Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in patient
with patella fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
AM, 47 year old woman with recent history of
patella fracture

1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Personal data

Patient Complaints
Moderate pain and stiffness in left knee, moderate disability in gait
Post surgical (fixation method of patellar fracture) rehabilitation status

ANAMNESIS (history)
Our 47 year old woman suffered, six weeks ago, a left knee injury - comminuted stable fracture - and has undergone
the surgical treatment.
She had previous history of hypertension, well controlled with medication.
She performed daily activities of standing and walking postures in her professional life.
Her history reveals a combination of the direct blow to the knee and a fall, during a gardening activity. When she
fell, her left knee was in a hyperflexion posture. After injury, AM could not walk, may be unable to perform a
straight leg raise and accused severe pain and swelling of her left knee. The surgical treatment was performed after 2
days for displaced left patella fracture - open reduction and internal fixation, cannulated screw tension band
technique - circumferential cerclage wiring and screw fixation which may reduce the frequency of hardware
symptoms, without patellectomy. Sutures are removed after 14 days.
AM is presenting in our department after she removed the knee cast, at 7 weeks after intervention, and to perform
and to teach the rehabilitation measures for regain her gait and her independence daily life.
Personal data
Questions (for assessment detailed answers see next page)

1. What is the important mechanism of injury to the patella in our patient?

a. A direct blow to the patella
b. A fall with a tensile force, as is sustained with hyperflexion of the knee
c. A indirect blow to the patella
R = a, b

2. Is important to regain the function of lower limb in our patient?

a. No
b. Yes
c. It is indifferent
R=b

3. How can explain the type of the patellar fracture in our patient?
a. Patella has anterior location and it is thin overlying soft tissue envelope
b. The muscles of lower limbs are hypotonic
c. Our patient has other diseases of patella
R=a

4. What is missed significant aspect in our patient (female) anamnesis?

a. The age of her menopausal status
b. The number of her children
c. Her marital status
R=a
 Personal data
Questions` answers

1. What is the most important mechanism of injury to the patella in our patient?
A direct blow to the patella most often results in a comminuted fracture. The compressive forces applied to the patella
result in a comminuted pattern. The energy of the blow is absorbed by the fracture and may cause damage to the
articular cartilage. Another mechanism of injury to the patella is a tensile force, as is sustained with hyperflexion
of the knee with an eccentric contraction of the quadriceps. A combination of these two mechanisms can lead to a
severe comminuted fracture patterns. A displaced transverse fracture can have comminution if a blow to the knee
occurs after the tensile force.

2. Is it important to regain the function of lower limb in our patient?

Yes. Restoration of the functional integrity and strength of the extensor mechanism in our patient is essential for gait
and performing the daily activities.

3. How can we explain the type of the patellar fracture in our patient?
The patella is prone to injury from a direct blow as a consequence of its anterior location and thin overlying soft tissue
envelope. Direct injuries may be low energy, such as after a fall from a sitting or standing height, or high energy,
as from a dashboard impact. Comminuted fracture patterns are often the result of high-energy, direct injuries.

4. What significant aspect in our patient (female) anamnesis was left out?
The menopausal status is important for bone resistance. If our patient would have a younger age of menopausal status
she is expose to higher risk for osteoporosis. Posttraumatic arthritis and osteoporosis are two disorders that sum
their disabiliry on the lower limbs.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

AM is 1.68 m height and a weight of 71 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine lumbar hyperlordosis, back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with her age.
Lower limb with knee minimal valgus, passively correctable to neutral. Skin in left prepattelar region with post
intervention scars, without any pathologic aspects. The patient mentions pain in the left peri-patellar region that is
aggravated by palpation and kneeling. Pain along the lateral and medial left knee sides. Three cm. left thigh
atrophy were noted.
Left AROM is from -5 to 60 degrees and right AROM is from 0 to 130 degrees. Without knee crepitus palpable with
ROM (active and passive). MMT values are +4 for great gluteus, +4 for hip stable muscles, 5 for right quadriceps
and +3 for left quadriceps, 3+ for and -5 for right / left hamstrings strength.
Gait is possible with cane in right hand (partial weightbearing gait on the left lower extremity). The patient complained
of left knee pain when she got up from a chair and walked.
Neurovascular status of lower limbs are intact.
Vital Signs: temperature 36.8C, blood pressure 140/70 mmHg, rhythmic pulse 72 b/min, 20 respirations / min.
Clinical data
Questions (for assessment detailed answers see next page)

