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Meniscal Tears

Background

Meniscal tears are a common source of pain around the knee. There are two menisci found within your knee, once on the inside (medial) and one on the outside (lateral). Both are designed to increase the surface area of your knee and serve as shock absorbers against load. For that reason your meniscus helps maintain the joint and thus prevent against the development of arthritis.

Meniscal tears may occur due to trauma or degeneration within the knee. Trauma may take many forms: from an athletic injury to a sudden twist or fall on a slippery surface. When a tear does occur the now-loose meniscal fragment may get caught within you knee. This causes pain and a sensation of ‘locking’ or ‘catching’.  For some, they may only notice this at extremes of motion (such as deep squats).

Once a tear occurs your body is often unable to heal it on its own (with rare exceptions). However, the pain associated with many tears recover with time and therapy. For that reason, the presence of a meniscal tear on MRI does not mean you need an operation!

It is also important to know that meniscal tears can also be the result of arthritis within the knee. The chance of having arthritis increases as we age, and is an important consideration when considering how to manage a meniscal tear. For example, arthritic knees do not respond to arthroscopic (or minimally invasive) surgeries. An overview of the treatment options for knee arthritis can be found here XXXX.

 

Work-Up

Patients are often seen first in their family physician’s office. For any patient with knee pain where a fracture has been ruled out, we first recommend a minimum of 6-12 weeks of formal physical therapy before considering additional investigations. Should pain persist beyond this point, the next step is to obtain an X-ray to rule out arthritis in at risk populations. If an X-ray identifies severe arthritis, then the results of an MRI no longer matter as it will not change treatment options. Only after this should other imaging (such as an MRI) be obtained.

Please note that the above approach to knee pain is not designed to ‘with-hold’ or ‘gate keep’ MRIs, but instead it reflects the fact that a significant proportion of painful knees resolve with time and therapy alone.

 

Treatment

If time and therapy do not resolve knee pain, and an MRI demonstrates a meniscal tear, you may be referred to an orthopaedic surgeon. The surgeon may still recommend one or more of the following non-surgical treatment options depending on the individual patients’ case and medical history:

  • Ongoing Physical Therapy: Not all therapists are alike. We favor ones that encourage movement and strengthening of the quadriceps, core and hip muscles over less proven ‘adjuvant’ modalities (i.e. ultrasound or laser). The best therapy makes you move, sweat and helps build muscle. Ensuring the proper therapy is performed is key to your recovery.
  • Injections: There are multiple injections around the knee that may be considered. All seek to provide pain relief. Newer injections, such as Platelet Rich Plasma, may have regenerative properties for other conditions around the knee but have limited evidence supporting their use in meniscal tears.
  • Weight Loss: Obesity can place great strain on knees, exacerbating pain associated with meniscal tears. Achieving and maintaining a healthy weight is an important consideration in helping rehabilitate a knee from any injury or arthritis.
  • Bracing: In instances of combined arthritis and meniscal tears, an off-loader brace may be considered. The purpose of these braces is to decrease the amount of force going through the affected side of the knee, and may be of use in certain circumstances. Similarly, knees with combined ligament and meniscal injuries may benefit from a brace designed to help compensate for the injured ligament. Bracing in isolated meniscal tears is, in our opinion, of limited use.

 

If the above recommended options are not successful in relieving pain, or in specific unique meniscal tears (i.e. a bucket handle tear with a locked knee), surgery will be discussed. The following are commonly recommended surgical procedures that may be recommended depending on your symptoms and imaging:

  • Knee Arthroscopy with Partial Meniscal Resection: For many tears around the knee, it is not possible for us to simply stitch a meniscal tear back together. Due to poor blood supply and often complex forms of tears, a repair is not possible in the vast majority of cases. As such, arthroscopic (or minimally invasive) knee surgery is recommended to resect the loose and torn meniscus. This alleviates pain by avoiding the loose fragments from becoming caught within the knee, and allows for immediate weight bearing and quick return to function.
  • Knee Arthroscopy with Meniscal Repair: In specific circumstances, it may be possible to repair a torn meniscus. A meniscus that is torn around the edge of its attachment (the so-called ‘bucket-handle meniscal tear’) may be amenable to repair if the meniscus comes away as a single large piece without degeneration in an area with a good blood supply. The rehab and recovery of a meniscal repair is prolonged when compared to a resection alone, and often requires a period of non-weight bearing. There is also a higher risk of failure with meniscal repairs, which depends on a complex interplay between tear appearance and location during surgery, age and activity level.
  • Total Knee Replacement: This treatment is here because it is not uncommon when we are referred a patient with a meniscal tear on MRI, only to diagnose them with severe arthritis on X-ray. Meniscal surgery in no way addresses symptoms related to knee arthritis. As such, patients with arthritis may be better served with knee replacement – an option your surgeon will discuss with you if relevant.

