PATELLAR FRACTURE

Karla Suzatte M. DasargoDdc PT -Intern

Fracture•Break or crack upon the continuity of a solid bone.

ANATOMY - PATELLA

•Largest sesamoid bone

•Plays an important role in the biomechanics of the knee.

•Very hard & triangular-shaped bone

ANATOMY - PATELLA•Situated in an exposed position in front of the knee joint

ANATOMY - PATELLA

•separated from the skin by subcutaneous bursa.

•Patella Surfaces▫Ant.▫Post▫Lat. & med.

ANATOMY - PATELLA•Patella borders

▫Base ▫Med and Lat.▫Apex

•Articulation

 ANATOMY - PATELLA•Post. surface central portion, is covered with a layer of hyaline cartilage.

•Articular cartilage of the patella is the thickest in the body (up to 7-mm thick).

 ANATOMY - PATELLA•Improves the efficiency of extension during the last 30° of knee extension.

PATELLA - FUNCTIONS•guide for the quadriceps or patellar tendon

•↓ friction of the quadriceps mechanism

•Acts as a bony shield for the cartilage of the femoral condyles

•Improves the aesthetic appearance of the knee.

PATELLAR ALIGNMENT

•Influenced by the line of pull of the quadriceps muscle group and by its attachment to the tubial tubercle via the patellar tendon.

•The result of these two forces is a bowstring effect on the patella, causing it to track laterally.

PATELLAR ALIGNMENT

• Q-angle is the angle formed by two intersecting lines.

•A normal Q-angle, women >men, is 10 to 15.

MUSCLES•Quadriceps Femoris

▫Rectus Femoris▫Vastus Lateralis▫VastusMedialis▫Vastus Intermedius

TYPES OF Fx•Open •Close

TYPES OF FRACTURE

RISK FACTORS•Sudden impact •Osteoporosis •History of falls

SIGNS AND SYMPTOMS of a Possible Fracture

•Localized pain aggravated by movement

•Muscle guarding with passive movement

•Decreased function of the part•Swelling, deformity, abnormal movement

•Sharp, localized tenderness at the site

CLINICAL MANIFESTATIONS

•Pain in the affected knee.

•Lacerations •Intra-articular effusion

•Palpable defect at the fracture site.

•Hemarthrosis•Unable to perform a straight leg raise

•Inability to extend the knee against gravity

EPIDEMIOLOGY

•~ 1% of all skeletal injuries.•MC in people who are 20 to 50 years old

•Men are twice as likely as women to fracture the kneecap

ETIOLOGY

•Subcutaneous location of the patella makes it prone to injury.

•Fractures occur as a result of a compressive force such as a direct blow, a sudden tensile force as occurs with hyperflexion of the knee, or from a combination of these.

•A combination of these 2 mechanisms can lead to a variety of other fracture patterns.

ETIOLOGY

DIFFERENTIAL DIAGNOSIS

•Knee dislocations•Fx of femur•Fx of fibula and tibia•Knee soft tissue injury•Osgood-Schlatter Disease•Trauma/PVI•Sinding-Larsen Johansson•Bipartite Patella

TESTS AND DIAGNOSTIC PROCEDURES

•X-rays•Aspiration of a hemarthrosis followed by instillation of intra-articular lidocaine

TREATMENT: NON-SURGICAL

•Protection phase▫Modalities▫Rest▫gentle motion,

▫muscle-

setting exercises in pain-free positions.

▫Casts or splints

▫Crutches

•Controlled Motion and Return to Function Phases▫Educate the Patient

▫Increase Flexibility of Restricting

Tissues

▫NWB(Open-Chain) Exercises

▫WB(Closed-Chain) Exercises

▫Functional Activities

TREATMENT: NON-SURGICAL

TREATMENT: SURGICAL

•Timing of surgery▫If the skin around your fracture has not been broken may recommend waiting until any abrasions have healed before having surgery.

▫Open fractures, however, expose the fracture site to the environment urgently need to be cleansed and require immediate surgery.

INTERNAL FIXATION

•A Surgical procedure that:▫allows shorter hospital stays▫enables individuals to return to function earlier

▫reduces the incidence of nonunion and malunion.

•Wires•Pins•Plates•Screws•Nails and Rods

INTERNAL FIXATION

•External Fixators•Other Considerations

▫Surgical techniques reduce, but do not remove, the risk of infection when internal fixation is used.

▫The severity of the Fx, its location, and the medical status of the patient must all be considered.

▫No technique is foolproof

POST-OP REHABILITATION

•dependent on the fracture pattern, stability of fixation, and status of the soft tissue.▫ Early ROM

Prognosis

•It depends primarily on the quality of articular restoration.

•Any intra-articular incongruities lead to posttraumatic arthritis.

•Depends on the amount of chondral damage sustained at the time of injury.

•Some of these changes are irreversible.

•Functional outcome depends on the ability to achieve early, pain-free, stable range of motion.

•If arthrofibrosis develops, it may require manipulation with the patient under anesthesia or arthroscopic release of adhesions.

Prognosis

EBP

•WHAT IS YOUR POSTOPERATIVE MANAGEMENT OF PATELLAR FRACTURES? Lang, Gerald J, MD. Thorofare: SLACK INCORPORATED, 2008.

•immediately weight bear as tolerated with the aid of crutches or walker. This should be done with the knee in a fully extended position.

•recommend static extension splinting of the knee (with either a knee immobilizer or hinged knee brace that is locked in extension) while weight bearing.

•.Active, active-assisted, and gravity-assisted flexion can be initiated while sitting on the edge of a table using the uninjured leg to assist in supporting the leg.

•Heel slides in a supine position can be done as well.

•Isometric strengthening of the extensor mechanism can commence as soon as comfort allows.

•With the knee fully extended, the patient can maximally contract the quadriceps muscles and attempt a straight leg raise

•Active extension against gravity can also begin in the early postoperative period.

•not recommended resistive exercises in extension until the extensor mechanism has healed (6 to 12 weeks).

•Passive ROM to obtain flexion is generally delayed until the fracture and soft-tissue repair are healed.

•Physiological and methodological considerations for the use of neuromuscular electrical stimulation

• by: Nicola A. Maffiuletti; Accepted: 30 April 2010 / Published online: 15 May 2010

•main aim of this review is to discuss some evidence-based physiological and methodological considerations for optimal use of neuromuscular electrical stimulation (NMES) in healthy and impaired skeletal muscles.

•suggestion that NMES effectiveness would not depend on external controllable factors (e.g., current or electrode characteristics), but rather on some intrinsic anatomical properties, such as individual motor nerve branching, which determines the response of the muscle to the application of electrical current over the skin.

•it is strongly recommended to use biphasic rectangular pulses of 100–400 ls delivered at a stimulation frequency of 50–100 Hz and at the highest tolerated current intensity & to apply NMES in a static loading condition

•There are several lines of evidence indicating that the higher the NMES training intensity, the higher the effectiveness of NMES (re)training, for both healthy and impaired muscles.

•It is also recommended to stimulate the muscle under resting conditions in order to facilitate the quantification of pure NMES evoked force.

•frail or current-sensitive subjects could be asked to voluntarily contract their muscle during the first few evoked contractions of a session and/or during the first

•training sessions of a program so as to decrease the sensation of discomfort associated with NMES.