Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with upper pole patella fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
ALM, 45 year old man with recent history of upper pole
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
Intense pain and stiffness in right knee, increased degree of gait dysfunction
Post surgical (fixation method of upper pole patellar fracture) rehabilitation status

ANAMNESIS (history)
Our 45 year old man suffered, 3 weeks ago, a right knee injury upper pole right patella fracture - and has
undergone surgical treatment.
He has a previous history of depressive anxiety syndrome in treatment (Alprazolam 0,5 mg/a day and Escitalopram
20 mg/a day).
He performed mainly sitting activities in his professional life. In his personal life he describes himself like a
sedentary person. He is also a smoker (up to 20 cigarettes a day), he started at age 17.
His history reveals a mild impact of the knee with a blunt object, 3 weeks ago. After injury, ALM could not walk,
was unable to perform a straight leg raise and accused severe pain and swelling of his right knee.
The surgical treatment was performed after 3 weeks - open reduction and internal fixation, using circumferential
cerclage wiring and 2 screws for fixation of the upper pole of the right patella. Sutures were removed after 14 days.
ALM is presenting in our department after he removed the knee cast, at 6 weeks after intervention, to perform and to
learn about the rehabilitation measures used to regain his gait and his independence in daily life.
Personal data
Questions (for assessment detailed answers see next page)

1. Which is the mechanism of injury of the patella in our patient?

a. An indirect blow to the patella
b. A direct blow to the patella
c. A fall with a tensile force
R=b

2. Which represents contributing factors of occurrence of patellar fracture?

a. The patient is a sedentary person
b. The patients smokes up to 20 cigarettes a day
c. The patella location
R=c

3. Can the mental status of our patient contribute to the way that he reacts to pain?
a. No
b. Yes
c. It is indifferent
R=b
 Personal data
Questions` answers

1. Which is the mechanism of injury of 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.

2. Which represents contributing factors of occurrence of patellar fracture?

The patellofemoral joint is exposed to the highest contact stress of any weight bearing joint. The patella is prone to
injury because of its anterior location and thin overlying soft tissue envelope.

3. Can the mental status of our patient contribute to the way that he reacts to pain?
The mental status can influence the way a person perceives pain intensity. Depression and pain share biological
pathways and neurotransmitters, which has implications for the treatment of both concurrently.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

ALM is 1.75 m height and a weight of 90 kg, BMI= 29.3 kg/m2.

Depressive facies, mentally influenced status.
Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam.
Vertebral spine lumbar scoliotic attitude
Upper limb joints ROM and muscle strength with normal values in accordance with his age.
Lower limb joints. Skin in right knee anterior region with post intervention scars, mild swollen aspect, with hardware
proeminence. The patient mentions mild to intense pain in the right peri-patellar region that is aggravated by
palpation and passive and active mobilizations. Pain along the right calf. Right thigh atrophy- 2 cm, was noted.
Right AROM is from 10 to 45 degrees and left AROM is from 0 to 120 degrees. Right knee crepitus palpable with
ROM (active and passive). MMT values are +4 for great gluteus, +4 for hip stable muscles, +4 for left quadriceps
and +3 for right quadriceps, 3+ for and 4+ for right / left hamstrings strength.
Gait is possible with cane in left hand (partial weight bearing gait on the right lower extremity) on short distances. The
patient complains of intense right knee pain when he moves the right feet, gets up from bed/ chair and walks.
Neurovascular status of lower limbs are intact.
Vital signs: temperature 36.7C, blood pressure 130/60 mmHg, rhythmic pulse 68 b/min, 25 respirations / min.
Clinical data
Questions (for assessment detailed answers see next page)

1. Which are the minimal range of motion values for normal ambulation?
a. 120 degrees in flexion
b. 90 degrees in flexion and complete extension
c. 75 degrees in flexion and complete extension
R=b

2. Why are the values of AROM lower in our patient?

a. The patient BMI is 29.3 kg/m2
b. Due to surgical technique used
c. Due to post surgery immobilization
R = a, c

3. Why are the values of the MMT (manual muscle testing) lower than normal for all muscles of both lower limbs?
a. Voluntary activation deficits, during immobilization, are the source of muscular atrophy
b. Because the patient is a sedentary person
c. Because the patient is a smoker
R = a, b
 Clinical data
Questions` answers

1. Which are the minimal range of motion values for normal ambulation?
For a normal ambulation on any type of surface, after suffering a patellar fracture a patient must have minimal 90
degrees in flexion and complete extension.