1. How can we explain the knee stiffness in our patient?

a. Because the cartilage is destroyed
b. Because our patient is female in menopausal status
c. Voluntary activation deficits, during immobilization, are the source of stiffness and atrophy
R=c

2. Knee range of motion is important for gait rehabilitation ?

a. Yes
b. No
c. It is a biomechanical parameter that can be ignored in gait rehabilitation program
R=a

3. Why is it important to perform AROM in our patient?

a. To establish the extension mechanism of knee
b. To complete the physical examination
c. To monitor the knee pain
R=a

4. What is important to perform MMT (manual muscle testing) for all muscles of lower limb?
a. For gait are important both extension and flexion kinetic chains of lower limb
b. For control the knee pain
c. For chose the AINS medication
R=a
 Clinical data
Questions` answers

1. How can we explain the knee stiffness in our patient?

Because treatment for a patellar fracture can sometimes require keeping your leg immobilized in a cast for a long
period of time, your knee may become stiff and your thigh muscles may become weak.

2. Knee range of motion is important for gait rehabilitation ?

For a normal gait any patient with any time of knee fracture must have minimal 90 degrees in flexion and complete
extension. These values are necessary for optimal ambulating in any type of surfaces.

3. Why is it important to perform AROM in our patient?

AROM of knee permits to establish the extensor mechanism. About 35% of patellar fractures involve the extensor
retinaculum. Disruption of the extensor mechanism renders the patient unable to extend the knee against gravity
and usually implies that a tear is present in the medial and lateral quadriceps expansion. They become
problematic if the extensor mechanism of the knee is nonfunctional, articular congruity is lost, or stiffness of the
knee joint ensues.

4. What is important to perform MMT (manual muscle testing) for all muscles of lower limb?
All rehabilitation programs for gait in patients with patellar fracture take into consideration the global kinetic
exercises, after analytic kinetic program. The kinetic muscle chains of the lower limb for extension and for
flexion are very important for independence ambulation, so previous kinetic program must do the MMT.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Imagistic data

X ray of knees in our patient after surgical intervention:

standard anteroposterior (AP)
lateral x-ray - patella fracture was aligned and fixed with stainless steel wires and two screws (tension band wiring)

!! Previous intervention, the AP view helps in assessing the fracture pattern and the direction of displacement
!! Previous intervention, the lateral x-ray and Merchant views help in evaluating the amount and location of
comminution
!! A merchant view after surgical intervention is performed to show the degenerative changes of the patellofemoral
joint.
Other imagistic data MRI before intervention or CT were not performed.
!! Computer tomography may be indicated for assessment of osteochondral fractures and intra-articular fragments. If a
stress fracture is suspected, bone scanning may be helpful for making the diagnosis
Imagistic data
Questions (for assessment detailed answers see next page)

1. Which is the position of studied patient for which we have the best evaluation ?
a. An anteroposterior (AP) radiography in extension
b. A lateral radiograph in mild flexion
c. A rest position for arthroscopic exam
R=b

2. The imagistic findings of X-ray knee can suggeted the type of surgical procedure ?
a. Yes
b. No
c. It is an incorrect knees X ray
R=a

3. Is CT / MRI examination essential for our patient?

a. Yes
b. No
c. It is possible to performe if the patient inssurance is complete and extended
R = b, c
Imagistic data
Questions` answers

1. Which is the position of studied patient for which we have the best evaluation ?
The lateral x-ray and Merchant views help in evaluating the amount and location of comminution. Fracture displacement
and degree of fracture displacement correlates with degree of retinacular disruption are best evaluated on lateral x-
ray. Also, the lateral X ray and Merchant view after surgical intervention are performed to show the degenerative
changes of the patellofemoral joint.

2. The imagistic findings of X-ray knee can suggeted the type of surgical procedure ?
Yes. In lateral X ray we can observe longitudinal cannulated screws combined with tension band wires, a
biomechanically superior technique in comminuted kneecap fracture.

3. Is CT / MRI examination essential for our patient?

Standard x-rays with special views of the patella are usually sufficient to diagnose a patellar fracture. However in more
difficult cases where x-rays are not decisive, CT scan may be necessary. Associated injuries to nearby tendons and
ligaments may need to be evaluated by MRI studies, previous surgical internvention.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Functional data

We assess, in accordance with ICF:

impairments of body functions - pain, stiffness, muscle weakness;
changes in body structures kneecap fracture, patellar tendon re-attachment;
activity limitation - limited walking ability and problems with ADLs;
participation restrictions - reduced participation in leisure activities and in household chores.

