1. Patellar Fractures RSAT 365
Angie Whittington

2. Classification Displaced Non-displaced Transverse Longitudinal
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: 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

19. ???Questions???