** Resisted ankle exercises (e.g. with theraband)
** Initiate SLR


<br><u>Phase
 IV:
10­-12 
Weeks</u><br>Knee
Brace:
Discontinue
==== Phase III: 6-10 weeks ====
* Range of motion brace:
** Unlocked; to be worn for weight-bearing activities
* Range of motion:
** Progress to full range of motion by week 10
* Exercises: As previous phase


*Weightbearing:
Full
==== Phase IV: 10-12 weeks ====
*Range
of
Motion:
Full
* Range of motion brace: Discontinue
*Therapeutic
 Exercises:
Isometric
 quadriceps/hamstring/adductor/abductor
 strengthening, Ankle 
theraband
exercises,
Initiate
 straight
leg
raises,
Start
 stationary 
bicycle
* Range of motion: Full
* Exercises: As previous phase
** Start with stationary cycling


<br><u>Phase
V:
3­6
 Months</u>: return 
to 
full 
activities
 as
 tolerated  
==== Phase V: Up to 3-6 months ====
Return to normal activities as tolerated.


(Strauss J. (MD)(level of evidence&nbsp;: 5), Elizabeth Arendt(MD) ( level of evidence: 5) )
== References   ==
 
<br>'''Treatment procedure Non-Operative&nbsp;:'''
 
<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>
 
[[Image:Knee braces.png]]<br>
 
<br>
 
<br>
 
Open kinetic chain strengthening and ROM of knee:
 
[[Image:Open ROM.png]]<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. <br>
 
== Key Research  ==
 
'''Key words: '''<br>- Patella<br>- Fracture<br>- Lower extremity<br>- Revalidation of the knee<br>- Treatment of patellar fractures<br>- Symptoms<br>- Diagnosis of patellar fracture<br><br>
 
== Resources <br>  ==
 
http://www.physioroom.com/injuries/knee/patella_fracture_full.php<br> http://www.summitmedicalgroup.com/library/adult_health/smapatellarfractureexecises_references/<br>http://www.mdguidelines.com/fracture-patella<br>http://www.ncbi.nlm.nih.gov/pubmed/?term=patellar%20fracture<br>http://www.healthline.com/human-body-maps/knee <br><br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])<br>  ==
<div class="researchbox">
New technique to treat a patellar fracture: El-Sayed and Ragab reported on arthroscopic-assisted reduction and fixation of displaced transverse fractures of the patella in 14 patients with displaced transverse fractures of the patella. Patients were treated by means of arthro-scopic-assisted closed reduction of the fracture with percutaneous screw fixation. Patella fractures were found to unite in a mean of 7 weeks. All 14 patients regained full extension of the knee, and full range of motion was achieved in 12 patients, with 2 patients experiencing a 10º loss of flexion.<ref>El-Sayed AM, Ragab RK.,‘Arthroscopic-assisted reduction and stabilization of trans-verse fractures of the patella.’, The Knee, Volume 16, Issue 1, Pages 54–57, January 2009. (level of evidence 1B)</ref><br><br>
</div>
== References<br>  ==


<references /><span style="font-size: 13.28px; line-height: 1.5em;"> </span><span style="font-size: 13.28px; line-height: 1.5em;"> </span><span style="font-size: 13.28px; line-height: 1.5em;"> </span><span style="font-size: 13.28px; line-height: 1.5em;"> </span><br>  
<references /><span style="font-size: 13.28px; line-height: 1.5em;"> </span><span style="font-size: 13.28px; line-height: 1.5em;"> </span><span style="font-size: 13.28px; line-height: 1.5em;"> </span><span style="font-size: 13.28px; line-height: 1.5em;"> </span><br>  
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[[Category:Injury]] [[Category:Knee_Injuries]] [[Category:Knee]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Injury]]  
[[Category:Knee_Injuries]]  
[[Category:Knee]]  
[[Category:Conditions]] 
[[Category:Knee - Conditions]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]  
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Primary Contact]]
[[Category:Acute Care]]
[[Category:Fractures]]

Latest revision as of 00:06, 11 January 2023

Original Editor - Rachael Lowe

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

Definition/Description[edit | edit source]

Patella fractures are caused by direct trauma or compressive force, or as the indirect 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 quadriceps muscles.[1] Patella fractures make up about 1% of all skeletal injuries and are found in all age groups.[4][5][6]