We used:
easily reproducible physical performance measures for activity limitation and participation restriction
VAS = 7 before, 3 after rehabilitation program;
6 Minute Walk, with cane = 250 meters before; 340 meters after rehabilitation program;
Timed Up and Go, with cane = 26 seconds before; 20 seconds after rehabilitation program;
scales for condition-specific health status measures
Modified scale of Bostman et al. (excellent = 29 - 32 points, without disability; good = 23 - 28 points, minimal
disability; poor = below 23 points, more disability) = 15 before rehabilitation; 24 after rehabilitation program;
Knee Society Clinical Rating Scale (KSCRS) (80-100 = Excellent Score, without disability; 70-79 = Good Score;
60-69 = Fair Score; below 60 = Poor score, more disability) = 62 before rehabilitation; 72 after rehabilitation;
SF-36 (the lower the score the more disability - a score of zero is equivalent to maximum disability; the higher the
score the less disability a score of 100 is equivalent to no disability) = 23 before rehabilitation; 35 after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

1. It is important to repair and maintain the patella in our patient for her lower limb function?
a. No
b. Yes
c. Is no important to mention
R=b

2. The changes in body structures that appeared from surgery may explain?
a. A further disturbance in the neuromuscular status
b. Optimal balance and gait
c. Back pain and lumbar stifness
R=a

3. The final score of the two scales used for our patient Modified scale of Bostman et al. and Knee Society Clinical
Rating Scale (KSCRS) are in concordance with the disability status ?
a. Yes
b. No
c. It is no possibility to compare the two score scales
R=a

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
a. There are no explanations
b. The functional status is not improved after intervention
c. The rehabilitation program for muscular joint status takes a few weeks after intervention
R=c
Functional data
Questions` answers

1. It is important to repair and maintain the patella in our patient for her lower limb function?
Yes. Patella is an essential little bone for effective function of quadriceps and for proper biomechanics of knee joint
so it should be preserved wherever possible. Careful and good surgical technique is essential for a good functional
outcome in fractures (comminuted) of patella. Preserving patella is important, because patellectomy leads to
impairment of power and some functional loss.

2. The changes in body structures that appeared from surgery may explain?
Additionally, the changes in body structures that appeared from surgery may explain the picture of a further
disturbance
in the neuromuscular status.

3. The final score of the two scales used for our patient Modified scale of Bostman et al. and Knee Society Clinical
Rating Scale (KSCRS) are in concordance for disability status ?
Yes. The both scales contain the items for ROM and various daily activities in which the lower limb, knee especially, is
responsible for balance and gait. The principal function of the extensor mechanism of the knee in humans is to
maintain erect posture. Activities such as ambulation, rising from chair and descending or ascending stairs are typical
examples. The force necessary for knee extension is directly dependent on the distance between the patellar tendon
and the knee flexion axis, in accordance with normal biomechanics status of patella.

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Patients' recovering from patellar fracture reclaim 2 3 months for plateau in strength and functional gains. The outcome
measures chosen for our patient study are common clinical measures and their associated impairments are
theoretically addressable by targeted rehabilitation techniques, in accordance with medical literature data.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

1. Comminuted left patellar fracture (operated 4 weeks ago, combined cerclage and tension band wiring
technique), with minimal disable of the extensor mechanism.
2. Mechanical low back pain. Lumbosacral spondylosis.
3. Hypertension (medication controlled)
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. What are the clinical arguments for our patient complete diagnosis?
a. Knee pain that is made worse with activity and is accompanied by stifness and abnormal gait
b. Hardware prominence
c. AROM and quadriceps muscle force limitation
R = a, b, c

2. The following diagnosis can take into consideration for possible complications in our patient?
a. Posttraumatic Arthritis
b. Muscle strengthening
c. Chronic knee pain
R = a, c

3. Do we have to mention all complete diagnosis for our patients? Why?

a. No, it is not an important aspect
b. Yes, because the disorders have an important conditioning for rehabilitation program goals and methods
c. Yes, but not important for rehabilitation program
R=b
 Complete diagnosis
Questions` answers

1. What are the clinical arguments for our patient complete diagnosis?
Examination revealed knee healed scar, with relative normal skin mobility, and 2 cm atrophy of her left thigh muscle
(10cm above patella). The initial kinesiological examination shows our patient has both muscular and structural
restrictions. Her left knee flexion ROM was zero to 50 degrees while sitting, and she complained of pain at end of
range knee flexion at the level of the patella. The quadriceps strength was left /right 3+/5 and hamstrings muscle
strength was right/left 3+/5-.

