A 63-year-old female football coach presents after a fall down two steps at training. She described landing heavily on her flexed left knee. She reports experiencing immediate pain and swelling. On examination she was noted to have a gross effusion, localised tenderness about the patella and a limitation of knee flexion to 60 degrees. Her extensor mechanism was intact.
X-ray images of the knee showed an effusion as well as mild tri-compartmental osteoarthritis. There was no overt bony abnormality. The MRI images show a sagittally oriented linear T1 low signal and T2 hyperintense band across the patella. This is in keeping with an undisplaced fracture. The fracture line runs through the lateral facet just lateral to the median ridge. There is no defect or gap in the articular cartilage.
This woman was managed in a range-of-motion (ROM) brace. For the first two weeks this was locked in extension. After this point she was allowed to start with basic ROM and some isometric quadricep strengthening. At six weeks post-injury she was able to come out of the brace and to walk unaided. At three-months post injury she reports being “90% of normal” with only some modest discomfort with prolonged periods on her feet, some difficulty with stairs and stiffness with prolonged sitting.
The management of patellar fractures depends on the orientation of the fracture and the presence of displacement.
Patients with a vertical fracture pattern, as seen in this case, generally do well with non-surgical treatment. Undisplaced (or minimally displaced) fractures, with an intact extensor mechanism (they are able to straight leg raise) can also generally be treated without the need for surgery. This usually involves a period of immobilisation with their knee in extension. In most cases this is for a period of between 4-6 weeks however early active movement, full weight-bearing and progressive flexion can be encouraged in compliant and more high-demand patients.
When there is significant displacement, or when the extensor mechanism is disrupted, surgical management is usually preferred. The surgical treatment of these fractures usually involves open reduction and internal fixation with tension band wires.
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