By Kritima Tarunotai

Medical student

Phramongkutklao college of medicine

CASE CONFERENCE

ORTHOPEDIC IN MAHARAT NAKHON RATCHASIMA

HOSPITAL

PATIENT PROFILE

• Case ผปวยหญงไทย

• อาย 60 ป

• ภมล าเนาจงหวดนครราชสมา

• อาชพ คาขาย

CHIEF COMPLAINT

• ปวดบวมเขาซาย 1 ชวโมงกอนมาโรงพยาบาล

PRIMARY SURVEY

• A – Can talk, no stridor, not tender along c-spine

• B – equal breath sound, RR 18/min, CCT neg

• C – BP 171/80 mmHg, PR 98 bpm

• D – E4V5M6, pupil 2mm RTLBE

• E – no wound at back, swelling and tender at left

knee with palpable bony stepping with limit ROM

due to pain

SECONDARY SURVEY

• A – none

• M – amlodipine(5) 2x1 PO pc, simvastatin(10) 1

tab PO hs, MFM(300) 2x2 PO pc, Enalapril(5)

1x1PO pc, Glipizide(5) 2x2 PO ac, ASA(81) 1

tab PO hs

• P – HT, DM, DLP

• L – not known

• E – Fall from standing height

PRESENT ILLNESS

• 1 ชวโมงกอนมาโรงพยาบาล ผปวยใหประวตวา ก าลงตนนอนลกขนจากเปลทนอน แตพลาดทา ลมเอาเขาซายลง

กระแทกพน ปวดเขาซายมาก pain score 8/10 เขาซายบวม เดนลงน าหนกไมได ไมมหมดสต ไมมลมศรษะ

กระแทก จงไดมาทโรงพยาบาลชมชนพระทองค า

• วนรงขนจงสงตวมารกษาตอทโรงพยาบาลมหาราช

นครราชสมา

PAST HISTORY

Underlying disease – DM , hypertension, DLP

No history of surgery

No history of accident

PERSONAL HISTORY

No history alcohol drinking and smoking

No herbal medication

No drug and food allergy

PHYSICAL EXAMINATION • Vital signs – BT 36.8 C HR 98 /min

RR 18 /min BP 171/80 mmHg

• General appearance – good consciousness, not pale,

no jaundice, hyperstehenic built

• HEENT – not pale conjuctivae, anicteric sclerae

• Cardiovascular – pulse full and regular, normal s1&s2

sound, no murmur

• Lungs and chest – equal chest expansion, equal breath

sound

PHYSICAL EXAMINATION • Abdomen – soft, not tender, no distension

• Extremities – tender and swelling at left knee, loss of

extensor mechanism, neurovascular intact, DP/PT

pulse 2+, capillary refill <2 sec

• LN – no lymphadenopathy

• Neuro exam – E4V5M6 pupil 3 mm RTLBE

• Motor : grade V all extremities

• Sensation : intact

• DTR : 2+

IMPRESSION

• R/O

• Closed Fracture left patella

• Patella tendon tare

MANAGEMENT AT ED

• Tramol 50mg v prn q 6hr

• Plasil 10mg v q 6hr

• CXR

• Film Left knee AP, lateral

• On cylindrical slab

CHEST X-RAY

normal

FILM LEFT KNEE AP

• Patella in midline

• Seen transvers fracture line and

vertical line

• Distal pole higher than

tangential line < 20 mm

• No condylar or plateau fracture

• No bipartite patella

FILM LEFT KNEE LATERAL

Post

Cylindrical slab

intraarticular displaced

5.58 mm

displaced patella

fracture 3.46 mm

FINDINGS • Closed complete transverse fracture of left patella

• Displaced patella fracture 3.46 mm (>3mm)

• Intraarticular displaced 5.58 mm (>2mm)

• Joint stepping

• Insall-Salvati ratio normal (height: patella/patella tendon)