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 sesamoid bone in the body and makes part of the knee joint.[7][8][9] The patella 's primary role is to function as a fulcrum with the aim to increase the moment arm of the quadriceps muscle and thus, knee extensive capacity. [10]

Vastus medialis and lateralis, as part of the quadriceps group, control movement at the patella.[11] The medial retinaculum, formed by the vastus medialis and quadriceps aponeurosis and lateral retinaculum, formed by the vastus lateralis and the ilotibial band, all aid in the extension of the knee. [6]

The extensor mechanism as a whole plays a major role in patella fractures. The extensor mechanism consists of the quadriceps, quadriceps tendon, retinaculum, patella tendon, tibial tubercle and patellofemoral and patellotibial ligaments.[12] See the page on the patella for more details on the anatomy.

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

Epidemiology[edit | edit source]

A 2016 study found the incidence of patella fracture to be 13.1/100,000 per year with an increasing incidence with increasing age[13]. Females accounted for 56% of patella fractures and males accounted for 44% of patella fractures. [13] A newer Swedish study also found that older (>65 years old) females had a higher percentage of patellar fractures (64%) compared to males . [14] Most fractures were caused by low-energy trauma, with 70% due to simple falls, especially in the winter months. [14]

Patella fractures are not associated with an increased mortality rate, as the relative risk of death was 0.9.[15] 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.

Complications[edit | edit source]

[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:[18]

  • 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.
  • Transverse/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[13]
    • 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][16][18][10][19]

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. [20]

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

[21][22][23]

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

[19][21][24]

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
AP view
Lateral view
  • CT scan: Usually not needed
  • MRI: Diagnosis of associated injuries to nearby tendons and ligaments
  • Bone scans: To identify stress fractures

[19][22][23][12]

Outcome measures[edit | edit source]

Medical management[edit | edit source]

  • In acute cases, local anesthetics can be given to eliminate pain.[21] This helps to aid in the assessment and diagnosis of the patella fracture.

Conservative management[edit | edit source]

Indication: Nondisplaced fracture (mostly vertical, horizontal and comminuted fractures) with extensor mechanism in place [1][20]

Management:[19][20][12][25]

  • 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 to restore full range of motion, strength, and return to function

Surgical intervention[edit | edit source]

Indication: Significant displacement with extensor mechanism not intact[1]or articular step off >2-3mm or fracture displacement >1-4 mm. [6]

Aim: Restore extensor function, align articular incongruities, and allow early motion[20][23][26][27]

Management:[1][19]

  • 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
Tension band wire ORIF
  • 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:[21]
    • Quadriceps muscles is is attached to the patellar ligament to ensure function of the extensor apparatus during a complete patellectomy[21]
    • Patellectomy: Relatively old procedure, last treatment of choice due to significant loss of extension
  • 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.[20]

Physiotherapy management[edit | edit source]

As clinical healing phases do not always correlate with theoretical healing, the surgeon will guide rehabilitation while 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 the referring 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[12][25]
    • Duration of crutches/weight-bearing restrictions as per surgeon
  • Patella mobilization
  • Pain & oedema management using cryotherapy

[1][27]

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

[27]

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:
    • Locked in extension (if POP cast not used)
    • Only to be taken off for physiotherapy sessions, 0-30° knee flexion range of motion allowed at first.
  • Mobilization:
    • Knee locked in extension with range of motion brace
  • Exercises:
    • Isometric quadriceps/hamstring/adductor/abductor strengthening
    • Resisted ankle exercises (e.g. with theraband)

Phase II: 2-6 weeks[edit | edit source]

  • Range of motion brace (if applicable):
    • To be worn for weight-bearing activities, locked in extension
    • May be removed at night
  • Range of motion:
    • 5° of flexion can be added each week to achieve 90° by week 6
  • Exercises:
    • Isometric quadriceps/hamstring/adductor/abductor strengthening
    • Resisted ankle exercises (e.g. with theraband)
    • Initiate SLR

Phase III: 6-10 weeks[edit | edit source]

  • Range of motion brace:
    • Unlocked; to be worn for weight-bearing activities
  • Range of motion:
    • Progress to full range of motion by week 10
  • Exercises: As previous phase

Phase IV: 10-12 weeks[edit | edit source]

  • Range of motion brace: Discontinue
  • Range of motion: Full
  • Exercises: As previous phase
    • Start with stationary cycling

Phase V: Up to 3-6 months[edit | edit source]

Return to normal activities as tolerated.

