Patellar Fractures RSAT 365

1. Patellar FracturesRSAT 365 Angie Whittington

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

3. Mechanism of Injury • Direct blow to patella • Indirect force from violent quadriceps contraction • Expected healing time: 8-12 weeks • Rehabilitation duration: 12-15 weeks

4. 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

5. Rehabilitation Goals • Restore full ROM in FLEX & EXT • Improve quad & hamstring strength & balance

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Treatment: Two Weeks • Stability at fracture site: None to minimal • Stage of bone healing: Beginning reparative phase • X-ray: No callus; fracture line visible

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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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