• No soft tissue swelling

• No tibial fracture

• Normal alignment of Femur, Tibia and Fibula

PLAN FOR MANAGEMENT

• Admit

• Regular diet

• Record v/s

• CBC, BUN, Cr, Electrolyte

• Tramol 50mg v q6hr

• Plasil 10mg v q6hr

• Paracetamol(500) 1 tab PO prn for pain q 4hr

LABORATORY

• CBC

Hb 11.4 g/dL Hct 35.7%

WBC 10,500 /uL Neutrophil 61.4%

Lymphocyte 30.1% Monocyte 7.8%

Eosinophil 0.6% Basophil 0.1%

Platelet 249,000 /uL MCV 79.4 fl

• Anti HIV negative

LABORATORY

• Electrolyte

Sodium 140 mmol/L

Potassium 3.85 mmol/L

Chloride 102.4 mmol/L

Bicarbonate 26.7 mmol/L

• BUN = 11.3 mg/dL

• Creatinine = 0.7 mg/dL

TREATMENT

ผาตดแบบ ORIF with tension

band construct

PATELLA

FRACTURE

PATELLA FRACTURE

• Patella fractures account for 1% of all skeletal injuries

• male to female 2:1

• most fractures occur in 20-50 year olds

ANATOMY

• Patella is largest sesamoid bone in body

• Articular cartilage thickest in body (up to 1cm)

• Most important blood supply to the patella is

located at the inferior pole

MECHANISM

• Direct impact injury – almost affected only bone

comminuted fracture

• Indirect eccentric contraction eg Quadriceps

contracture – almost injury bone and soft tissue

tranverse fracture

CLASSIFICATION

PRESENTATION

• Anterior knee pain and swelling

• Non weight bearing

• palpable patellar defect

• significant hemarthrosis

• unable to perform straight leg raise indicates failure of extensor mechanism (ไมสามารถเหยยดหวเขา maintain ได)

• retinaculum disrupted

IMAGING • Film anteroposterior(AP), lateral ( initial ) view

• Lateral view can identify fracture pattern and

associated extensor mechainsm disruption

IMAGING

• Tangential or axial view

of patelllofemoral joint

( for osteochondral fx of patella )

• Fracture displacement

• best evaluated on lateral x-ray

• degree of fracture displacement correlates with degree of retinacular disruption

MRI

TREATMENT

• Nonoperative

• Operative

NON-OPERATIVE TREATMENT

knee immobilized in extension (brace or cylinder cast)

and partial weight bearing in 6-8 weeks

indications

• intact extensor mechanism (patient able to perform

straight leg raise)

• nondisplaced or minimally displaced fractures

• vertical fracture patterns

--Follow up in 3 weeks: x-ray knee to check displaced--

--Rehabilitation program ROM after off cast 3-4 weeks--

early active ROM with hinged knee brace

• early WBAT in full extension

• progress in flexion

• after 2-3 weeks

NON-OPERATIVE TREATMENT

OPERATIVE TREATMENT

ORIF with tension band construct

indications

• extensor mechanism failure (unable to perform

straight leg raise)

• fracture articular displacement >2mm

• displaced patella fracture >3mm

• open fractures

• preserve patella whenever possible

• patella sleeve fractures in children

partial patellectomy

indications

• comminuted superior or inferior pole fracture

measuring <50% patellar height ONLY if ORIF is not

possible

techniques

• quadricep or patellar tendon re-attachment

• reattachment close to articular surface prevents

patellar tilt

• medial and lateral retinacular repair essential

total patellectomy

indications

• reserved for severe and extensive comminution not

amenable to salvage

• quadriceps torque reduced by 50%

• medial and lateral

retinacular repair essential

Significant

Quadricep

weakness

COMPLICATION

• Post-traumatic osteoarthritis

FOR THIS PATIENT

• ผปวยรายนเมอดจากอาการ ตรวจรางกาย ท าใหทราบไดวา ผปวย

มอาการทเขาไดกบ fracture patella เพราะมเขาบวมแดง และ

เจบบรเวณดานหนาเขา รปทรงของ patella เปลยนแปลง คล าได

stepping และยงไมสามารถยกขาข นลอยคางจากเตยงได (loss

of extensor mechanisim) ซงบงบอก วานาจะมการขาดของ

retinacular sleeve ดวย

• จากแผนฟลม X-ray left knee AP and lateral view : พบ ม

patella fracture แบบ transverse and joint stepping

• วางแผนการรกษา จ าเปนตองผาตดแบบ ORIF with

tension band construct เนองจาก

-ผปวยม ปญหา loss of extensor mechanism

(unable to perform straight leg raise)

-ฟลมเจอ patella displaced มากกวา 3 มม.

-patella bone เปน sesamoid bone ทลอยอยใน

intraarticular ท าใหการเชอมของกระดกเปนไปไดไมดนก

-ผปวยรายน ฟลมเจอ joint stepping

THANK YOU