 

Expected Follow-up and Recovery

Recovery can be unique to each patient depending on the extent of meniscal damage, and the presence of ligamentous injury or arthritis. The following is a common recovery pathway experienced by most patients:

  1. No Surgery: Most meniscal injuries should be initially treated with physical therapy and avoidance of aggravating activity. As symptoms resolve, the goal is to regain and maintain strength followed by a return to activity. Ideally, a patient continues at their place of work as part of their rehabilitation program. Return to full function depends on the nature of the injury and may range from 1-10 weeks.
  2. Surgical Partial Meniscectomy: Patients are able to walk out of hospital post-surgery and progress activity rapidly from there. We recommend walking and light cycling for 2 weeks following the operation, and progressing to full activity 4-6 weeks after that. Office workers can return within 1-2 weeks while taking time off for ongoing physical therapy. Extremely physical jobs may require 4-6 weeks before returning to work on progressive hours and duties.
  3. Surgical Meniscal Repair: Attempt at meniscal repair requires a brief period of minimal weight bearing, which greatly impacts recovery timelines. According to our protocol, patients remain non-weight bearing in a knee immobilizer for 6 weeks, but may perform focused physical therapy with an experienced provider.  At 6 weeks patients begin gait retraining and progressive strengthening.  Return to work occurs between 2-6 weeks (for office jobs) and 6-12 weeks (for laborers). Maximal recovery is expected somewhere between 3-5 months after surgery.

 

General Information

  • See our Knee Arthroscopy Patient Handout for specific post-operative recommendations.
  • The presence of arthritis is thought to delay recovery by 1-2 weeks depending on severity.
  • Surgery is designed to take away the catching/locking feeling within a knee and the pain associated with this. It will not address arthritis symptoms (i.e. stiffness, activity related ache).
  • Arthroscopic surgery is performed in a water environment under pressures of 60mmHg. Due to this, swelling for 2-4 weeks following an operation is to be expected.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. As each injury is unique, the below may not apply to everyone.

 Post-operative rehabilitation should be guided by the procedure performed. Obtain your surgeons post-operative protocol, in advance if possible, so that you and your therapist fully understand any rehabilitation required following surgery.

 

The general non-operative rehabilitation protocol is as follows

  • Brief RICE: A brief period of rest, ice, compression and elevation can be useful for a few days but detrimental in the long run if range of motion is not started ASAP.
  • Early Range of Motion: As pain subsides, you can begin to perform light range of motion exercises with the goal of regaining active range of motion of the knee as quickly as possible. Inability to bend or straighten your knee should prompt return to your physician.
  • Strengthening: Once range of motion is approaching pre-injury levels, strengthening may begin. Strengthening should focus on quadriceps, core and hip abductor strengthening to improve function and decrease risk of future re-injury.
  • Maintenance: As with any injury, exercises should be incorporated into a philosophy of active and healthy living to prevent the risk of future re-injury.

 

Expected Outcomes

Meniscal injuries can be expected to have an excellent result in the majority of people, regardless of what treatment is required. The more meniscus damaged, the greater the chance of developing arthritis later in life. An active lifestyle with maintenance of a healthy weight can decrease those risks as much as possible.

 

Notable Challenges

  • Knee Stiffness: May develop due to post-injury scarring or due to the meniscal tear blocking movement within your knee. Follow-up with your family physician or surgeon to discuss management options.
  • Knee Swelling: Swelling is expected for a few weeks post injury or surgery. Persistent swelling may impede rehabilitation or necessitate more aggressive therapies to manage. Follow-up with your family physician or surgeon to discuss management options.
  • Arthritis: a meniscal tear may be the cause of development of post-traumatic arthritis. Alternatively, arthritis may be the cause of the meniscal tear. Regardless, the presence of a meniscal tear may signal the development of ongoing issues with the affected knee. Your physician will be able to help predict future treatment requirements for your knee.