2. Why are the values of AROM low in our patient?

AROM values are lower in our patient due to post surgery immobilization. The treatment of the upper pole patella
fracture required a cast immobilization for 6 weeks, causing the knee stiffness. The patient is overweight, having
a BMI of 29.3 kg/m2 , higher BMI is associated with lower knee flexion.

3. Why are the values of the MMT (manual muscle testing) lower than normal for all muscles of both lower
limbs?
Because the treatment of upper pole patellar fracture required keeping his leg immobilized in a cast for 6 weeks,
the thigh muscles became weak. An inactive (sedentary) lifestyle can cause muscle weakness and fatigue.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Imagistic data

X ray of the right knee of our patient before and after surgical intervention:
standard antero-posterior (AP)
lateral x-ray - upper pole right patella fracture was aligned and fixed with stainless steel wires and two screws (tension
band wiring).
Imagistic data
Questions (for assessment detailed answers see next page)

1. The imagistic findings of X-ray knee can suggest the type of patellar fracture ?
a. Yes
b. No
c. It is an incorrect knee X ray
R=a

2. What kind of patellar fracture does our patient have?

a. Stable fracture
b. Displaced fracture
c. Cominutive fracture
R= b, c

3. Is ultrasound examination useful for our patient?

a. Yes
b. No
c. It is indifferent
d. R = a
Imagistic data
Questions` answers

1. The imagistic findings of X-ray knee can suggest the type of patellar fracture ?
The lateral x-ray and Merchant views help in evaluating the amount and location of comminution. The lateral X
ray and Merchant view after surgical intervention are performed to show the degenerative changes of the
patellofemoral joint.

2. What kind of patellar fracture does our patient have?

In a displaced fracture, the broken ends of the bone are separated and do not line up correctly. The normally
smooth joint surface may also be disrupted. This type of fracture often requires surgery to put the pieces of bone
back together. In cominutive fracture, the bone shatters into three or more pieces. Depending on the specific
pattern of the fracture, a cominutive fracture may be either stable or unstable.

3. Is ultrasound examination useful for our patient?

Associated injuries to nearby tendons and ligaments may need to be evaluated by ultrasound, previous surgical
internvention. While magnetic resonance imaging has traditionally been the reference imaging standard for knee
tendon and ligament injuries, ultrasound also has a high sensitivity for the diagnosis of these injuries and is
cheaper and faster to perform.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Functional data

We assessed, 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 activities limitation and participation restriction
VAS = 9 before, 5 after rehabilitation program;
6 Minute Walk, with cane = 200 meters before; 290 meters after rehabilitation program;
Timed Up and Go, with cane = 31 seconds before; 23 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; 23 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) = 59 before rehabilitation; 67 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. The activity limitations may be explained by?

a. The neuromuscular status
b. The long period of time between trauma and surgery (3 weeks)
c. The presence of pain
R = a, c

2. Do the scores, obtained after applying the rehabilitation program, of the scales Modified scale of Bostman et al.
and Knee Society Clinical Rating Scale (KSCRS) correlate with gait improvement ?
a. Yes
b. No
c. The scores obtained from the 2 scales can not be compared
R=a

3. How can we explain the high values of the Visual Analogue Scale for pain ?
a. There are no explanations
b. The pain was not improved by the surgical intervention
c. The comorbidities of the patient influence the pain status
R=c
Functional data
Questions` answers

1. The activity limitations may be explained by?

The neuromuscular poor status due to immobilization and surgery, the increased pain perceived by the patient
explain the disturbance appeared in carrying out the daily life activities. Patients' recovering from upper pole
patellar fracture need at least 2 3 months for regaining normal neuromuscular status necessary for the
development of the daily activities.

