Conference Ext. กฤตพร 15 ม.ค. 61

1. ORTHOPEDIC
CONFERRENCE
Extern KRITTAPAUN SOMBATWATTHANA

2. CASE
• ผู้ป่วยชายไทย อายุ 51 ปี
• CC: จักรยานยนต์ล้มเข่าขวากระแทกพื้น 30 นาทีก่อนมา
โรงพยาบาล

3. CASE
• 2 ชั่วโมงก่อนมาโรงพยาบาล ขณะกาลังจะจอดจักรยานยนต์ เสีย
หลัก ล้มหัวเข่าขวากระแทกพื้น หลังจากนั้นไม่สามารถลุกขึ้นเองได้
มีแผลถลอกที่เข่าขวา ไม่สวมหมวกนิรภัย ไม่มีศีรษะกระแทก ไม่
สลบ จาเหตุการณ์ได้ ไม่ดื่มสุราก่อนเกิดอุบัติเหตุ

4. CASE
• No underlying disease
• No drug or food allergy

5. CASE
• ABCD : pass
• Vital sign: BP120/70mmHg
RR 18/min PR 80bpm
• Affected part
• Right knee swelling with
abrasion wound 1x2 cm.
• Capillary refill < 2 sec
• DPA 2+ PTA 2+
• Can not extend/flex Knee
• Toe full ROM

6. CASE

7. PATELLAR
FRACTURE

8. OUTLINE
• Anatomy
• Mechanisms of injury
• Signs and symptoms
• Imaging and other diagnostuc
studies
• Classification
• Treatment

9. ANATOMY
OF PATELLA

10. The patella
is the largest sesamoid in the body
Anatomy
“
”

11. Anatomy

12. Anatomy

13. Anatomy
Superficial femoral artery
Anterior tibial artery
Popliteal artery
Extra-osseous blood supply

14. Anatomy
Intra-osseous blood supply
From..
Inferior geniculate artery
Medial geniculate artery
Lateral geniculate artery
Recurrent tibial artery

15. Anatomy

16. Anatomy
Origination: apex of the patella
insertion: tibial tubercle

17. MECHANISM
OF INJURY FOR PATELLAR FRACTURES

18. Mechanisms of injury
Direct injury
Indirect injury
 Low energy
fall from a sitting or standing height
 High energy
dashboard impact in motor vehicle collision
Comminuted
fracture patterns
Secondary to the large forces generated through the extensor mechanism.
Typically result from forceful contraction of the quadriceps with knee in a
flexed position
Retinacular
disruption
Knee extension
is compromised
Transverse
fracture patterns

19. Signs & Symptoms
OF PATELLAR FRACTURES

20. Signs & Symptoms
Difficult ambulation
after fall
Cant extend knee
Anterior knee pain

21. Signs & Symptoms
Anterior knee
Tenderness
Swelling
Hemarthosis
Stepping
Wound

22. Signs & Symptoms
Anterior knee
Tenderness
Swelling
Hemarthosis Displaced
patella fracture
Stepping
Wound

23. Signs & Symptoms
Anterior knee
Tenderness
Swelling
Hemarthosis Displaced
patella fracture
Stepping
Wound
Open fracture
Communication
with knee joint

24. Signs & Symptoms
Anterior knee
Tenderness
Swelling
Hemarthosis Displaced
patella fracture
Stepping
Wound
Open fracture
Communication
with knee joint

25. Signs & Symptoms
Wound
Open fracture
Communication
with knee joint

26. Signs & Symptoms
Wound
Open fracture
Communication
with knee joint
Joint aspiration,
followed by infusion of 150 mL
of saline in to knee joint

27. Signs & Symptoms
Wound
Open fracture
Communication
with knee joint
Joint aspiration,
followed by infusion of 150 mL
of saline in to knee joint
Urgent
irrigation & debridement
in OR

28. Imaging & Other diagnostic studies
OF PATELLAR FRACTURES

29. Plain Radiographs
Investigation of choice for confirm diagnisis of patellar fracture
Magnatic Resonance Imaging
For evaluate suspected extensor mechanism injuries
Computed Tomography
Improved evaluation of articular congruity, fracture communication,
patella stress fracture, nonunion or malunion.
Imaging & Other diagnostic studies

30. Plain Radiographs
Investigation of choice for confirm diagnisis of patellar fracture
Magnatic Resonance Imaging
For evaluate suspected extensor mechanism injuries
Computed Tomography
Improved evaluation of articular congruity, fracture communication,
patella stress fracture, nonunion or malunion.
Imaging & Other diagnostic studies

31. Plain Radiographs
Investigation of choice for confirm diagnisis of patellar fracture
Magnatic Resonance Imaging
For evaluate suspected extensor mechanism injuries
Computed Tomography
Improved evaluation of articular congruity, fracture communication,
patella stress fracture, nonunion or malunion.
Imaging & Other diagnostic studies

32. Plain Radiographs
Imaging & Other diagnostic studies
Normal
Anteroposterior lateral
Axial view
Of
patellofemural
joint
View of the contralateral knee are helpful for comparison and may prevent
the erroneous diagnosis of normal anatomical variant as a fracture.

33. Plain Radiographs
Imaging & Other diagnostic studies
Normal variation
Bipartite patella: typically bilateral

34. Plain Radiographs
Imaging & Other diagnostic studies

35. Classification
OF PATELLAR FRACTURES

36. Classification

37. Treatment
OF PATELLAR FRACTURES

38. Treatment
The management of the patellar fracture
base on…
 Fracture classification
 Extensor mechanism injury
 Age
 Bone quality
 Patient expectation
 Associated injury

39. Treatment
Main treatment options
for patellar fracture are:
 Non-operative management
 Open reduction and internal fixation
 Partial patellectomy
 Complete patellectomy

40. Treatment
Non-operative management

41. Treatment
Non-operative management
Extension splint/brace
Long cylinder cast
Knee immobilize: 4-6 weeks
Weight bearing
Exercise
 Range of motion : Straight-leg raises
 Strengthening: isometric quadriceps exercise

42. Treatment
Open reduction and internal fixation
Tension band

43. Treatment
Open reduction and internal fixation
Tension band

44. Treatment
Open reduction and internal fixation
Postoperative care
▷ Early knee range of motion
▷ Early protected weight bearing
Continuous passive motion
Reduce postoperative stiffness
Improve articular cartilage healing

45. Treatment
Partial patellectomy
Indication
▷ Comminution of the distal pole
▷ Fragment of the patella is extensive and cannot be stabilized
with internal fixation
 Dysvascular fragment
 Free fragment with limited soft tissue attachment

46. Treatment
Partial patellectomy
Postoperative care
▷ Extension bacing
▷ Partial weight bearing with crutch
For 6 weeks

47. Treatment
Complete patellectomy

48. Treatment
Complete patellectomy
Postoperative care
▷ Extension bacing
▷ Partial weight bearing with crutch

49. Treatment

50. Referrence
Rockwood and Green’s Fracture in adult