 

Summary of Common Treatment/Rehabilitation Pathway

Tibial Shaft Fractures

Introduction

Tibial shaft fractures are relatively common and may generally be separated into two broad categories:

  • “Low energy” tibial shaft fractures typically occur following a rotational injury. These are commonly sustained while participating in sports such as downhill skiing or ice hockey. The twisting mechanism usually causes fractures of both the tibia and fibula at different levels and it is uncommon for these fractures to be “open” (fracture ends protruding through open wound in skin).
  • “High energy” tibial shaft fractures are usually caused by a direct blow to the leg. Common mechanisms for this injury include motor vehicle accidents and pedestrians being struck by cars. This typically results in tibial and fibular injuries at the same level and these injuries are more likely to result in “open” fractures.

Treatment

Fractures of the tibial shaft are almost always diagnosed in the emergency department after an x-ray. Once the fracture has been accurately diagnosed, a “closed reduction” to align the tibia will be performed and a splint will be applied. If the fracture is “open” then you will be asked if your tetanus prophylaxis is up to date and a dose of IV antibiotics will be administered as soon as possible. Definitive treatment of your fracture will depend on several variables and can be divided into two broad categories:

  1. Conservative Treatment: It is uncommon for a tibial shaft fracture to be managed without an operation. Patients with a tibial shaft fracture that is well aligned can be treated in an above knee cast and a prolonged period of non-weight bearing on the injured leg. Most patients prefer an operation to allow a more prompt return to full activity. Some patients will have many other medical conditions that make them unfit for surgery and these patients will be treated in a cast. Other patients who are only minimally or non-ambulatory before their injury will be treated without an operation.
  2. Operative Treatment: The implant most commonly used to treat a tibial shaft fracture is a rod (intramedullary nail) that is inserted the full length of the bone.  Occasionally, your surgeon may decide to treat your fracture with a plate and screws instead.  The most common reason why this decision would be made is if your fracture is very close or even extending into the knee or ankle joint. Following surgery, you may require a short admission to hospital, especially if your fracture is complicated or you have other medical conditions. Your weight bearing instructions following surgery will be based on the implant used and the orientation of your fracture.

Follow-Up and Rehabilitation

  • 0 – 2 Weeks: At this early point your rehabilitation will be focused on improving your mobility. Depending on how your fracture is being treated you may or may not be permitted to put weight on your injured leg. A follow-up appointment will be scheduled at approximately 2 weeks from your initial injury. At this time repeat x-rays will be done to ensure your fracture has not shifted, your skin staples or sutures will be removed and a repeat physical examination will be performed.
  • 2 – 6 Weeks: Your pain and mobility should continue to improve at this interval. You may have been prescribed oral pain medication at the time of your injury and you should be weaning from this as soon as possible. A follow-up appointment will likely be scheduled at approximately six weeks from your injury for repeat x-rays and physical exam.
  • 6 – 12 Weeks: After your six week examination, all but the most severe injuries will be permitted to put weight on the injured leg. You may initially be asked to wear a cast boot for additional protection while starting to walk on your injured leg. Referral to physiotherapy may be considered to help you regain the strength in your injured leg.  A follow-up assessment will be scheduled at approximately three months from your initial injury.  If you are doing well at this stage, this may be your final scheduled follow-up.  Additional follow-up may be required for patients with more complex injuries.

Complications

If you have an operation to treat your tibial shaft fracture, there are standard surgical risks that apply to all patients undergoing surgery. There are some additional complications that are specific to tibial shaft fractures. These include the following:

  1. Compartment Syndrome: The muscles of your leg are separated into four separate compartments by a strong tissue called fascia. The swelling and bleeding caused by a tibial shaft fracture (especially from one sustained via a “high energy” mechanism) can cause the pressure in the compartments to increase. If this pressure becomes too high, the muscles in these compartments can start to die. For this reason, you will be monitored very carefully before and after your operation for any signs or symptoms of compartment syndrome. If you do develop compartment syndrome, you will require emergency surgery to release the fascia (“fasciotomy”) to decrease the pressure in the compartment and prevent the muscle from dying.
  2. Non-Union: In large studies of patients who are treated with a rod (“intra-medullary nail”) for their tibial shaft fracture, about 5% did not heal their fracture after one operation. This risk is increased in patients who have “open” fractures and “high energy” mechanisms of injury. If your fracture does not heal, you will likely require at least one additional procedure to address this “non-union”.
  3. Knee Pain: Patients that have tibial shaft fractures treated with a “rod” (intra-medullary nail) often have difficulty with pain in the front of their knee following surgery. Your surgeon will pay careful attention to ensuring that the rod is not left proud in your leg but even with perfect surgical technique patients often have some pain in the front of their knee. Once your fracture has healed you and your surgeon may consider removing the rod to address this pain, although the success of this operation is unpredictable.
  4. Infection: A relatively high number of patients with fractures of the tibial shaft will have “open fractures” (bone coming through skin). In this situation, the emergency room doctor will give IV antibiotics as soon as possible. You will also be asked if your Tetanus immunizations are up to date.

