A 19-year-old Thai male presented to the emergency room after his motorcycle was hit by a car. He reported left knee pain for 30 minutes. On examination, he had a 4x6cm laceration wound on his left knee with exposed bone and active bleeding. Imaging showed an open left patellar fracture. He was diagnosed with an open left patellar fracture and treated empirically with antibiotics. He underwent debridement and tension band wiring in the operating room.

1. EXTERN’S
CONFERENCE
KULISSARA PALANUPHAP 5602009 RA

2. A 19 year-old Thai male was
brought to ER
“His motorcycle got hit by
car and he had left knee pain
for 30minutes”

3. Primary Survey
A: Airway and C-spine protection
Can speak, no hoarseness, no stridor, no C-spine
tenderness, full active ROM

4. B: Breathing and
ventilation
RR 20/min, SpO2 99%
Normal chest contour, equal chest expansion,
trachea in midline, chest compression test negative,
Clear Breath sound equally both lungs
Primary Survey

5. C: Circulation and hemorrhagic
control
Temp 36.5c, Pulse 77bpm, BP 122/71mmHg
Pelvic compression test: negative
Primary Survey

6. D: Disability
E4V5M6, pupil 3mm RTLBE
Primary Survey

7. E: Exposure
Laceration wound 4x6cm with bone fracture seen
with active bleeding
Primary Survey

8. Adjunct to Primary
Survey
Monitoring vital signs, Pulse
oximetry
Hct: 134%
DTX: 293mg%
CXR
FAST: Negative

10. Secondary Survey at MRH
• Allergy : none
• Medications: none
• Past illness: none
• Last meal: 12hours PTA
• Event or environment related to injury: ขับ
มอเตอร์ไซค์ชนรถกระบะ ไม่สลบ จำเหตุกำรณ์ได้ ไม่ได้ดื่มสุรำ ปวดเข่ำ
ซ้ำย มีแผลฉีกขำดเห็นกระดูกโผล่ เดินลงน้ำหนักไม่ได้

11. Physical Examination
• Head and Maxillofacial: no scalp laceration, no
fracture, no malocclusion, no crepitus, laceration
wound 1*3cm on chin
• Cervical spine and neck: no c-spine tenderness, full
active ROM,
• Chest: normal chest expansion, no tenderness, clear
BS equal both lungs
• Abdomen and pelvis: soft, not distend, no abdominal
tenderness
• Spinal cord: no spine tenderness, no stepping
• Neurologic: alert, E4VTM6, pupil 3mm RTLBE, motor
gr. V all

12. Physical Examination
• Extremities:
Left leg : Laceration wound 4*6cm on left knee with
active bleeding with bone fracture seen

13. Physical Examination
DPA 2+, PTA 2+
Can dorsiflexion,
Can extend 1st toe
ABI 1

14. Adjunct to secondary survey
none

16. Open Left Patellar Fracture
Diagnosis

17. •Start empiraical ATB: Cefazolin 1g IV stat then q6h
•dT booster 0.5ml IM
•Scrub and NSS Irrigation
•On Posterior long leg slab
•Set OR for Debridement with tension band wiring

19. •Clinical findings
•Fracture associated with wound
•Bleeding with fat globule
•Radiographic findings
•Free air located in the joint or around the
fracture
•Fracture associated with wound
•Bleeding with fat globule

21. Factors that modified classification
• Contamination
• Exposure to soil
• Exposure to water (pool, lake/stream)
• Exposure to fecal material
• Exposure to oral flora (bite)
• Gross contamination on inspection
• Delayed in treatment > 8-12hours

22. Factors that modified classification
• Signs of high-energy mechanism
• Segmental fracture
• Bone loss
• Crush mechanism
• Shotgun wound
• High velocity gunshot wound
• Compartment syndrome
• Extensive degloving of subcutaneous fat and skin
• Requires flap coverage (any size of wound)

23. Principle of treatment
• Initial at ER
• Primary survey and resuscitation
• Bleeding control
• Gross decontamination and wound dressing
• Temporary immobilization of the fracture
• Tetanus prophylaxis
• Determine antibiotic administration
• Type I and II: 1st Gen cephalosporin
• Type III: Add aminoglycoside, or add Pen.G
• Duration: 3-5days

24. Principle of treatment
• Initial at OR
• Irrigate and systematic debridement
• Assess the extent of injury
• Repair the damage structures
• reduce and stabilize the fracture
• Wound coverage

25. Patellar fracture

26. Mechanism of injury
• Direct impact injury
• Indirect eccentric contraction
• Rapid knee flexion against contracted Quadriceps
muscle
• Associated injury: femoral neck fracture, posterior wall
acetabular fracture or knee dislocation

30. Presentation
• History
• Direct blow to knee or extensor mechanism injury
• Physical examination
• Inspection
• palpable Patellar defect
• Significant hemarthosis
• Motion
• Unable to perform straight leg raise
• Provocative test
• Perform Saline load test to exclude Open Fracture

31. Imaging
• Knee AP, lateral, tangential view

32. Treatment
•Non-operative
• Knee immobilized in extension and full
weight bearing
• Indication
• Intact extensor mechanism (Patient can perform
straight leg raise)
• Nondisplaced or minimally displaced fracture
• Vertical fracture pattern
• Early ROM with hinged knee brace

33. Treatment
•operative
• ORIF with tension band wiring
• Indication
• Extensor mechanism failure
• Open fracture
• Fracture articular displacement >2mm
• Displaced patellar fracture >3mm
• Partial patellectomy
• Total patellectomy