|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2021 | Volume
: 9
| Issue : 1 | Page : 6-9 |
|
Clinical profile of patients with patellar fractures at a tertiary care hospital
G Krishnamurthy1, Goutham Kumar2
1 Department of Orthopedics, Dhanalakshmi Srinivasan Medical College and Hospital, Trichy, Tamil Nadu, India
2 Department of Orthopedics, Kamineni Institute of Medical Sciences, Nalgonda, Telangana, India
| Date of Submission | 26-Oct-2020 |
| Date of Decision | 05-Nov-2020 |
| Date of Acceptance | 10-Nov-2020 |
| Date of Web Publication | 30-Mar-2021 |
Correspondence Address:
Dr. Goutham Kumar
Department of Orthopedics, Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, Telangana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/mjhs.mjhs_20_20
Background: Patellar fractures are injuries of a serious nature. Among the skeletal injuries, they constitute about 1%. Males are affected double than that compared to the females. It is not easy to perform a stable form of reconstruction of the facture of the patella, and it is a major challenge to the surgeons.
Objective: The objective of the study was to study the clinical profile of patients with patellar fractures.
Materials and Methods: We conducted this study on forty patients with fracture patella in 2-year duration. The period of follow-up was 4–14 months. Management options included partial and/or total patellectomy and internal fixation with tension band wiring with K wire. All the fracture of patella cases by accident or due to fall were included. Careful clinical examination and history taking was carried out. X ray of the knee joint, anterior posterior, lateral view was also advised.
Results: Male-to-female ratio was 4:1. Twenty percent of patients underwent conservative management. Among them, internal fixation with K wire banding was done in 60% of the cases, while 5% required total patellectomy and 15% required partial patellectomy. Majority, i.e., 85% had fracture of the patella due to road traffic accidents. Fifty-five percent of the cases had no complications. The most common complication was infections in 20% of the cases, followed by effusion in 10% and wire breakage in 10% of the cases. Only two cases had delayed union.
Conclusion: As for as possible patella should be preserved with good surgical techniques, proper antibiotics and with good physiotherapy results are excellent.
Keywords: Internal fixation, knee joint, partial patellectomy, patella, tension band wiring
How to cite this article:
Krishnamurthy G, Kumar G. Clinical profile of patients with patellar fractures at a tertiary care hospital. MRIMS J Health Sci 2021;9:6-9 |
| Introduction | |  |
Patellar fractures are injuries of a serious nature. It has a variety of subtypes. The age of 20–50 years is commonly affected. Among the skeletal injuries, they constitute about 1%.[1] Males are affected double than that compared to the females, i.e., the incidence is double in males compared to females. This can be attributed to the more physically active nature of males compared to the females.[2],[3] It is not easy to perform a stable form of reconstruction of the fracture of the patella, and it is a major challenge to the surgeons. This is because of certain factors such as location of the patella, functions, and transmission of force.[4]
The type of fracture of the patella depends on various factors such as the mechanism of trauma caused to it, and the force with which the trauma is caused. Dashboard injury is the most common type of injury seen in cases of patella, which is a result of direct blow to the patella. There can be insufficiency of the knee joint due to lesion of the bone in the patella. Its severity depends on a few factors such as nature of damage caused to it. There can be chances of injury to the adjacent bones. All these injuries depend on the force and nature of injury or blow to the leg.[5]
The most common patella injuries are closed fractures of the patella. It has been stated that about 7% of the cases are of open fracture types.[2],[6] High force injuries generally result in open fractures of the patella, and they are associated with the damage to the soft tissues. Open type of fractures of the patella is generally found to be associated with the multiple fractures of the adjoining bones and soft-tissue injuries.[6],[7]
The most common cause of the fracture of the patella is the road traffic accidents. Next most common cause is accidents at the workplace and finally common is the accidents at home. Injury and fracture of the patella due to sports are rare.[1]
Operative indications include fractures of the patella which are displaced or those injuries which disturb the extensor mechanism. Tension band wire is the currently used standard therapy with additional cerclage wiring or through cannulated screws.[8]
The present study was carried out to study the clinical profile of patients with patellar fractures at a tertiary care hospital.
| Materials and Methods | | |
Study design
This was a hospital-based follow-up study.
