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Extern Conference
Ext. Korawee Matasareyapong
Case
 ผู้ป่วยชายไทย 34 ปี
 CC : เหยียดเข่าไม่สุด 3 วัน
 PI : 3 วัน ลื่นล้มเข่าด้านขวากระแทกพื้น จาเหตุการณ์ได้ ลงน้าหนักขา
ขวาไม่ได้ เหยียดเข่าขวาได้ไม่สุด เข่าขวามีลักษณะบวมมากขึ้น ไม่ชา ขยับ
ข้อเท้าได้ ไป รพ.เอกชน on cylinder slab แล้ว
 NPO time : 13.00
 No known underlying disease, allergy
Physical examination
 Vital signs : BT 37 C HR 114 bpm BP 139/84 mmHg RR 16 bpm
 GA: A Thai man, good consciousness, well co-operated
 HEENT : not pale conjunctive, anicteric sclera
 Heart : normal S1S2, no murmur
 Lungs : clear both lungs, equal breath sound
 Abdomen : soft, not tender, no guarding
 Ext : tender and swelling at Rt. knee, limit ROM due to pain at Rt.
knee, intact extensor mechanism, stepping at patella, neurovascular
intact, sensory intact
Patella Fracture
Epidemiology
 Incidence
 1% of all skeletal injuries
 Demographics
 Male : Female = 2:1
 Most occur in 20 – 50 year old
Mechanism of injury
 Direct impact injury
 Fall or dashboard injury -> failure in compression
 Comminuted fracture pattern
 Indirect eccentric contraction
 Rapid knee flexion against contracted quadriceps
muscle -> failure in tension
 Transverse fracture pattern
Associated injury
 High-energy dashboard injuries
 Femoral neck fracture
 Posterior wall acetabular fracture
 Knee dislocation
Classification
 Based on fracture pattern
 Nondisplaced
 Displaced
 Transverse
 Lower or upper pole
 Vertical
 Marginal
 Osteochondral
 Comminuted
Presentation
 History
 Direct blow to knee
 Extensor mechanism injury
 Physical examination
 Palpable patella defect
 Hemarthrosis
 Unable to perform straight leg raise = Failure of extensor
mechanism
Imaging
 X-ray
 Recommended views
 AP
 Lateral – transverse fracture
 Tangential – vertical fracture
Bipartite patella
 8% of population
 50% bilateral
 Superolateral position
Treatment
 Non-operative
 Knee immobilized in extension and full weight bearing
 Brace
 Cylinder cast
 Operative
Non-operative treatment
 Indication
 Intact extensor mechanism
 Nondisplaced or minimally displaced fracture
 Vertical fracture pattern
Operative treatment
 Indication
 Extensor mechanism failure
 Open fracture
 Fracture articular displacement > 2mm
 Displaced patella fracture > 3 mm

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Patella fx

  • 2. Case  ผู้ป่วยชายไทย 34 ปี  CC : เหยียดเข่าไม่สุด 3 วัน  PI : 3 วัน ลื่นล้มเข่าด้านขวากระแทกพื้น จาเหตุการณ์ได้ ลงน้าหนักขา ขวาไม่ได้ เหยียดเข่าขวาได้ไม่สุด เข่าขวามีลักษณะบวมมากขึ้น ไม่ชา ขยับ ข้อเท้าได้ ไป รพ.เอกชน on cylinder slab แล้ว  NPO time : 13.00  No known underlying disease, allergy
  • 3. Physical examination  Vital signs : BT 37 C HR 114 bpm BP 139/84 mmHg RR 16 bpm  GA: A Thai man, good consciousness, well co-operated  HEENT : not pale conjunctive, anicteric sclera  Heart : normal S1S2, no murmur  Lungs : clear both lungs, equal breath sound  Abdomen : soft, not tender, no guarding  Ext : tender and swelling at Rt. knee, limit ROM due to pain at Rt. knee, intact extensor mechanism, stepping at patella, neurovascular intact, sensory intact
  • 4.
  • 5.
  • 7. Epidemiology  Incidence  1% of all skeletal injuries  Demographics  Male : Female = 2:1  Most occur in 20 – 50 year old
  • 8. Mechanism of injury  Direct impact injury  Fall or dashboard injury -> failure in compression  Comminuted fracture pattern  Indirect eccentric contraction  Rapid knee flexion against contracted quadriceps muscle -> failure in tension  Transverse fracture pattern
  • 9. Associated injury  High-energy dashboard injuries  Femoral neck fracture  Posterior wall acetabular fracture  Knee dislocation
  • 10. Classification  Based on fracture pattern  Nondisplaced  Displaced  Transverse  Lower or upper pole  Vertical  Marginal  Osteochondral  Comminuted
  • 11. Presentation  History  Direct blow to knee  Extensor mechanism injury  Physical examination  Palpable patella defect  Hemarthrosis  Unable to perform straight leg raise = Failure of extensor mechanism
  • 12. Imaging  X-ray  Recommended views  AP  Lateral – transverse fracture  Tangential – vertical fracture
  • 13. Bipartite patella  8% of population  50% bilateral  Superolateral position
  • 14. Treatment  Non-operative  Knee immobilized in extension and full weight bearing  Brace  Cylinder cast  Operative
  • 15. Non-operative treatment  Indication  Intact extensor mechanism  Nondisplaced or minimally displaced fracture  Vertical fracture pattern
  • 16. Operative treatment  Indication  Extensor mechanism failure  Open fracture  Fracture articular displacement > 2mm  Displaced patella fracture > 3 mm