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Problems with the knees are common due to this being a vulnerable area of the body. The knees have to take the full weight of the body and extra forces whenever we run or jump. Although knee twists and sprains can occur regularly from overwork or twisting when playing sport, a broken knee cap is less common.
Patella fractures account for 1% of all fractures and are most common in people in the 20-50 age group, with men more than twice as likely to suffer from a fractured knee cap.
A patella fracture or broken knee cap is usually the result of a direct blow to the knee area. This can happen from falling forward, from a car accident when hurtling forward on to the dashboard or from sporting injury, such as from a tackle in rugby.
Some sports which are particularly dangerous for knees are those that require jumping, such as athletics and basketball. Other sports that make knees vulnerable are contact sports, such as football and rugby, along with sports that stress the knee with twisting, such as skiing, squash and dancing.
Once a person has fractured their knee cap, many symptoms will occur. Severe pain and swelling will be present along with some deformity in the knee area and thigh. If the knee cap is totally fractured, it may be possible to feel a gap.
The patient will be unable to walk with a broken knee cap or put weight on or lift the knee area, although the ankle and toes can normally be moved as usual, except if there is injury to the neuro-vascular system in addition to the knee cap.
Knee fractures can be a series of small cracks or a single or multiple break. To diagnose and successfully treat a patella fracture, it needs to be assessed by scans.
Firstly, an X-ray taken on two planes will often reveal the fracture pattern. However, in order to assess the extent of the fracture, sometimes the patient may need a CT scan. To assess the tissue damage there may also be the need for an MRI scan.
Once the extent of the damage is discovered using X-rays and scans, a treatment plan can be prepared to begin the healing and the rehabilitation of the broken knee cap.
There are three classifications of knee fracture:
Extra-articular or supracondylar fracture: Where the fracture stops before the knee joint line. This is the smallest level of fracture.
Partial-articular or condylar fracture: Where the fracture reaches the knee joint but the condyles remain attached to the femur shaft. This is the middle level of fracture.
Complete-articular or intercondylar fracture: Where the fracture reaches the knee joint and the condyles are separated from the femur shaft. This is the highest level of fracture.
Patella fractures can also be displaced or non-displaced.
Non-Displaced Fractures: Vertical fractures that are stable. These hold themselves in place throughout healing, as the bone has not been misaligned.
Displaced Fractures: Where the bone parts have moved and now do not line up in the correct way. These are more difficult to deal with and require surgery to correct the misalignment.
The classification of the knee fracture determines the best form of treatment. Initially, the fracture needs to be immobilised with plaster of Paris.
A vertical fracture is more straightforward, whilst a traverse fracture of the knee cap is sometimes caused by a pull of the thigh muscle that has been violent enough to displace the knee cap. Treatment for this type of fracture requires a more demanding procedure. The knee cap displacement means that the medical team will need to perform an internal fixation.
In a vertical and non-displaced fracture, a plaster cast is applied for 6-12 weeks. After this period, a knee brace (potentially limiting range of motion) is often applied in order to stabilise the joint, maintaining alignment in the knee while allowing the joint to move. During the recovery time, X-rays are usually taken every 10 days to ensure proper healing of the knee and to make sure the bones are aligned correctly.
If a patella fracture is displaced, as is often the case in traverse fractures, surgery is always needed. The surgeon will place a nail, a series of screws or a plate and screws to secure the joint and hold it in alignment throughout the healing process.
Recovery times after a broken knee cap can vary with the degree of severity of the fracture. Normally, a patella fracture is healed enough within 8-12 weeks to allow the patient to resume walking. In order to ensure movement is maintained in the knee after treatment, handling of the knee should be careful during the treatment phase to ensure there is no lingering scar tissue that can hinder recovery.
It is not only the bone that is damaged by a patella fracture, as muscles will necessarily weaken due to lack of use of the limb throughout the healing time. Without a strong physiotherapy programme, a patient may not recover full strength again in their leg for eight months to a year.
Physiotherapy shortens the amount of time muscles take to get back to full strength and level of flexibility by several months. Most patients will fully recover by six months if using appropriate physiotherapy (focusing on strengthening the muscles in the leg).
The chances of a patella dislocation re-occurring are between 15% and 40%. After two dislocations, the risk is raised to 60% to 80%. A full fracture of the patella is not at as high-risk as long as precautions are taken and the patient is fully healed before normal activity is resumed. Sports should not be resumed fully until at least six months with physiotherapy, and the patient is advised to wear a cushioned support around the knee to protect it from damage.
The patient should be aware of the risks of playing sports that require contact or involve twists to the knee, and they may choose to refrain from these in the future to reduce their risk of damage. Many people choose to wear a knee brace or protective bandage to give extra support to the area around the knee whenever they play a sport.
Other ways to protect the knee from recurring damage include limiting activities that require deep squatting or bending of the knees, while climbing stairs is also an activity that should be limited due to the stress it places on the knee.
When climbing stairs after knee problems, it is advisable to put weight through the heel and not the front of the foot, which can help to protect the knee, while any squatting should also be done through the back of the foot with the knees never coming further forward than the toes. These small lifestyle changes can help to protect the knee and reduce the risk of recurring patella damage.
Although most people recover well from a broken knee cap, there are some undesirable outcomes and complications that can occur.
This can be a problem in the future due to damage to the cartilage that protects the bone around the knee. Mild arthritis is quite common, and around 20% of patients may develop more severe arthritis. Where the condition worsens patient may require a partial knee replacement or even a full knee replacement to help rectify the complaint.
Another possible problem after a patella fracture is permanent weakness of the quadriceps muscle in the thigh, along with a small amount of loss of motion in the flexing and extending of the leg.
Long-term knee pain can also be a recurring problem in patients who have suffered from a knee fracture. A patella knee brace can be worn post recovery to help manage any inflammation experienced which in turn can reduce pain and enhance mobility.