The patient, a 45-year-old female, presented with left patella fracture following a fall. She underwent tension band wiring surgery under spinal anesthesia to repair the fracture. Post-operatively, she was treated with IV and oral antibiotics, analgesics, calcium supplements and physiotherapy. Her pain and swelling gradually reduced and she was discharged on the 10th post-operative day with medications and advice to continue calcium and physiotherapy.

1. CASE PRESENTATION ON
PATELLA FRACTURE
By
BASIL WILSON
13Q0408
PHARM D IVth yr

2. The patello-femoral joint is the
heaviest-loaded joint in the body. Any
compromise of the joint surface is
likely to lead to degenerative joint
disease. It is, therefore, highly
desirable, in patellar fractures to strive
for anatomical reduction of the joint
surface and stable fixation.
The patella is the largest sesamoid
bone in the human body. It is located
within the extensor apparatus of the
knee.

3. A patella fracture is a fracture of the kneecap,
which is one of the most common knee injuries. It
is usually the result of a hard blow to the front of
the knee.
Currently three forms of operative treatment for
displaced
patella fractures are most commonly utilized.
• Open reduction and internal fixation, usually with a
tension
band wiring technique or cannulated screw tension
band
technique
• Partial patellectomy
• Total patellectomy

4. A–L: Illustrations of patellar fracture fixation constructs.

5. Patellar Fracture Classification
Patellar fracture classification is typically descriptive in nature, and can be based
on fracture pattern, degree of displacement, or mechanism of injury.

6. Demographic Details
Name : ABC Age : 45 Sex : F
I.P No : 1679 Dept. : Orthopaedics Unit : A
D.O.A : 15/01/2017 D.O.D :02/01/2017

7. Reason For Admission
History Of Present Illness
H/o fall yesterday morning
H/o pain in left patella
Swelling of left leg
Loss of consciousness for 5-10 minutes
H/o injury to head
C/O trauma to forehead and left knee
Patient was apparently alright till yesterday
morning, then she had a h/o fall. C/o pain insidious
in onset, gradually progressive in nature. Patient
also c/o swelling, initially of peanut size now
progressed to present size.
H/O unconsciousness

8. Family History
 Diet : Veg
 Sleep : Normal
 Appetite : Good
 Habits : Nil
No Known Allergies

9. General Physical Examination
Patient is moderately built and nourished, well
oriented to Time Place & Person
Afebrile
Oedema positive
BP : 170/100 mmHg
PR : 78 bpm

10. Local Examination
Tenderness - +ve(over left knee)
Peripheral Sensation - +ve
Swelling - +ve

11. Investigations
CBC
X-RAY
RBS
HIV
HBs Ag
Sr. CREATININE
Sr. UREA
ECG
CHEST X-RAY
BT & CT

12. Provisional Diagnosis :
LEFT PATELLA FRACTURE

13. INVESTIGATIONS RESULTS REFERENCE
Hb (g/dl) 10.2 ↓ 12.0-16.0
WBC 4800 4500-10500
Lymphocytes 30 20-40 %
Monocytes 03 0-7 %
Basophils 00 0-1 %
Eosinophils 02 0-5 %
Polymorphs 65 45-75 %
RBC (millions/uL) 3.97 ↓ 4.2-5.4
Platelet (cells/mm3) 285000 150000-450000
RBS (mg/dL) 105 65-140
Laboratory Data

14. INVESTIGATIONS RESULTS REFERENCE
ELECTROLYTES
Sodium (mEq/L) 136 135-147
Potassium (mEq/L) 4.2 3.5-5.2
Calcium (mEq/L) 103 95-107
ECG Normal
BT (min) 3.30 1-6
CT (min) 5.30 5-10
Sr. Urea (mg%) 12 10-50
Sr. Creatinine (mg/dl) 0.8 0.6-1.2

17. TREATMENT CHART
BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DAYS
Tab. ZERODOL SP PARACETAMOL
ACECLOFENAC
SERATIOPEPTIDASE
500 MG P/O 1-0-1 1-6
Tab. RAZO RABEPRAZOLE 20 MG P/O 1-0-0 1-6
INJ.VOVERAN DICLOFENAC 75 MG IM S-O-S 1-2
TAB.XTRACAL CALCITRIOL
CALCIUM CITRATE
1 GM P/O 0-1-0 1-6