2. Do the scores, obtained after applying the rehabilitation program, of the scales Modified scale of Bostman et
al. and Knee Society Clinical Rating Scale (KSCRS) correlate with gait improvement ?
Both scales contain items for various daily activities such as ambulation, rising from chair and descending or
ascending stairs, in which the lower limb, the knee especially, is responsible for gait.

3. How can we explain the high values of the Visual Analogue Scale for pain ?
Due to his depressive anxiety syndrome and the stress caused by the surgery and being immobilized for a long
period (6 weeks), increased the way that the pain is perceived by the patient.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

1. Comminuted upper pole right patellar fracture (operated 6 weeks ago, combined cerclage and tension band
wiring technique), with minimal disable of the extensor mechanism.
2. Depressive anxiety syndrome.
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. Is it important to mention the depressive anxiety syndrome for our patient complete diagnosis? Why?
a. No, it is not an important aspect
b. Yes, because it has an important role in establishing the rehabilitation program goals and methods
c. Yes, but not important for rehabilitation program
R=b

2. What are the clinical arguments for our patient complete diagnosis?
a. Skin in right knee anterior region with post intervention scars
b. Knee pain that is made worse with activity and is accompanied by stifness and abnormal gait
c. Hardware prominence
R = b, c

3. Which of following complications is more unlikely to occur in the future in our patient?
a. Chronic knee pain
b. Posttraumatic Arthritis
c. Avascular necrosis of the patella
R=c
 Complete diagnosis
Questions` answers

1. Is it important to mention the depressive anxiety syndrome for our patient complete diagnosis? Why?
Rehabilitation programs have to take into account all the comorbidities of the patient in order to have the best
results. In our patients case, beside the therapeutic methods for regaining the knee functionality, means like
pharmacological modalities- anxiolytic drugs, non-pharmacological modalities: psychotherapy- cognitive therapy,
relaxation exercises and electrotherapy such as magnetodiaflux were used in order to improve the mental status of our
patient.

2. What are the clinical arguments for our patient complete diagnosis?
Skin in the right knees anterior region with post intervention scars, mild swollen aspect with hardware
prominence. The initial examination shows our patient has both muscular and structural restrictions. His right
knee flexion ROM was 10 to 45 degrees while sitting, and he complained of pain mild to intense pain in the peri-
patellar region that is aggravated by palpation and passive and active mobilizations as well along the right calf.
The quadriceps strength was right /left 3+/4+ and hamstrings muscle strength was right/left 3+/4+.

3. Which of following complications is more unlikely to occur in the future in our patient?
Avascular necrosis of the patella is the most unlikely complication that can occur in an upper pole patella fracture
because most of the blood supply of the patella comes from the inferior pole.
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, anti-inflammatory drugs, chondroprotective drugs, anxiolytic drugs
non-pharmacological modalities:
- psychotherapy- cognitive therapy,
- educational, dietary and hygienic,
- posture (activity modification), relaxation exercises;
- physical (thermotherapy cryotherapy to control pain and edema; electrotherapy - TENS, laser, NMES,
-magnetodiaflux ) - decreased joint swelling and pain will reduce chances of developing complications during the
rehabilitation process;
- massage classic and special massage (Cyriax massage) of right 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 the right side of the body
b. Because the RP improves the lower limb function
c. Because the RP improves only the knee ROM
R= b

2. The rehabilitation program should take into account improving the mental status of the patient?
a. Yes
b. No
c. It is not important to the functional outcome
R= a

3. It will be useful for our patients outcome to continue the rehabilitation program?
a. It is not important
b. Yes
c. No
R=b
 Rehabilitation program
Questions` answers

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

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. The rehabilitation program should take into account improving the mental status of the patient?
An important aim of the rehabilitation program should be to improve the mental status of the patient in order to
enhance his quality of life and functionality. In our patients case we used means like pharmacological modalities-
anxiolytic drugs, non-pharmacological modalities: psychotherapy- cognitive therapy, relaxation exercises and
electrotherapy such as magnetodiaflux in order to improve the mental status of our patient.

3. It will be useful for our patients outcome to continue the rehabilitation program?
Yes, short term goal 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 goal will be to maintain strength
and stability of the knee. These goals can only be achieved if the rehabilitation program is continued in the next
period of time.