Patellar Fractures RSAT 365

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Patellar FracturesRSAT 365

• Angie Whittington

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Classification

• Displaced
• Non-displaced
• 1 to 2 mm articular step-off
• 3 mm fragment separation
• Transverse
• Longitudinal
• Comminuted

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Mechanism of Injury

• Direct blow to patella
• Indirect force from violent quadriceps
  contraction
• Expected healing time 8-12 weeks
• Rehabilitation duration 12-15 weeks

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Treatment Goals

• Alignment
• Open repair of the retinaculum if extensor lag is
  present
• Stability
• Best achieved by restoring bony congruity with
  hardware to rigidly fix fracture

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Rehabilitation Goals

• Restore full ROM in FLEX EXT
• Improve quad hamstring strength balance

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Methods of Treatment

• Cast or Knee Immobilizer
• Biomechanics Stress-sharing device
• Mode of Bone Healing Secondary
• Indications Used for nondisplaced Fx
• Cylinder cast allows full ROM at ankle
• Examine knee to insure full active EXT
• Cast vs. immobilizer based on patient compliance

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Methods of Treatment

• Open Reduction Internal Fixation
• Biomechanics Stress-shielding sharing
• Mode of Bone Healing Primary, unless solid
  fixation is not achieved, then secondary also
• Indications Used for comminuted displaced Fx
• Open reduction to align articular surface
• Retinacular destruction openly repaired

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Methods of Treatment

• Partial/Total Patellectomy
• Used when comminuted Fx cannot be repaired
• Extremity immobilized in full FLEX for 4 wks to
  allow tendon-to-bone healing
• Full AROM begins after with gradual increases of
  FLEX

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Special Considerations

• Bipartite Patella
• Pieces of patella fail to fuse together
• Carefully examine knee for tenderness
• Radiograph comparison to assist with Dx
• Long-Term Sequelae
• Degenerative disease
• Decreased knee ROM secondary swelling
• Perm. Extensor Lag

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Treatment Early to Immediate(Day One to One
Week)

• Stability at fracture site None
• Stage of bone healing inflammatory phase
  debridement of fracture
• X-ray visible fracture line no callus formation

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Prescription Early to Immediate (Day One to Week
One)

• Precautions Avoid PROM
• ROM (knee) None if casted
• Strength None
• AROM of knee in sitting position NWB with open
  red/internal fixation
• Functional Activities FWB during transfers and
  ambulation assistive devices

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Treatment Two Weeks

• Stability at fracture site None to minimal
• Stage of bone healing Beginning reparative phase
• X-ray No callus fracture line visible

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Prescription Two Weeks

• Precautions Avoid PROM
• ROM (knee) None
• Strength (knee) None
• Active FLEX NWB with open reduction/internal
  fixation
• Functional Activities FWB during ambulation
  transfers

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Treatment Four to Six Weeks

• Stability at fracture site None to minimal
• Stage of bone healing Reparative phase
• X-ray No callus fracture line less visible
• Sesamoid bone produce minimal callus

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Prescription Four to Six Weeks

• Precautions maintain knee immobilizer if tender
• ROM (knee) AROM in FLEX/EXT
• Strength (knee) Isometric quad hamstring
• Week 6 45º-0º 90º-0º
• Functional Activities FWB during ambulation
  transfers.
• Remove immobilizer for level ground walking

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Treatment Eight to Twelve Weeks

• Stability at fracture site Stable
• Stage of bone healing Remodeling phase
• X-rays Small callus noted fracture line fading
  over time

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Prescription Eight to Twelve Weeks

• Precautions None
• ROM (knee) AROM PROM
• Extension lag secondary to quad weakness
• Strength (knee) resistive quad hamstring
  exercises with weights
• Isokinetics closed chain plyometrics
• Functional Exercises FWB during ambulation
  transfers w/o assistive devices

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Long-Term Considerations Problems

• Radiographs should be taken at each stage of
  treatment for loss of correction
• Quad shortening can reduce knee EXT
• Chondromalacia patella from direct trauma to
  cartilage
• Reflex inhibition of ilipsoas muscle post surgery

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???Questions???