| A fracture of the patella is a break or crack in the kneecap (patella), a round bone with a deep projection that sits at the front (anterior) of the knee against the bottom end of the thigh bone (femur). Fractures of the patella can result from direct blows to the knee in sports injuries or accidents, or from indirect stresses caused by twisting actions or violent contractions in the muscles surrounding the knee.
Patellar fractures are classified as either nondisplaced, in which the broken bone is stable and has remained in place, or displaced, in which the pieces of broken bone have shifted out of position and developed gaps. Displaced fractures are unstable.
A history of bone or joint disease, such as osteoporosis, can increase the susceptibility to a fracture of the patella. Other rare conditions, such as bone infections (osteomyelitis) and bone tumors, can weaken the patella enough to precipitate a fracture (pathologic fracture).Risk: These fractures occur in all age groups. Incidence and Prevalence: Patellar fractures account for approximately 1% of all skeletal injuries. (Lamoureux). |
Source: Medical Disability Advisor
| History: The individual usually reports pain in the affected knee. Individuals may report an accident, a fall from a height, or a direct blow to the knee while playing a contact sport, or they may report a near fall or some sudden twisting motion of the knee that resulted in persistent pain and tenderness. Physical exam: Painful swelling (edema) and bruising (ecchymosis) may be present around the patella. Extending or bending the knee may prove painful or impossible, depending upon the degree of bone displacement or associated injury to tendons and ligaments surrounding the knee. Nevertheless, the ability to bend or extend the knee does not rule out a patellar fracture. Following serious accidents, associated injuries may be present, which may include injuries to the hip or spine. Tests: Standard x-rays with special views of the patella are usually sufficient to diagnose a patellar fracture. CT scan may be necessary for more difficult cases where x-rays are not definitive. Patella fractures themselves generally do not require MRI evaluation, but associated injuries to nearby tendons and ligaments may need to be evaluated by MRI studies. A standard x-ray of the unaffected (contralateral) knee may prove helpful by providing a comparison.
Aspiration of fluid from the affected knee may be performed both to relieve pain and to check for the presence of fat, which often indicates the presence of a fracture. |
Source: Medical Disability Advisor
| Treatment of patellar fractures is determined by displacement. Nondisplaced fractures are typically treated without surgery (conservative treatment) by splinting the knee in extension (straight) for 4 to 6 weeks. Since the patella does not bear weight, there is no weight bearing restriction. Crutches, canes, or a walker may be used to aid in walking. Exercise of other leg muscles is encouraged while wearing the splint. After 4 to 6 weeks when the fracture is considered healed, physical therapy to regain range of motion is begun.
Displaced fractures of the patella are treated surgically to stabilize the fragments. Metal pins, screws, wires, or plates may be used to hold pieces of bone together. In cases in which too much bone has shattered, a partial or complete removal (excision) of the patella itself (patellectomy) may be performed. Surgeons generally retain as much of the original patella as possible to aid the knee in maintaining strength.
Following surgery, the knee usually will be immobilized in a brace. Weight bearing and walking are permitted as tolerated as soon as possible after surgery. Exercises to strengthen important muscles of the leg are begun immediately and range of motion exercises are begun at 4 to 6 weeks after surgery. A healed fracture and a strong quadriceps muscle permit a return to vigorous activity in 6 months. |
Source: Medical Disability Advisor
| Generally a good outcome can be expected in about 90% of properly selected patients from nonoperative treatment of nondisplaced patellar fractures (Lyn; Schwartz). Outcomes of surgery to repair displaced patellar fractures vary according to the type of fracture, patient comorbidities, and the operative technique used. Partial excision of the patella may result in some loss of motion, but results appear to improve when as much of the original patella as possible is retained. Total patellectomy results in some loss of strength, but ordinarily good function of the extremity is maintained. |
Source: Medical Disability Advisor
| Note on research and authorship The goals of rehabilitation after a patella fracture are to reduce pain and to restore function of the involved limb. The rehabilitation protocol depends upon the type, severity, and operative or nonoperative management of the fracture. If the fracture is managed operatively, postoperative rehabilitation is guided by the treating physician.
Regardless of how the fracture is managed, the knee may be immobilized for a certain period of time (Bucholz). The physician will indicate when the immobilizer can be removed for exercise.