Study period
The study duration was 2 years from June 2016 to May 2018.
Sample size
Forty patients were included with patellar fractures.
Follow-up period
Patients were followed for 4–14 months.
Inclusion criteria
- Age 20–40 years
- Isolated patella fracture
- Willing to participate in the study.
Exclusion criteria
- Associated tibial or femoral condyle fractures
- Old malunion or nonunion patella.
All patients were examined thoroughly. The quadriceps mechanism was evaluated to judge whether patients could do active extension. X-rays of the injured knee were taken in anteroposterior and lateral views. Routine investigations such as blood glucose, blood urea, and serum creatinine were done. X-rays were studied for fracture pattern, displacement, and communication. An open fracture was treated as an emergency.
Conservative treatment
Undisplaced fractures with intact extensor mechanism with fragment separation of <3 mm and articular step off <2 mm were managed nonoperatively; operative treatment was done in patella fracture for more than 2 mm of articular displacement for 3 mm of fragment separation.
Surgical management
Surgical options included (1) internal fixation (tension hard wiring with K wire) and (2) partial patellectomy with extensor mechanism repair. Operative treatment was done in patella fractures for more than 2 mm of articular displacement for 3 mm of fragment separation. Tension band wiring was done for patella fracture, which has 2-part transverse or multiple fragment fractures with large fragments, which would be converted to two parts by screw fixation. Partial patellectomy and repair of the extensor mechanism were done in a fracture that included severe communication of one pole that was not amenable to internal fixation. In case of several inferior poles of communication, resection of the fragments with patellar tender reattachment was performed.
Internal fixation
Tension band wiring was done patella fixation, which has 2 past transverses or multiple fragment fracture with large fragments which be converted to 2 pasts by screw fixation.
Partial patellectomy and repair of extensor mechanism were done in a fracture that included severe combination of one pole that was not amenable to internal fixation; all attempts were made to retain all large fragments and the articular surface when possible.
Postoperative management
Static quadriceps exercise was started from the 1st postoperative day. Check X-rays were taken. The first postoperative dressing was done after 48 h, and drain was removed. The second dressing was done on the 5th day. Patients are made to stand with the help of axillary crutches or walker. Sutures were removed on the 12th day. Patients were discharged and called for regular follow-up at 2–4-weak interval. Knee banding and range of motion exercises were started after 3 weeks.
Patients were followed for up to 14 months. The minimum follow-up period was 4 months, and maximum follow-up period was 14 months, depending on the outcome.
| Results | | |
[Table 1] shows the distribution of study participants as per sex. Males were more than females. Male-to-female ratio was 4:1.
[Table 2] shows the distribution of study participants as per different treatment modalities. Twenty percent of patients underwent conservative management while remaining 80% required surgical intervention. Among them, internal fixation with K wire banding was done in 60% of the cases, while 5% required total patellectomy and 15% required partial patellectomy. | Table 2: Distribution of study participants as per different treatment modalities
Click here to view |
[Table 3] shows the distribution of study participants as per the mode of injury. Majority, i.e., 85% had fracture of the patella due to road traffic accidents and 15% had it due to fall from a height.
[Table 4] shows postoperative complications. Fifty-five percent of the cases had no complications. The most common complication was infections in 20% of the cases followed by effusion in 10% and wire breakage in 10% of the cases. Only two cases had delayed union.
| Discussion | | |
Males were more than females. Male-to-female ratio was 4:1. Twenty percent of patients underwent conservative management while the remaining 80% required surgical intervention. Among them, internal fixation with K wire banding was done in 60% of the cases, while 5% required total patellectomy, and 15% required partial patellectomy. The majority, i.e., 85% had fracture of the patella due to road traffic accidents and 15% had it due to fall from a height. Fifty-five percent of the cases had no complications. The most common complication was infections in 20% of the cases followed by effusion in 10% and wire breakage in 10% of the cases. Only two cases had delayed union.