18. Daily Assessments
Day 2
c/o pain in left knee
Afebrile
PR : 78 bpm
B.P : 170/80 mmHg
L/E : Tenderness +
Swelling +
Treatment Advice
Tab. Zerodol sp 1-0-1
Tab. Razo 1-0-0
Tab. Xtracal CT 0-1-0
Inj. Voveran 75mg IM sos

19. Day 3
Afebrile Continue Same Treatment
C/o pain in left knee
B.P : 136/84
P.R : 80 bpm
L/E : Tenderness +
Swelling +
Day 4
Afebrile
C/o pain in left knee
B.P : 130/90
P.R : 80 bpm
L/E : Tenderness +
Swelling +

20. Day 5
Afebrile Continue Same Treatment
C/o pain in left knee
B.P : 130/90
P.R : 78 bpm
L/E : Tenderness +
Swelling +
Day 6
Afebrile
C/o pain in left knee
B.P : 130/90
P.R : 78 bpm
L/E : Tenderness +
Swelling +
Treatment Advice
Tab. Zerodol sp 1-0-1
Tab. Razo 1-0-0
Tab.Xtracal CT 0-1-0
SURGERY TOMORROW

21. PRE-OPERATIVE DIAGNOSIS:
LEFT PATELLA FRACTURE
PROPOSED SURGERY :
TBW
(TENSION BAND WIRING)

22. A tension band wire is a form of
orthopaedic internal
fixation method used to convert
distraction forces into compression
forces, promoting bone healing.
Tension-band wiring is commonly
used to treat transverse patella
fractures. The most common
configuration has parallel Kirschner
(K) wires and a stainless steel wire
loop placed in a vertically oriented
figure of eight.

23. Tension band principles
The forces produced by the quadriceps
on patellar fractures are significant and
cause early fixation failure.
In most cases, the stability necessary to
achieve this is obtained using the
tension band fixation.

24. The anterior tension band converts tensile forces on the
anterior aspect of the knee joint into compression forces
at the joint line.
In the patella, an anterior figure-of-eight wire loop acts
as a tension band during flexion of the knee.
Multi fragmentary patellar fractures cannot be fixed with
a tension band.
The figure-of-eight wire loop lies on the anterior surface
of the patella and acts as a tension band when tightened.

25. PRE-OPERATIVE ORDERS
NBM
Informed Written Consent
Inj.TT 0.5 CC
Inj. Ceftriaxone 1 gm IV
Inj. Amikacin 500 mg IV
Inj. Emset 4 mg IV
Inj. Rantac 50 mg IV
Informed OT Staff
Shift the patient to OT at 8:30 AM

26. ANAESTHESIA RECORD
INDUCTION : Under SPINAL ANAESTHESIA
Under Aseptic precautions LP
(LUMBAR PUNCTURE) was
done at L3 &L4 in sitting position
with 25-guage needle. Free flow
of CSF is seen.
Inj. ANACAINE
(BENZOCAINE) 0.5 % 2.5 cc is
given. Adequate block achieved.
Vitals monitored and maintained.

27. SPINAL ANAESTHESIA
Spinal anaesthesia , also called
spinal block, subarachnoid block,
intradural block and intrathecal
block, is a form of regional
anaesthesia involving the injection
of a local anaesthetic into the
subarachnoid space, generally
through a fine needle, usually 9 cm
(3.5 in) long.
A spinal anaesthetic delivers drug to
the intrathecal space (the CSF), and
acts on the spinal cord directly.

28. Regardless of the drug used,
the desired effect is to block
the transmission of afferent
nerve signals from peripheral
nociceptors. Sensory signals
from the site are blocked,
thereby eliminating pain. The
degree of neuronal blockade
depends on the amount and
concentration of local
anaesthetic used and the
properties of the axon.

