Medical statistics indicate that a fracture of the kneecap or patella accounts for about 1.5% of the total number of such injuries to the human bone skeleton. Most often, the condition is diagnosed in middle-aged and elderly people, and the main cause is a fall on the street. There are several types of damage.
The condition is accompanied by the formation of swelling and the development of pain, which becomes more pronounced during flexion of the lower limb. If the fracture is accompanied by displacement of the bone, the ability to walk is temporarily lost. To diagnose the condition, an x-ray method is used, and to obtain additional information, an MRI of the knee joint is used.
Anatomy of the kneecap
The structure of the patella
To understand the mechanism of development of the condition, it is important to know the basic anatomical elements of the patella. Naturally, it is a flat, slightly rounded bone that is located on the front, outer surface of the knee. The tendons that go to the quadriceps femoris muscle are attached to its upper part. And the upper one serves as the attachment point for the patellar ligament. The outer and inner parts of the bone are supported by lateral ligaments.
Important: the anatomical function of the patella is to protect the knee in traumatic situations. It also acts as a block that increases the resistance force of the quadriceps femoris muscle.
What happens during a fracture and types of damage
The picture shows a fracture of the patella.
The complex anatomical structure of the patella explains the wide variety of types of fractures. According to ICD 10 (International Classification of Diseases, 10th edition), a fracture of the patella is coded S82.0.
If a fracture occurs, the knee joint rapidly changes its size upward. The reason is the extensive release of blood into the joint cavity. The result of natural muscle contraction is the displacement of the upper fragment upward. Then you can observe the formation of an extensive bruise (subcutaneous hematoma), which after some time spreads to the entire area from the knee to the foot.
In traumatology, patellar fractures are divided into open and closed. In case of closed injuries, rupture of the skin. And in the first case, the skin tears, even the bone can be seen through it.
Important: an open fracture takes a long time to heal. In the absence of properly selected therapy or delay in seeking medical help, there is a high risk of complications. This is explained by the fact that this type of damage is accompanied by a violation of the integrity of not only the muscle itself, but also the tendons.
A fracture with and without patellar displacement is also observed. The simplest case in traumatological practice is one that is not accompanied by displacement of bone fragments or the bone itself. The entire bone apparatus remains in its natural place if the fracture occurs along a vertical line. The muscle located along it holds the bones of the knee joint and the resulting fragments in place.
When bone fragments are displaced, the severity of the victim’s condition depends on how badly the lateral tendon apparatus, which is responsible for implementing the extensor function of the knee joint, is damaged. The higher the degree of damage, the higher the resulting inert fragment has shifted.
Most often, displacement can be observed with transverse and horizontal fractures. This is explained by the anatomical structure of the kneecap. The tendon of the muscle that attaches to the upper lobe of the patella pulls it upward when struck. This leads to the separation of the fragments and the formation of a gap between them, which allows bone particles to migrate freely.
Radial head fracture
Frequency of occurrence
Recently, the number of injuries with fracture-dislocations of the forearm bones has increased significantly. One of the reasons for this increase is the increase in the number of victims in road accidents, the increase in the number of catatraumas and other high-energy injuries (for example, in athletes). According to the literature, fracture-dislocations of the forearm bones account for approximately 1-2% of all forearm injuries. Fracture of the head of the radial bone, in turn, accounts for up to 20% of all injuries to the elbow joint, and in half of the cases it is combined with damage to other structures of the elbow joint. About 10% of cases of fractures in this area are accompanied by dislocations of the forearm bones in the elbow joint.
Mechanogenesis of damage
Fracture of the head of the radius (according to ICD-10: S52.1 Fracture of the upper end of the radius) is a high-energy injury, more common in men. This fracture most often occurs as a result of a fall on an outstretched upper limb when the forearm is pronated. An axial load is applied to the radiohumeral joint, causing the head of the radius to collide with the humerus, which leads to a fracture.
Clinical case
Possibilities of modern treatment of patients with comminuted fracture of the radial head
Shuginov A.A., Nikitin A.V.
