Patellar Fractures RSAT 365 Angie Whittington

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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