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Fracture Patella

The mechanical function of patella is to hold the entire extensor strap away from the centre of rotation of knee, there by lengthening the anterior lever arm and increasing the efficiency of the quadriceps.
Description: fracture_patella
  1. Mechanism of Injury
    1. Direct injury due to fall onto the knee or knee hitting the dashboard of car (dash board injury) cause either undisplaced crack or else a comminuted (stellate) fracture.
    2. Indirect fracture due to forceful contraction of quadriceps muscle cause transverse fracture with displacement
  2. Management 
    1. The key to the management of patella a is the state of entire extensor mechanism.
    2. If the extensor retinacula are intact, active knee extension is still possible even if the patella itself is fractured.
    3. If the patient can actively extend leg upto full extent (i.e. no extension lag) it means the extensor mechanism (retinacula) is intact
  3. Undisplaced / Minimally Displaced Fracture With Intact Extensor Mechanism (i.e. No Extension Lag)
    Cylinder / tube cast in full extension
  4. Displaced Transverse Fracture (Extension lag present)
    Tension Band wiring by k-wires and stainless steel (SS) wire
  5. Comminuted (stellate) Fracture 
    1. At least proximal third of patella is intact
    2. Partial Patellectomy
    3. Severe Comminution
    4. Total Patellectomy

Fracture Tibia

  1. Fracture through the lower third of tibia is more liable to go onto delayed union because the lower fragment becomes relatively avascular due to poor vascularity.
  2. Sarmiento PTB (patellar tendon bearing) plaster, is a carefully moulded patellar bearing below knee plaster which is used in fractures of shaft of tibia in the later stages of conservative treatment when the fracture is more stable (& sticky) and requires the stimulus of direct weight bearing.
  3. It is firmly moulded over- anterior tibial surface, lateral peroneal mass and posterior gastrocnemius mass in order to achieve a triangular shape which will prevent rotation and angulation of fragments. And a hydraulic environment provided by soft tissues is responsible for returning of the fracture to its preload state on release of pressure (i.e weight bearing).
  4. Patellar moulding is done in 45° flexion. Most of the pressure is taken over gastrocnemius mass rather than over the bony prominences. 80% of weight is still taken through the leg. That’s why it is not recommended for unstable early fractures.
  5. In children treated by cast and adults conservative trial is given if it fails than nailing is done.

Compartment Syndrome

  1. Tibial diaphyseal fractures is the most common cause of compartment syndrome (overall and in adults); in children the most common cause is fracture supracondylar humerus.
  2. It mainly affects young male and is best detected by compartment pressure monitoring.
  3. Most of the classical symptoms of compartment syndrome only occur only after there has been irreversible soft tissue damage.
  4. If the surgeons wait for paresthesia, paralysis, or pulselessness, the patient is highly unlikely to recover full function and it is probable that myonecrosis will already have started.
  5. If clinical suspicion is to be used for diagnosis, the diagnosis must be based on increased pain (disproportionate) and pain on passive muscle stretch, as these clinical signs usually occur at an earlier stage. It is extremely difficult to diagnose compartment syndrome clinically, and this problem is exacerbated by the fact that a number of patients will be pain free, unconscious, on ventilators, or anesthetized when compartment syndrome becomes clinically important.
  6. The pressure is highest nearer the fracture site, it is therefore important to locate the tip of the catheter near to the fracture site to ensure that the muscle with the highest pressure is monitored. Continuous pressure monitoring is better than single reading
  7. Surgeons use a single pressure level, usually 30 mm Hg, or a difference between intra compartment pressure and diastolic blood pressure (diastolic BP - ICP) <30 mmHg as an appropriate criteria to base the decision to undertake fasciotomy.
  8. Subtotal fasciotomy should never be undertaken. All four compartments should be decompressed. Compartment decomression (fasciotomy) should be performed immediately as delay carries risk of permanent dysfunction. 

Extra Edge: So compartment syndrome affecting posterior leg can be earliest diagnosed by passive stretch of toe plantiflexors that occurs during (passive) toe dorsiflexion movement.

  1. Use of Single Crutch
    In opposite side Fracture both bone leg and hip pathology

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