Patient I., 39 years old, suffered an injury to the elbow joint while roller skating, falling on her outstretched arm. She independently went to the emergency department of city hospital 40. Upon admission, an X-ray examination was performed (Fig. 1).
Plaster immobilization was performed in a functional position. To clarify the diagnosis and preoperative planning, the patient underwent a CT scan (Fig. 2).
This fracture can be classified as type 3 according to the Mason classification, and 21C3 according to the AO classification. Taking into account the patient’s young, working age, high functional requirements, and the complexity of the fracture, endoprosthetics of the radial head was chosen as the treatment method.
During the operation, a comminuted fracture of the head of the radial bone was revealed (Fig. 3, Fig. 4).
During the operation, a component was selected that most accurately replicates the dimensions of the own head of the radial bone (Fig. 5, Fig. 6).
On control radiographs, the position of the endoprosthesis components is satisfactory (Fig. 7).
The next day after surgery, the patient is allowed passive movements in the elbow joint. Full range of motion has been achieved. After the stitches were removed, the patient resumed normal daily activities and went to work.
Thus, a rational examination, careful planning, and the use of modern techniques made it possible to achieve complete restoration of joint function as early as possible and return the patient to his daily activities without restrictions, which is the main criterion for the treatment of any pathology.
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Clinical manifestations of injury
It can be determined whether a fracture of the patella occurred without displacement or whether it can only be dealt with by a traumatologist. However, there are common clinical manifestations of the condition that help the victim without sufficient medical training describe it.
These include:
- rapidly developing pain syndrome, which becomes even more pronounced the moment the victim tries to raise a limb or lean on it. A change in the anatomical position of the joint is visually noticeable - due to injury, it bends and turns to the right or left side. If the ligamentous apparatus is damaged, it is not possible to perform the extensor function;
- swelling. A fracture is always accompanied by the release of varying amounts of blood into the joint cavity. This condition in traumatology is called hemarthrosis. As a result, rapid formation of edema occurs. Victims often complain of a feeling of fullness, and physical activity is sharply limited.
After swelling appears, the joint area becomes covered with a bruise. After some time (from several days to two to three weeks), the hematoma gradually moves towards the foot. This is considered an example of the norm in medical practice.
A cause for concern is the rapid growth of the bruise against the background of a simultaneous increase in swelling and impaired motor activity. This condition indicates that the victim has a fracture, accompanied by displacement of bone fragments. Another sure sign is that the edges of pieces of bone can be easily felt through the skin.
Terms of fusion
Healing of shin bone fractures depends on:
- the age of the victim and his general health;
- the presence of concomitant bone diseases or other pathologies that may affect the rate of callus formation, for example, diabetes mellitus;
- specific location of injury, type and severity;
- method of selected immobilization of inert debris and fragments.
Averaged data on periods of immobilization and disability
Diagnosis
Transverse fracture
The initial diagnosis of “patella fracture” is made on the basis of a thorough analysis of the complaints of the injured person. If the traumatologist suspects an open, penetrating type fracture, the initial diagnosis is carried out as follows:
- A sterile needle is inserted into the joint cavity and the accumulated blood is collected;
- the place of the removed blood is taken by physiological solution (volume does not exceed 50 ml).
If, as a result of the manipulation, leakage of the injected fluid is observed, an open type of fracture can be suspected.
To make a final diagnosis, radiography in three projections is prescribed. Direct projection demonstrates the presence of a condyle fracture (internal or external) located inside the joint.
Axial projection helps diagnose osteochondral and vertical fractures. Lateral photographs reflect transverse type fractures and the condition of any condyle.
First aid rules
In order to be able to walk after suffering a fracture of the patella, it is important to provide first aid in a timely and correct manner.
First aid for a fracture
First of all, it is important to completely immobilize the injured limb. This will avoid post-traumatic displacement of bone fragments. To reduce swelling, a source of cold is applied to the site of impact - ice, a bottle of cold water.
Using improvised or special means, the knee joint is fixed exclusively in an extended form. The splint should cover not only the knee, but the entire area from the hip to the ankle.
After the manipulations, the patient should be taken to the trauma center as soon as possible.