Outcome

Patients with fractures of the tibial shaft generally do well post-operatively. It is important to participate fully with your rehabilitation following surgery and follow your weight bearing restrictions, if any. It is equally important to wean from your prescription pain medication as soon as possible as these medications are addictive.

 

 

 

Anterior Cruciate Ligament Tears

Background

Damage to the anterior cruciate ligament (ACL) is a commonly encountered sports medicine condition. The ACL is one of four major ligamentous stabilizers of the knee. The main purpose of the knee is to prevent forward movement of the tibia (shin bone) on the femur (thigh bone). The ACL also helps to prevent excessive rotation through the knee. The dual function of the ACL is explained by two different bundles of fibers within the ACL: anteriormedial and posterolateral.

Although ACL tears can occur in many ways, the most common mechanism is a twisting force through the knee with the foot planted (the so-called non-contact pivot). Immediate pain, a ‘popping’ sensation, swelling and inability to continue participating in sport or activity are common symptoms. People are often able to walk with extreme difficulty. Following injury, they are often seen in the emergency room or urgently in their family physicians office. X-rays are commonly normal for any major fracture but a careful look will often identify a small fleck of bone pulled off the outside of the front of the tibia. This so-called Segond fracture represents a failure of the anterolateral ligament (ALL), another stabilizing structure of the knee.

ACL injuries commonly occur along with other injuries. For example, the so-called ‘Terrible Triad of the Knee’ includes an ACL tear along with a lateral meniscal tear and a Medical Collateral Ligament Tear. The chance of additional injury is often predicted by the severity of the initial injury.

Once a tear occurs your body is often unable to heal it on its own. However, the pain associated with many tears recover with time and therapy. For that reason, the presence of an ACL tear on MRI does not absolutely mean you need an operation! We operate on ACL tears in people that have feelings of instability despite an attempt at physical therapy.

 

ACL Tears and Arthritis

We as a profession have likely not done a good enough job advertising two facts which have been consistently shown to be true across multiple studies:

  1. ACL Tears greatly increase the chance that an injured knee will develop arthritis in the decades to come. The chance of developing arthritis likely depends on multiple factors, including muscle strength, obesity, presence of meniscal tears, and/or high-impact activity. I quote a 90% chance of developing arthritis over the next 3 decades, although recent data suggests rates may in fact be higher.
  2. ACL Surgery does not decrease risk of developing arthritis.

Despite evolution of technique, reconstructing torn ACLs has not shown to decrease development of arthritis – even in young patients. Although ACL reconstructive surgery is successful at improving sensations of instability and allowing many people to return to sport, no therapy to date has been proven to decrease the chance of developing arthritis.

 

Work-Up

Patients are often seen first in either the emergency room or their family physician’s office. For any patient with knee pain where a fracture has been ruled out, clinical exam will dictate how quickly an MRI should be considered. If a clinical exam is very highly suggestive of an ACL injury, an MRI can be arranged on a non-urgent fashion.  Regardless, we recommend having your family physician refer you to a formal physical therapy program to regain quads strength and maintain range of motion.

The diagnosis of an ACL tear on MRI inevitably prompts a referral to an Orthopaedic surgeon.  It is important that you continue performing physical therapy until assessed by a surgeon. We cringe when we hear ‘I did not want to do any exercises until I saw you Doc’, as this represents a missed opportunity to maintain or improve the condition of your knee.

 

Treatment

If time and therapy do not resolve symptoms of knee instability, additional treatments may be entertained:

  • Ongoing Physical Therapy: Not all therapists are alike. We favor ones that encourage movement and strengthening of the quadriceps, core and hip muscles over less proven ‘adjuvant’ modalities (i.e. ultrasound or laser). The best therapy makes you move, sweat and helps build muscle. Ensuring the proper therapy is performed is key to your recovery.
  • Injections: There are multiple injections around the knee that may be considered. All seek to provide pain relief. Newer injections, such as Platelet Rich Plasma, may have regenerative properties for other conditions around the knee but have limited evidence supporting their use in ACL tears.
  • Weight Loss: Obesity can place great strain on knees, exacerbating pain associated with ACL tears. Achieving and maintaining a healthy weight is an important consideration in helping rehabilitate a knee from any injury or arthritis.
  • Bracing: Bracing can take many forms, from an over the counter knee sleeve to a custom fitted ACL brace. Some braces can be very expensive and may not be required in all patients. We recommend extensive physical therapy before considering bracing. If the mutual decision is made to brace a knee, the brace should be fit by an experienced individual who will be available to service the brace in the future.