2. The following diagnosis can take into consideration for possible complications in our patient?
Posttraumatic knee arthritis is a type of arthritis that develops after knee injury, when the articular cartilage covering the
bones can be damaged, leading to pain and stiffness over time. Mild to moderate arthritis (chondromalacia patella) is
a common type in patients with patellar fractures. Severe arthritis is rare.
Chronic Pain. Long-term pain in the front of the knee is common with patellar fractures. While the cause of this pain is
not completely understood, it is likely that it is related to posttraumatic arthritis, stiffness, and muscle weakness.
Some patients find that they are more comfortable wearing a knee brace or support.

3. Do we have to mention all complete diagnosis for our patients? Why?

Rrecovery programs typically reclaim kinetic exercises. In cardiac patient all kinetic program must respect the intensity,
duration and frequency in accordance with cardiac status. Also, the back pain (lumbosacral spondylosis) is a real
stone in rehabiliation program goals and sessions.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Rehabilitation program (RP)

1. Objectives of RP in our patient:

painful status control;
controlling the residual inflammatory process;
to restore function of the involved limb
correcting abnormal walking scheme, with recovery of normal walking;
keeping the knee in the economy of the limb biomechanics;
maintenance of normal daily activities;
maximization of quality of life.

2. Methods of RP used in our patient:

pharmacological modalities - analgesics, chondroprotective drugs
non-pharmacological modalities:
- educational, dietary and hygienic,
- posture (activity modification),
- physical (thermotherapy cold/paraffin to control pain and edema; electrotherapy - TENS, laser, NMES) - decreased
joint swelling and pain will reduce chances of developing complications during the rehabilitation process;
- massage classic and special massage (Cyriax) of knee,
- kinetic
- early rehabilitation includes gait training with assistive devices, canes or crutches; isometric quadriceps
exercises and straight-leg raises: exercises to prevent loss of motion and strength in adjacent joints (ankle
exercises promote circulation);
- range of motion, strengthening, and proprioceptive exercises of the knee joint is initiated and progressed as
indicated and tolerated by the individual; exercises are continued until flexibility and strength are restored in the
knee joint, a normal gait pattern is observed, and full function returns.
Rehabilitation program
Questions (for assessment detailed answers see next page)

1. Why is a rehabilitation program (RP) important in our patient?

a. Because the RP improves only the knee ROM
b. Because the RP improves the upper limb function
c. Because the RP improves the lower limb function
R=c

2. Why should we respect the kinetic algorithm program in our patient rehabilitation ?
a. Because ROM exercises must preceded the strength exercise
b. Because it is the patient option
c. Because the kneecap is replaced
R=a

3. What are the goals of RP in our patient, when she presents in our department ?
a. Initiate functional weightbearing exercises , open kinetic chain AROM and isotonic strengthening exercises
b. Initiate balance/proprioception exercises and increasing intensity of PROM
c. Gradual restoration of strength, power, and endurance
R = a, b

4. Is the dysfunction in the lower limb optimally controlled, in our patient?

a. Yes
b. No
c. It is no important
R=a
 Rehabilitation program
Questions` answers

1. Why is a rehabilitation program (RP) important in our patient?

The main aim of the operation is to achieve freedom from pain and mobility including restoration of the patella.
Rehabilitation program is essential to preserve the joint mobility, to counterbalance flexion deformity of the knee,
and above all, to maintain the strength of peri-articular muscles, which assists to improve the joint stability.

2. Why we should respect the kinetic algorithm program in our patient rehabilitation ?
The range of motion, strengthening, and proprioceptive exercises of the involved joint should be initiated and
progressed as indicated and tolerated by the individual.

3. What are the goals of RP in our patient, when she presents in our department ?
The patient is coming in our department after she removed the knee cast, after 7 weeks after intervention. In the
phase II (6 12 weeks after intervention), the goals of rehabilitation program are: continuing healing of fracture site,
restoring full PROM by week 12, normalizing AROM and initiate gradual return to functional activities and light
work activities. All rehabilitation has to respect the progression for optimal control of patients impairments and
functional limitation.

4. Is the dysfunction in the lower limb optimally controlled, in our patient?

During the immobilization of the knee the patient is encouraged to train other leg muscles. After removing the cast or
splint, and the fracture is considered healed, the therapy to regain range of motion starts.
There are instructions to prevent loss of motion and strength in adjacent joints. Ankle exercises are taught to promote
circulation. Short term plan will be to relax hypertonic muscles, stretch shortened muscles and gain muscle strength
and ROM in knee and hip joint as well as remove the blockage on patella. Long term plan will be to maintain
strength and stability in knee joint.