General treatment algorithm
Manual reduction of the internal tibial condyle and osteosynthesis of the internal malleolus
After clarifying the diagnosis, for which X-rays will be needed, but the results of a CT or MRI examination are better, depending on the type and severity of the damage, the bone fragments are repositioned:
- closed manual;
- skeletal traction;
- Ilizarov apparatus or other modification of the distraction apparatus;
- open - submersible or external osteosynthesis.
Unfortunately, in case of severe multiple bone injuries, when it is impossible to restore the anatomical shape of the bone or joint, amputation of the limb above the site of injury or joint replacement will be required.
Photos of orthoses for the knee and ankle, bandages for diaphyseal fractures of the tibia and/or fibula
After comparing the fracture, in accordance with the location of the damage, immobilization is carried out using a traditional plaster cast or modern orthoses.
The price of the latter is, of course, not comparable with conventional plaster, but the advantages of the varieties of elegant fixing devices are obvious:
- they are not afraid of water;
- excellent air permeability;
- when taking control x-rays, reduce the level of radiation;
- Some varieties, subject to precautions, allow you to inspect the fracture site, ventilate the skin, apply pain-relieving ointments and take physiotherapeutic procedures, for example, “sunbathing”.
In cases of damage to the upper or lower parts of the tibia and fibula, after removing the plaster, wearing a knee brace or ankle bandage is indicated for 1-2 months.
Treatment tactics
The exact timing of treatment for a fracture of the patella without displacement or, conversely, with the formation of freely migrating fragments, can only be established by a traumatologist. Also, all manipulations are carried out under his supervision. Treatment can be either conservative or surgical.
Conservative treatment methods
Stages of hemarthrosis
This method is preferable in cases where the fragments diverge relative to each other by no more than 3 mm, and also if the victim is diagnosed with a non-displaced fracture.
First of all, the doctor eliminates hemarthrosis. The procedure is carried out in several stages:
- treating the skin surface in the area of injury with an antiseptic solution;
- An anesthetic is injected into the joint cavity using a thin needle;
- After enough time has passed for the anesthesia to take effect, a substance with a thinning spectrum of action is injected into the joint cavity with another needle and the blood is carefully sucked out.
The final stage of the procedure is always application. Its central part should be in the area just above the patella. The limb is immobilized by applying a plaster splint.
Plaster splint
After 4 days, a course of physiotherapy using a UHF device is prescribed. After one week, static loads begin to be applied to the thigh muscles with caution. It is best to use physical therapy exercises. Movement is possible only with the use of supporting devices - crutches.
Movement with little support on the affected limb is possible when 30 days have passed since the injury. At this point the splint is removed. Be sure to continue physical therapy and exercise therapy.
Control X-rays must be taken before and after the removal of the plaster. This helps to establish the correctness of the selected therapy and, if necessary, make changes.
The disadvantage of the conservative method is the likelihood of incorrect fusion of bone fragments. This situation can result in the development of arthrosis and disruption of the anatomically correct functioning of the knee joint.
Surgery
In horizontal and transverse patellar fractures, the formation of a large number of fragments is often observed. The impact of the muscle leads to their strong divergence relative to each other, as well as rupture of the tendons responsible for knee extension. Violations of this kind do not grow together on their own.
Figure eight fixation of the kneecap
To prevent this type of kneecap fracture from having serious consequences, surgical intervention must be performed. The most commonly used and most effective technique is fixation of the patella:
- "eight";
- Kirschner knitting needles.
In order for the fragments to heal correctly, the doctor fixes them with medical screws, silk or lavsan threads, and a purse-string suture. General anesthesia is sufficient for pain relief.
The most difficult case is a comminuted fracture.
The surgeon removes the smallest fragments, after which the remains of the cup are connected to tissues and tendons. In some cases, screws are used to fix large fragments. Sometimes the injury causes the entire surface of the kneecap to split into numerous small fragments. This phenomenon can only be corrected by removing the entire patella. Any surgical intervention ends with the application of a fixing bandage. The duration of wearing it is determined by the surgeon and can range from 6 to 8 weeks. After the plaster is removed, a rigid removable plate is prescribed to consolidate the achieved result.