If the above recommended options are not successful in relieving pain, or in specific unique circumstances (i.e. a bucket handle tear with a locked knee), surgery will be discussed. Surgery may not be advisable in several circumstances, such as in older individuals or in knees with pre-existing arthritis. It is important to know that surgery is not designed to stitch the ACL back together again. Instead, the surgery focuses on ‘reconstructing’ the ACL by replacing the old ACL with different tissue. Most surgical procedures are arthroscopically assisted, meaning the size of incisions can be decreased.

If surgery is felt to be indicated, your surgeon should inform you of the type of graft that they prefer. There are several graft choices, each with unique sets of pros and cons. An important factor is also surgeon preference, as some surgeons exclusively utilize one graft and refer to other surgeons should another graft be chosen.

Common Graft Choices Include:

  • Bone Patellar Tendon Bone: The center of the patellar tendon is harvested, along with bone from the patella (knee cap) and tibia (shin bone). This tendon will then be weaved into the knee and secured. This surgery is technically demanding and comes with a larger scar over the knee when compared to other techniques, but it is largely considered the ‘gold standard’ graft and is thought to have the lowest chance of re-rupture. Because of its strength, it is our graft of choice in younger athletes or those participating in contact sports. Because of how the graft is harvested, this graft has a higher chance of pain under the knee-cap, stiffness and has a low risk of a patella fracture.
  • Hamstrings Tendon: Two of the three hamstrings tendons are harvested from the inside of the knee/thigh and are doubled-up on one another to create a 4 strand graft. The hamstring is then weaved through the knee and secured. This technique comes with less scars around the knee and has an excellent track record, but has been found to have a slightly higher risk of surgical failure when compared to the graft mentioned above. As no bone is harvested, the recovery is felt to be easier and as such we prefer this graft in older individuals that are more likely to be affected by post-operative stiffness. One significant consideration with this graft is the hamstrings muscles will not work to the same degree they did before surgery. There is thus a concern that knee functional kinematics will be disrupted and in turn predispose an athlete to re injury. This is one of the most common grafts used.
  • Allograft Tissue: Allograft refers to tissue obtained from another organism. Relating to ACL surgery, cadaver tissue is used. This tissue is sterilized to decrease risk of disease transmission, and is used to reconstruct the ACL by weaving it through the knee and securing it. The recovery with this graft is the easiest, as no other tissue needs to be harvested as part of the surgery. The most notable draw-back with this surgery is the allograft tissue is simply not as strong as tissue harvested at time of surgery from your own body. For that reason, risk of failure or graft rupture is much higher than with other graft choices. We consider this graft choice in revision surgery settings or in older individuals where the risk of recovering from a graft harvest may be significant.

 

Expected Follow-up and Recovery

Recovery can be unique to each patient depending on multiple factors (presence of meniscal tears, other ligaments injured, pre-existing knee strength, presence of osteoarthritis, etc.). The following is a common recovery pathway experienced by most patients, but may be modified depending on graft choice and the presence of other injuries within the knee:

  1. No Surgery: Most ACL injuries should be initially treated with physical therapy and avoidance of aggravating activity. As symptoms resolve, the goal is to regain and maintain strength followed by a return to activity. Ideally, a patient continues at their place of work as part of their rehabilitation program. Return to work or sport depends on the nature of the injury and the demands of the activity and may range from 1-12 weeks.
  2. Surgical Reconstruction: Patients are placed in a knee immobilizer post-operatively. Ability to walk immediately after surgery depends on individual surgical post-operative protocols and the type of graft used. Therapy can start immediately in the brace and with protected active range of motion via heel drags. At 6 weeks more aggressive range of motion is instituted and light quads strengthening is encouraged. More intense strengthening starts at 3 months post-operatively. Running is allowed 4 months post-operatively. Return to contact sport is allowed at 6 months post-operatively. Office workers can return to work within 1-2 weeks while taking time off for ongoing physical therapy. Extremely physical jobs may require 12 weeks before returning to work on progressive hours and duties.