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. 2012; 626-683.
  2. ↑ 2.0 2.1 Schuett D., Hake M., Mauffrey C., Hammerberg E., Stahel P., Hak D. Current treatment strategies for patella fractures. Orthopedics. 2015;38(6):377-84.
  3. ↑ 3.0 3.1 Archdeacon M., Sanders R. Chapter 54 - Patella Fractures and Extensor Mechanism Injuries. In: Browner B.D., Jupiter J.B., Krettek C., Anderson P.A., (eds). Skeletal Trauma, 4th edition. Elsevier Health Sciences, 2008.
  4. ↑ Crowther M., Mandal A., Sarangi P. 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. ↑ 6.0 6.1 6.2 Posner A., Zimmerman J. Surgical management of patella fractures: a review. Archives of Orthopaedics 2022; 3(1):17-21.
  7. ↑ 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).
  8. ↑ Schunke M. Anatomische atlas Prometheus, algemene anatomie en bewegingsapparaat. Bohn Stafieu van Loghum: 2e druk. 2010.
  9. ↑ 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.
  10. ↑ 10.0 10.1 Melvin S.J., Mehta S. Patellar fractures in adults. Journal of the American Academy of Orthopaedic Surgeons 2011;19(4):198-207.
  11. ↑ Orthopaedia. Collaborative Orthopaedic Knowledgebase, http://www.orthopaedia.com/display/Main/Patella+fractures (accessed November 10, 2010).
  12. ↑ 12.0 12.1 12.2 12.3 Duke Orthopaedics. Wheeless’ textbook of Orthopaedics. Fractures of the patella.http://www.wheelessonline.com/ortho/fractures_of_the_patella (accessed November 10 2010).
  13. ↑ 13.0 13.1 13.2 Larsen P., Court-Brown C., Vedel J., Vistrup S., Elsoe R. Incidence and Epidemiology of Patellar Fractures. Orthopedics; 2016 Nov 1;39(6):e1154-e1158.
  14. ↑ 14.0 14.1 Kruse M, Wolf O, Mukka S, Brüggemann A. Epidemiology, classification and treatment of patella fractures: an observational study of 3194 fractures from the Swedish Fracture Register. European Journal of Trauma and Emergency Surgery. 2022 May 30:1-8.
  15. ↑ Larsen P., Elsoe R. Patella fractures are not associated with an increased risk of mortality in elderly patients. Injury 2018; 49(10):1901-1904.
  16. ↑ 16.0 16.1 Medscape. Patella Fracture Imaging. http://emedicine.medscape.com/article/394270-overview&gt (accessed 25/07/2018).
  17. ↑ Insall JN. Fractured kneecap: treatments. Institute for Orthopaedics and sports medicine 2007.
  18. ↑ 18.0 18.1 Whittle P. Fractures of the Lower Extremity. In: Canale S., Beaty J., (eds). Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier, 2008.
  19. ↑ 19.0 19.1 19.2 19.3 19.4 Walters J. (ed). Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.
  20. ↑ 20.0 20.1 20.2 20.3 20.4 Mehling I., Mehling A., Rommens P. Comminuted patellar fractures. Current Orthopaedics 2006;20(6):397-404.
  21. ↑ 21.0 21.1 21.2 21.3 21.4 Günal I., Karatosun V. Patellectomy: an overview with reconstructive procedures. Clinical Orthopaedics and Related Research 2001;389:74-8.
  22. ↑ 22.0 22.1 McRae R., Esser M. Practical fracture treatment E-book. Churchill Livingstone/ Elsevier; 2002.
  23. ↑ 23.0 23.1 23.2 Fourati MK. Reeducation du genou après fracture de la rotule. Ann. Kinésitherapie 1986.
  24. ↑ Scolaro J, Bernstein J, Ahn J. In brief: patellar fractures. Clinical Orthopaedics and Related Research®. 2011 Apr;469(4):1213-5.
  25. ↑ 25.0 25.1 American Academy of Orthopaedic Surgeons. Diseases and conditions - Patellar (Kneecap) Fractures. http://orthoinfo.aaos.org/topic.cfm?topic=A00523 (accessed November 10 2010).
  26. ↑ Shang ZG. Patellar fractures treatment and management. Unbound medline 2013;26(6):445-8.
  27. ↑ 27.0 27.1 27.2 Strauss J. ORIF Patella Fracture Post-Operative Rehabilitation Protocol, Hospital for Joint Diseases, 2008.



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