Desai and Moradiya[9] evaluated prospectively 15 patients for the functional combined encircle wiring and tension band fixation in comminuted patellar fractures. They found that, at the end of 1st week, 13 out of 15 patients gained up to 90° of active flexion. Four patients required vigorous physiotherapy who had 10°–15° of extensor lag by 1st week. By 12 weeks, all cases fracture united. The second surgery was required in one patient as the implant malfunctioned. The average Rasmussen scores were 27.9 out of 30 (range: 27–29).
Matthews et al.[10] found that the risk factors for fixation failure and stiffness after surgery were comminuted fracture and age more than 65 years. They required special care. The functional outcome was found to be improved a lot when augmented fixation using mesh or plates was used.
Smith et al.[11] carried out a retrospective study to review early complications after surgery for fracture of the patella among 87 cases over 5 years. They found that, in 11 cases, there was a displacement of >2 mm before healing. The reason as evaluated by the author was technical errors in five cases, patient noncompliance with postoperative activity restrictions in another five cases. Two cases were due to superficial infection. Hardware removal was required in nine patients.
Saltzman et al.[12] assessed the results of partial patellectomy in forty patients followed for 8.4 years on an average. They found that the active range of motion was 94%. Thigh circumference was 100% and quadriceps strength was 85%. Excellent results were found in twenty cases, good results were seen in 11 cases, fair results were observed in six cases, and poor results were noted in three cases. The outcome was found to be significantly associated with the type of the fracture. The authors concluded that partial patellectomy can be an effective management option in certain cases.
| Conclusion | | |
As for as possible patella should be preserved with good surgical techniques, proper antibiotics and with good physiotherapy results are excellent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Wild M, Windolf J, Flohé S. Patellafrakturen. [Fractures of the patella]. Unfallchirurg 2010;113:401-11.  |
| 2. | Boström A. Fracture of the patella. A study of 422 patellar fractures. Acta Orthop Scand Suppl 1972;143:1-80. |
| 3. | Lotke PA, Ecker ML. Transverse fractures of the patella. Clin Orthop Relat Res 1981; 158):180-4. |
| 4. | Nummi J. Fracture of the patella. A clinical study of 707 patellar fractures. Ann Chir Gynaecol Fenn Suppl 1971;179:1-85. |
| 5. | Scolaro J, Bernstein J, Ahn J. Patellar fractures. Clin Orthop Relat Res 2011;469:1213-5. |
| 6. | Torchia ME, Lewallen DG. Open fractures of the patella. J Orthop Trauma 1996;10:403-9. |
| 7. | Catalano JB, Iannacone WM, Marczyk S, Dalsey RM, Deutsch LS, Born CT, et al. Open fractures of the patella: Long-term functional outcome. J Trauma 1995;39:439-44. |
| 8. | Neumann MV, Niemeyer P, Südkamp NP, Strohm PC. Patellar fractures—a review of classification, genesis and evaluation of treatment. Acta Chir Orthop Traumatol Cech 2014;81:303-12. |
| 9. | Desai TV, Moradiya NP. Management of communited patellar fracture with combined tension band wiring technique and encirclage. Int J Res Orthop 2019;5:104-8. |
| 10. | Matthews B, Hazratwala K, Barroso-Rosa S. Comminuted patella fracture in elderly patients: A systematic review and case report. Geriatr Orthop Surg Rehabil 2017;8:135-44. |
| 11. | Smith ST, Cramer KE, Karges DE, Watson JT, Moed BR. Early complications in the operative treatment of patella fractures. J Orthop Trauma 1997;11:183-7. |
| 12. | Saltzman CL, Goulet JA, McClellan RT, Schneider LA, Matthews LS. Results of treatment of displaced patellar fractures by partial patellectomy. J Bone Joint Surg Am 1990;72:1279-85. |
[Table 1], [Table 2], [Table 3], [Table 4]
|
Search Pubmed for