 

General Information

  • See our Knee Arthroscopy Patient Handout for specific post-operative recommendations on wound care.
  • The presence of arthritis is thought to delay recovery by 1-2 weeks depending on severity.
  • Surgery is designed to improve the stability of the knee but will not address arthritis symptoms arthritis symptoms (i.e. stiffness, activity related ache) nor will it prevent the development of arthritis.
  • ACL surgery involves drilling holes into bones within the knee. Due to this, swelling for 6-10 weeks following an operation is to be expected.
  • Sudden chest pain or shortness of breath is not normal and should prompt immediate assessment at the most local emergency room to rule out a blood clot.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. As each injury is unique, the below may not apply to everyone.

 Post-operative rehabilitation should be guided by the procedure performed. Obtain your surgeons post-operative protocol, in advance if possible, so that you and your therapist fully understand any rehabilitation required following surgery.

The general non-operative rehabilitation protocol is as follows

  • 0-4 weeks: A brief period of rest, ice, compression and elevation can be useful for a few days but detrimental in the long run if range of motion is not started ASAP. Come out of the knee immobilizer to start heel drags from 0-90o in the first two weeks, and progress to 120o between week 2-4. The short-term goal should be to regain extension of the knee. In the knee immobilizer, leg lifts may be started to encourage quads strengthening. Patients may be either toe touch weight bearing or full weight bearing in a knee immobilizer depending on a surgeons post-operative protocol.
  • 4-6 weeks: Full active range of motion is allowed within tolerance of pain. Care is taken to avoid passive manipulation of the knee. Straight leg raises out of the knee immobilizer may be considered, if able.
  • 6-12 weeks: Focus is on achieving full range of motion while progressively strengthening the knee. The knee immobilizer is weaned.
  • 12-24 weeks: Progressive strengthening continues, with a gradual shift in sport-specific conditioning.
  • 4 months: Running is allowed
  • 6 months: Return to sport is allowed

 

Expected Outcomes

ACL injuries can be expected to have an excellent result in the majority of people, regardless of what treatment is required. The more associated injuries around the knee, the slower the recovery and the greater the chance of developing arthritis later in life. An active lifestyle with maintenance of a healthy weight can decrease those risks as much as possible.

It is important to consider that return to sport rates may not be as high as previously thought. Many non-professional athletes choose to avoid the sport that led to the ACL injury given the length of recovery required and the knowledge that they are at a higher risk of arthritis. Psychological factors should also be considered, as many athletes struggle with concerns of re injury that impact performance. Each person is unique, and it is important to explore your future goals with your surgeon and your therapist so a realistic timeline can be set.

 

Notable Challenges

  • Knee Stiffness: May develop due to post-injury or post-surgical. Follow-up with your surgeon to discuss management options.
  • Knee Swelling: Swelling is expected for several weeks post injury or surgery. Persistent swelling may impede rehabilitation or necessitate more aggressive therapies to manage. Follow-up with your family physician or surgeon to discuss management options.
  • Blood Clot: Sudden onset calf swelling, shortness of breath or chest pain may represent a blood clot and should prompt a visit to a local emergency room.
  • Arthritis: an ACL tear may be the cause of development of post-traumatic arthritis as detailed above.

 

Summary of Common Treatment/Rehabilitation Pathway

 

 

Patella Fractures

Introduction

Patella (“kneecap”) fractures are relatively common and typically occur following a fall directly onto the knee. Your patella is a “sesamoid” bone meaning that it is found within a tendon, in this case the quadriceps tendon. The patella is vitally important to normal quadriceps function and hence fractures can be terribly debilitating. Some people are born with what is known as a “bipartite” patella as a result of failure of normal ossification during development. These patients are functionally normal but it is important to differentiate these patients from those with an acute fracture.

Treatment

Patients with patella fractures are typically assessed initially by a physician in the emergency department. Occasionally, patients with patella fractures may present with “open” injuries meaning that the fractured bone is open to the environment. In this case, it is important to administer IV antibiotics and ensure your tetanus prophylaxis is up to date as soon as possible. Once the diagnosis of a patella fracture has been made, you will be assessed by an orthopaedic surgeon to decide on the best course of treatment going forward. Broadly speaking, there are two options for treatment:

  1. Non-Operative Treatment: There are certain situations in which it may be appropriate to treat your patella fracture without surgery. If your fracture has shifted only minimally and you are able to extend your injured knee, you can likely be treated with a functional brace.