Patella, Tibial plateau, and Distal femur fractures
What is the patella?
The patella (kneecap) is a triangular bone at the front of the knee. Though the kneecap is not needed for walking or bending your leg, it makes your muscles more efficient and absorbs much of the stress between the upper and lower portions of the leg. Climbing stairs and squatting can put up to seven times your normal body weight on the kneecap and the joint behind it.
What causes a patella fracture?
Because the patella acts as a shield for your knee joint, it is vulnerable to fracture if you fall directly onto your knee or hit it against the dashboard in a vehicle collision. The kneecap can fracture in many ways: partially or completely, into a few or into many pieces. Sometimes when the kneecap is fractured, the ligaments or tendons attached to it can be sprained or torn.
What are the symptoms?
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Sudden and severe knee pain
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Difficulty extending the leg or doing a straight-leg raise
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Pain with moving or walking
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Swelling in the knee
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A deformed appearance of the knee due to the fractured pieces
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Warmth or redness in the area of the fracture
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Bruising
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Tenderness over the kneecap
How is a fractured kneecap diagnosed?
X-rays, taken from several angles, are the best way to assess the extent of a patella fracture and to check for other injuries. If other injuries are suspected, an MRI or CT scan may be done.
How is a patella fracture treated?
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Nonsurgical – If the pieces of bone are not out of place (displaced), you may not need surgery. You may be placed in a splint or brace to keep your knee straight and help prevent motion in your leg. Depending upon your specific fracture, you may be allowed to bear weight on your leg while a brace. With some fractures, however, weight bearing is not allowed for 6 to 8 weeks.
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Surgical – If the fracture pieces are displaced, you will most likely require surgery with an Open Reduction and Internal Fixation. (ORIF) of the patella with tension band
What is the tibial plateau?
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A tibial plateau fracture is a break or crack in the top of the tibia, at the knee. These types of fractures are typically seen with high-energy trauma in young patients or low-energy falls in the elderly.
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Fractures of the tibial plateau are complex injuries, especially since it is one of the most critical load-bearing areas in the human body. This joint helps supports your body weight, and when it is fractured, it is unable to absorb shock. Early detection and appropriate treatment of these fractures are essential in minimizing patient's disability in range of movement, stability and reducing the risk of documented complications.
What are the symptoms?
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Pain or discomfort in or around the upper part of your shin from impact
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Pain and difficulty bearing weight on your leg
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Bruising and swelling
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Limited range of motion
How is a tibial plateau fracture diagnosed?
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Tibial plateau fractures have a wide range of presentations – from very small fractures only seen on MRI scans, to significant injuries with several bone pieces that are nearly impossible to put back together. While those with fractures that only show up on MRI scan have an excellent outcome and a fairly quick return to activities, those involving significant disruption with multiple pieces of the lateral tibial plateau often have a poor prognosis.
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X-rays are always the first line when assessing fractures, but MRI has been shown to classify and assist the management of tibial plateau fractures better than any other imaging study.
What is the treatment of tibial plateau fractures?
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The primary aim of surgical management is to restore the articular cartilage surface and ensure proper alignment. Tibial plateau surgery is commonly executed with Open Reduction and Internal Fixation (ORIF). In more complex cases, fractures are sometimes managed with external fixation followed by further ORIF at a later time.
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Minimally displaced tibial plateau fractures:
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Ends of the fracture are displaced < 1 to 2 mm
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Often discovered in patients who injure themselves, have negative x-rays, and later obtain an MRI that reveals the fracture
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Typically treated non-operatively for up to six weeks to ensure the fracture heals in a good position and doesn’t become displaced
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Fractures involving only one tibial plateau:
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If it’s in a critical location or has a significant step-off deformity, treat with surgery to restore the joint surface in almost all circumstances – very important since there is a much higher risk of developing traumatic arthritis if the joint surface is not lined up
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There are multiple classification schemes for these types of fractures, but the most common are involving only one of the tibial plateaus (medial or lateral)
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Fractures involving both tibial plateaus:
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Biggest concern is significant instability and displacement
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Even if there is only minimal displacement, a fracture involving both tibial plateaus may still benefit from surgical fixation
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For severe fractures with multiple pieces, the goal of surgery is to get the joint surface together as best as possible in anticipation of a potential knee replacement once the fracture fragments heal and the arthritis pain becomes more significant
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Development of osteoarthritis following tibial plateau fracture is common (approximately one-third of all tibial plateau fractures) due to the articular surface being involved, despite the age of the patient at the time of fracture
What is the distal femur?
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Distal femur fractures most often occur during high-energy trauma in young patients and low-impact injuries in older patients. When the distal femur breaks, both the hamstrings and quadriceps muscles tend to contract and shorten. When this happens the bone fragments change position and become difficult to line up with a cast.
What are the most common types of distal femur fractures?
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Transverse fractures – straight across the bone
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Comminuted fractures – bone is broken into multiple pieces
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Intra-articular fractures – extend into the weight bearing surface of the joint and disrupts the cartilage surface. These fractures are more complex and difficult to treat, and the management is largely surgical as these fractures tend to displace even in a cast.
What are the symptoms?
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The most common symptoms of distal femur fracture include:
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Inability to bear weight
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Swelling and bruising
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Tenderness to touch
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Deformity — the knee may look "out of place" and the leg may appear shorter
What are the treatment options for distal femur fractures?
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Nonsurgical management is reserved for stable, minimally displaced, and non-articular fractures. Other indications include non-ambulatory patients with additional comorbidities presenting with significant anesthesia/surgical risk. Conservative management consists of splinting, bracing, or skeletal traction to prevent shortening. Surgical treatment of distal femur fractures consists of internal fixation, with intramedullary nailing or plates and screws.