29. Use the 10-mL syringe to administer a local
anaesthetic . Raise a skin wheal using the 25-gauge
needle, then switch to the longer 20-gauge needle
to anesthetize the deeper tissue. Insert the needle
all the way to the hub, aspirate to confirm that the
needle is not in a blood vessel, and then inject a
small amount as the needle is withdrawn a few
centimetres. Continue this process above, below,
and to the sides very slightly (using the same
puncture site).

30. OPERATIVE NOTES
Patient is under Spinal Anaesthesia in supine
position on OT table. Parts are scrubbed, painted,
and draped. IV antibiotics given.
Vertical incision taken over the patella. The patella
fracture site identified. Fracture site is cleared off
with the help of bone-nibbler. Reduction achieved
with the help of 2 patella holding clamps.2 parallel
K-wire is passed vertical through the patella.18
gauge SS wire is bound around wire in ‘8’-
shape.Tension is created and compressing of
fracture achieved. Thorough wash is given. Stitch
skin. Dressing done. Patient shifted to recovery
room.

31. POST OPERATIVE NOTES
NBM for 6 hours
Monitor vitals
Inj. Xone 1 gm IV BD
Inj. Amikacin 500 mg BD
Inj. Emset 4 mg IV BD
Inj. Tramadol 1 amp in 100 ml NS
Inj. Pantop 50 mg IV BD
Tab. Xtracal CT 0-0-1
IVF – 1 pint NS & 1 pint DNS @50 ml/hr

33. TREATMENT CHART (POST-OPERATIVE)
BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY PO-DAYS
INJ. CEFTRIAXONE CEFTRIAXONE 1 GM IV 1-0-1 1-5
INJ. AMIKACIN AMIKACIN 500 MG IV 1-0-1 1-2
INJ. RANTAC RANITIDINE 50 MG IV 1-0-1 1-4
TAB-5-8
INJ.VOVERAN DICLOFENAC 75 MG IM S-O-S 1-2
INJ. TRAMADOL TRAMADOL 50MG IN
100MLNS
IV 1-0-1 1
TAB. ZERODOL SP ACECLOFENAC
PARACETAMOL
SERRATIOPEPTIDASE
500 MG P/O 1-0-1 1-8
TAB.XTRACAL CALCITRIOL
CALCIUM CITRATE
1 GM P/O 0-1-0 2-10
SYP. A-Z MULTIVITAMIN 2.5 ML P/O √-×-√ 3-10
TAB. COVATIL CEFUROXIME 500 MG P/O 1-0-1 5-10
TAB. RAZO RABEPRAZOLE 20 MG P/O 1-0-0 9-10

34. PHYSIOTHERAPY
DAYS POD 2 POD 3 POD 4 POD 5 POD 6
PHYSIOTHERAP
Y
√ √ √ √ √

35. Day 8
POD 1
GC fair
Afebrile
BP : 130/90 mmHg
PR : 82 bpm
L/E
Tenderness +ve
Dressings intact
Treatment Advice
Inj. Ceftriaxone 1 gm IV 1-0-1
Inj. Amikacin 500 mg IV 1-0-1
Inj. Rantac IV 1-0-1
Inj. Voveran IM s-o-s
Inj. Tramadol IV 100 ml NS 1-0-1
Inj. Emset IV s-o-s
Tab. Zerodol sp 1-0-1

36. Day 9
POD 2
C/O pain at operated site
Afebrile
BP : 130/80 mmHg
PR : 88 bpm
L/E
Tenderness +ve
Dressings intact
No soakage
Treatment Advice
Inj. Ceftriaxone 1 gm IV 1-0-1
Inj. Amikacin 500 mg IV 1-0-1
Inj. Rantac 1 amp IV 1-0-1
Inj. Voveran IM s-o-s
Tab. Zerodol sp 1-0-1
Tab. Xtracal CT 0-1-0

37. Day 10
POD 3
C/O Pain over operated site
O/E PR :80 bpm
BP :110/70 mmHg
L/E Tenderness +ve
No soakage
Continue Same Treatment
ADD-Syp. A-Z 5 ml √-0-√
Long Knee Brace

38. Day 11
POD 4
C/O Pain over operated site
O/E PR :80 bpm
BP :130/80 mmHg
L/E Tenderness +ve
No soakage
Continue Same Treatment

