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- 2. History ◂ HN 199-00-24 ◂ผู้ป่วยชายไทย อายุ 82 ปี ◂ No known underlying disease ◂ เชื้อชาติไทย สัญชาติไทย ศาสนาพุทธ ภูมิลาเนา อ.พระทองคา จ. นครราชสีมา 2
- 3. Chief complaint :เจ็บหัวเข่าขวา 3 ชั่วโมง ก่อนมา รพ 3
- 4. Primary Survey ◂ A:patent airway, no posterior spine tenderness ◂ B: normal and equal breath sound,RR 18/min, trachea in midline ◂ C: no active bleeding, capillary refill < 2 sec, pulse full and regular, PR 97/min, BP 134/86mmHg, abdomen soft not tender ◂ D: E4V5M6, pupil 2 mm RTLBE ◂ E: no tenderness along spine 4
- 5. Secondary survey ◂ A:no food and drug allergy ◂ M: no current medication, TT < 1 year ◂ P: no underlying disease ◂ L: last meal 19.00 รับประทานข้าว ◂ E: 3 ชั่วโมงก่อนมา โรงพยาบาล ขณะผู้ป่วยกาลังเดินเล่นโทรศัพท์ สะดุดประตูบ้าน ล้มเข่าขวากระแทกพื้นในท่างอ หลังจากนั้นมีอาการ เข่าบวม เดินลงน้าหนักขาขวาไม่ได้ ไม่มีอาการชา ไม่อ่อนแรง ไม่ล้ม ศีรษะกระแทก ไม่มีการบาดเจ็บบริเวณอื่น 5
- 6. Physical Examination ◂ Vitalsign : BT 37 C, BP 134/86 mmHg, PR 97/min RR 18/min ◂ GA: good consciousness, well- cooperated ◂ HEENT : not pale conjunctivae, anicteric sclerae ◂ CVS : pulse full and regular, normal S1S2 no murmur ◂ Lungs: clear both lungs, no adventitious sound ◂ Abdomen: soft, not tender 6
- 7. 7 • Right kneemarked swelling and tender, not warm • No laceration wound or opened wound • Palpable patella defect and joint effusion • Cannot full extend right leg against gravity • Anterior and posterior drawer test negative • Valgus and Valrus straight test negative • PTA 2+, DPA 2+, normal pinprick sensation Extremities
- 8. 1. Film Right Knee:AP, lateral
- 9. Film right kneeAP, lateral Closed comminuted fracture at Right patella 9
- 10. “ Diagnosis :Closed comminuted fracture at right patella 10
- 11. Management at ER ◂Immobilization ; on cylindrical slab ◂ Observe compartment syndrome ◂ Set OR for ORIF with tension band construct 11
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- 16. Type of patellafracture 16
- 17. Non-operative management knee immobilizedin extension (brace or cylinder cast) and full weight bearing Indications ◂ intact extensor mechanism (patient able to perform straight leg raise) ◂ non displaced or minimally displaced fractures ◂ vertical fracture patterns early active ROM with hinged knee brace ◂ early weight barring as tolerate in full extension ◂ progress in flexion after 2-3 weeks 17
- 18. Indication for Surgery ◂Fractures with greater than 2 mm of articular step-off ◂ Fractures with greater than 3 mm of fragment separation ◂ Comminuted fractures, with or without displacement of the articular surface ◂ Disruption of the extensor mechanism ◂ Any open fracture or persistent neurovascular deficit requires immediate surgical referral ◂ Avulsion of superior or inferior pole of patella 18 Harris, RM. Fracture of the patella. In: Rockwood and Green's Fractures in Adults, Bucholz, RW, Heckman, JD (Eds), Lippincott Williams & Wilkins, Philadelphia 2002. p.1775. DeLee, J, Drez, D. Patellar fractures in the adult. In: Orthopaedic Sports Medicine: Principle and Practice, 2nd, WB Saunders, Philadelphia 2003. p.1760.
- 19. 19 Post Open reductionwith internal fixation with transosseous suture
- 20. Bipartite Patella ◂ Congenitalcondition ◂ Secondary ossification center fails to fuse with the main patella ◂ Differentiated from acute fracture by radiographic location and clinical ◂ Both pieces of a bipartite patella have smooth, well-corticated borders and minimal separation ◂ Specific location ◂ Most common : Superolateral type 75% ◂ Obtain film contralateral side to confirm 20
- 21. ◂ Weight bearingas tolerate and strengthening exercise ◂ Isometric quadriceps contraction in early phase 21 Rehabilitation ◂ Hold for 10 seconds ◂ 3 set of 10 repetitions/day ◂ Immobilization in full extension Straight Leg Rising Short Arc Quad
- 22. Hip abductors andhip extensors exercise 22
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