Early rehabilitation includes gait training with assistive devices, such as canes or crutches, as needed. Individuals are immediately instructed in exercises to prevent loss of motion and strength in adjacent joints. Ankle exercises are taught to promote circulation, and individuals are encouraged to perform these intermittently. Modalities including heat and cold can be used to control pain and edema (Braddom). As guided by the treating physician, range of motion, strengthening, and proprioceptive exercises of the involved joint can be initiated and progressed as indicated and tolerated by the individual (Bucholz). Once the fracture is healed, exercises are continued until strength is restored in the knee joint, a normal gait is observed, and full function returns.
A home program should be taught to complement supervised rehabilitation and to be continued after the completion of physical therapy.
Occupational therapy may be recommended to maximize independence in activities of daily living. An ergonomic assessment may be indicated to assess the workplace and suggest adaptations to allow the individual to return to work. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical ‡ | |
| Physical or Occupational Therapist | | Up to 24 visits within 12 weeks | | | | | | | | Surgical | |
| Physical or Occupational Therapist | | Up to 16 visits within 8 weeks | |
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| ‡ Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Complications associated with a fracture of the patella may include wound infection, stiffness, loss of fixation, and arthritis. Persistent knee (patellofemoral) pain can continue for some time after treatment and has been reported in up to 56% of patients (Lyn). |
Source: Medical Disability Advisor
| Individuals whose jobs require prolonged standing may need temporary reassignment to sedentary duties. If crutches or mobility aids are prescribed, relocation to an accessible area of the workplace may be required, along with additional safety precautions. Individuals wearing casts or braces will need frequent rest periods to allow for elevation of the lower leg. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. Individuals whose injuries do not require surgical repair or reconstruction must nonetheless undergo extended physical therapy to regain full function.
Individuals whose injuries require surgery may need time off from work for extensive physical therapy during the recovery phase after surgery. Avoidance of squatting, crawling, or kneeling for several months, along with use of a cast or protective brace, may be necessary. Other activities to be avoided until recovery is complete include jumping, twisting, lifting, pushing, or lunging. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did individual report a sudden fall or direct blow to the knee?
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Did individual recall a twisting motion of the knee resulting in sudden pain?
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Do radiographic studies confirm a fracture?
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Is the fracture displaced?
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Are there associated injuries to ligaments and tendons surrounding the knee?
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Has the tibia or femur also been fractured?
Regarding treatment:
- Is surgery necessary to realign fractured bone and/or repair associated injuries?
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Has individual been prescribed a cast or brace that immobilizes the site of fracture while allowing for as much movement in the leg as possible? Has individual worn it as instructed?
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Has individual been active in a comprehensive rehabilitation program, beginning with rest and elevation and progressing to passive motion and active exercise to strengthen muscles and restore flexibility?
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Was this rehabilitation program begun at the appropriate time?
Regarding prognosis:
- If fracture was treated nonsurgically, has the individual returned to strenuous activity too soon?
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If fracture was treated surgically, has the individual been prescribed and followed a treatment plan for postoperative rehabilitation?
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Has quadriceps muscle been exercised properly to promote strength and increase the knee's stability?
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Has individual been instructed in a home-based program of exercise and treatment modalities? Is individual compliant with this program?
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Is individual's employer able to accommodate any workplace restrictions?
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Source: Medical Disability Advisor
| Braddom, Randolph L. Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: W.B. Saunders, 2000.Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, 2002. Everett, Lyn, et al. "Knee and Lower Leg." Rosen's Emergency Medicine: Concepts and Clinical Practice. Ed. J. A. Marx. 6th ed. Philadelphia: Mosby Elsevier, 2006. Lamoureux, Christine. "Patella, Fractures." eMedicine. Eds. David S. Levey, et al. 24 May. 2007. Medscape. 23 Dec. 2009 <http://emedicine.medscape.com/article/394270-overview>. Schwartz, Alexandra K. "Patella Fractures." eMedicine. Eds. Robert D. Bronstein, et al. 16 Mar. 2006. Medscape. 13 Feb. 2009 <http://emedicine.medscape.com/article/1249384-overview>. Whittle, Paige A. "Fractures of the Lower Extremity." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beatty. 11th ed. Philadelphia: Mosby Elsevier, 2008. |
Source: Medical Disability Advisor
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