39. Day 12
POD 5
No Fresh Complaints
O/E Afebrile
PR :80 bpm
BP :130/80 mmHg
L/E Tenderness +ve
No soakage
Dressing intact
TREATMENT ADVICE
Tab. Covatil 500 mg 1-0-1
Tab. Rantac 1-0-1
Tab. Zerodol sp 1-0-1
Tab. Xtracal CT 0-1-0
Syp. A-Z 2.5 ml BD

40. Day 13
POD 6
No Fresh Complaints
O/E PR :80 bpm
BP :132/80 mmHg
L/E Dressings intact
No soakage
Continue Same Treatment

41. Day 14
POD 7
No Fresh Complaints
O/E PR :80 bpm
BP :120/80 mmHg
L/E Dressings intact
No soakage
Continue Same Treatment

42. Day 15
POD 8
No Fresh Complaints
O/E PR :80 bpm
BP :120/80 mmHg
L/E Dressing intact
No soakage
Continue Same Treatment

43. Day 16
POD 9
No Fresh Complaints
O/E PR :80 bpm
BP :120/80 mmHg
L/E Tenderness reduced
No soakage
Peripheral Pulsation +ve
Treatment Advice
Tab. Covatil 500 mg 1-0-1
Tab. Razo 1-0-0
Tab. Xtracal CT 0-1-0
Syp. A-Z 2.5ml BD

44. Day 17
POD 10
GC Fair
O/E PR :80 bpm
BP :130/80 mmHg
L/E Tenderness reduced
Peripheral Pulsation +ve
Continue Same Treatment

45. FINAL DIAGNOSIS
PATELLA FRACTURE

46. BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DURATION
TAB. COVATIL CEFUROXIME 500 MG P/O 1-0-1 10 DAYS
TAB. RAZO RABEPRAZOLE 20 MG P/O 1-0-0 10 DAYS
TAB. XTRACAL CT CALCIUM CITRATE
CALCITRIOL
1 GM P/O 0-1-0 30 DAYS
SYP. A-Z MULTIVITAMIN 2.5 ML P/O √-×-√ 10 DAYS
DISCHARGE MEDICATIONS

47. PHARMACEUTICAL CARE PLAN
Subjective Evidence
Objective Evidence
H/O Fall
Swelling in left leg
H/O Pain in the left patella
X-RAY of left leg showing Fracture of patella

49. Assessment
Based on the Subjective and Objective evidences ,
it is assessed that the patient is suffering from
LEFT PATELLA FRACTURE

50. Plan
Treatment Goals
Doing the Surgery successfully
Reduce Pain and swelling
Prevent possible surgical site infections
Improve the quality of life

51. Surgery done successfully
Swelling reduced
Tenderness reduced

52. Drugs : ACECLOFENAC-DICLOFENAC
Severity : MAJOR
Summary : Concurrent use of DICLOFENAC and
NSAIDs may result in increased risk of bleeding.
Not seen in the patient

53. Patient Counselling
About drugs
• Pantoprazole-should be taken 1hr before
food
• Do not skip the medication .
• Strictly adhere to medication .

54. RECOVERY
Recovery times after a broken knee cap can vary with the degree of
severity of the fracture. Normally, a patella fracture is healed enough
in 8-12 weeks to allow the patient to resume walking. In order to
ensure movement is maintained in the knee after treatment, handling
of the knee should be careful during the treatment phase to ensure
there is no lingering scar tissue that can hinder recovery.
It is not only the bone that is damaged by a patella fracture, as
muscles will necessarily weaken due to lack of use of the limb
throughout the healing time. Without a strong physiotherapy
programme, a patient may not recover full strength again in their leg
for eight months to a year. Physiotherapy shortens the amount of time
muscles take to get back to full strength and level of flexibility by
several months. Most patients will fully recover by six months if
using appropriate physiotherapy.

55. Life Style Modification
Avoid walking through stairs
Avoid doing hard works
Avoid lifting heavy weights
Reduce activities that requires
bending of knee
Wear Knee brace or other protective
bandage to get extra support