The patella, an important component of the knee joint, acts as a fulcrum during knee extension movements, helping the knee to be more comfortable in exerting maximum force. Because of its importance and its location at the knee joint, it can be a vulnerable link in a variety of direct violence injuries, and fractures can occur in various forms when the quadriceps muscle is overstretched. Zheng Lu, Center for Rehabilitation Medicine, Peking University Third Hospital
This article does not discuss the specific causes of fractures and the specific methods of post-injury management, but only suggests rehabilitation aspects for this type of injury. The specific exercises mentioned in this article can be found in my other articles, where they are described in detail.
In general, there are two types of post-injury treatment: surgical and conservative. The principles of post-injury rehabilitation exercises are completely different for the two types of treatment methods.
I. Principles of postoperative rehabilitation after internal fixation of patella fracture
For patellar fracture, the common surgical methods are: Kirschner pin + wire reduction fixation method, hollow screw + wire reduction fixation method, patellar claw fixation method, braided wire “purse” suture method. Depending on the fixation method, the principles of postoperative exercises are also slightly different.
The contents of postoperative exercises are mainly divided into several categories: extension function exercises, antithrombotic exercises, flexion function exercises, strength exercises, etc.
1.Extension function
From the moment you get off the operating table, the lower limb should be placed in the hyperextended position to ensure that the extension function is not hindered. Postoperative extension exercises should always be a priority until the flexion and extension angles are normalized.
2.Ankle pump
After the postoperative anesthesia subsides, you should try to do as much as possible, flex and extend the ankle joint slowly at the maximum, you should try to do at least 5 minutes every hour, massage the blood vessels of the lower limb with the squeezing pressure generated by the muscle contraction itself to prevent thrombosis, this way is not only for middle-aged and elderly patients, young patients should also pay enough attention.
3.Flexion function
Flexion exercises should be started at most 2-3 days after surgery, and there is no need for any additional external fixation after surgery. The first step is to loosen the patella and to push the patella in a scientific way to maintain the normal range of motion as much as possible without touching the internal fixation and the wound (which may increase the pain, but usually does not lead to loosening of the fixation). The next step is to practice the flexion angle in a step-by-step manner, following the methods and principles described in the article. There is no limit to the progress, and the maximum range of motion is achieved gradually with a scientific training volume within the tolerable range of pain. Among the several common surgical methods described in the previous paragraphs, the first few metal fixation methods can make the patella more reliable in the early postoperative period and can withstand large pulling stimuli, so the general exercises are completely safe. The last type of “purse-string” suture, because the strength of the braided wire is not as strong as that of the metal, more emphasis is placed on controlling the pain intensity at the beginning of the early exercises, strictly within the medium intensity, and mild pain can ensure safety. (During practice, it is not possible to visually monitor the patella for safety, and this is where pain is the most reliable measure. Usually in early practice, the pain of the skin incision is very strong, at this time the pain of the tissues around the patella is usually below the intensity of the pain of the incision, and at this time the patella itself is very little stimulated by the pulling of the surrounding tissues, so the pain of the incision is used to control the safety of the patella, although it is not direct enough, but it is completely reliable)
4, the best rehabilitation period delay
If the best rehabilitation period is unfortunately delayed and serious joint flexion dysfunction occurs, there is no shortcut but to follow the various methods introduced in my top article on this website. However, if there is a strong irritation of the subcutaneous tissue by the internal fixation, sometimes it may not be necessary to practice hard to the end. In other words, if the pain is mainly caused by the internal fixation, the goal of restoring the flexion angle can be set at 120 degrees of flexibility, so there is no need to endure severe pain and practice to the end to prevent additional injuries. The remaining dysfunction will be further improved after the removal of the internal fixation, which is the most economical choice.
5.Strength exercise
Strength exercises are also an important guarantee of joint stability. In the early postoperative period and for a long time afterwards, due to the presence of various metal internal fixations, the process of strength exercises may inevitably cause strong pain due to the contraction of the knee extension device stimulating the soft tissues around the fixation, if this pain occurs, it is not possible to force the exercises, and it is necessary to prevent the sharp internal fixation from piercing the subcutaneous tissue. At this point, one can only hope that the fracture will heal as soon as possible and that the internal fixation will be removed as soon as possible, followed by strength strengthening exercises.
Specific exercises.
This is not only to maintain a certain degree of strength, but also to enable the patella to move as much as possible in its normal trajectory by pulling on the patella, which in turn pulls on the patellar tendon to prevent patellar adhesion and patellar tendon contracture.
Straight leg raise: in a fully straightened position without pain, lift the entire thigh until it is about 15 degrees from horizontal, stop until exhaustion, slowly lower it and repeat several times, 2-3 sets per day. The first few metal fixation methods can be started early in the postoperative period because of their reliable fixation and can be tried to adapt even if they are slightly painful. In the case of the ruffled suture procedure, it depends on the level of their surgery when to start lifting the leg.
Other strength exercises can be continued after a certain period of time under the guidance of the pain-free principle, as described in the article.
Postoperative exercise considerations
In the postoperative period, bed rest may occur for a few days, and when you get out of bed in the early days, you may experience vascular swelling: swelling and pain in the calf, purple skin, or even dizziness due to sudden filling of the blood vessels causing transient ischemia in the brain.
If there is any other injury to the joint, the affected limb can be weighted down and gradually taken off the crutches as the fracture heals and function is restored. But should not take off the crutch as a stage victory to congratulate themselves, when completely off the crutch still depends on the specific recovery level.
Second, the patella fracture conservative treatment rehabilitation principles
The above-mentioned are some simple rehabilitation programs after fracture fixation, and the following is a brief description of the rehabilitation principles of conservative treatment of patella fracture. Conservative treatment, as the name implies, is not through surgical means, through strict braking, relying on the patella’s own healing ability to achieve the final healing, only applicable to the patella fracture without any displacement of the broken end of the case. If the orthopaedic surgeon determines that the fracture is in a reliable position with no displacement, it can be fixed directly in a cast or straight splint, usually with weekly radiographs for up to 1 month after fixation to monitor the stability of the fracture. During this period, the quadriceps should be braked as quietly as possible, and only very gentle patellar release exercises can be performed: pushing on the upper and lower poles of the patella with both hands and applying pressure to the broken end in a compressed state to release the patella, usually in each direction to ensure movement and avoid stubborn patellar adhesions, without excessive pushing to prevent separation of the broken end. If there is a very experienced rehabilitation therapist around or if you have a strong ability to control the strength, you can start small-scale joint flexion exercises 4-6 weeks after the injury as appropriate, when the fracture is only in the fibrous healing phase, you can take advantage of the poor intensity of this exercise, but it should be emphasized that this process is more dangerous and the amplitude should be strictly controlled. avoiding the development of stubborn adhesions. In the post-injury period, exercises for extension are still not limited in any way, and it is important to ensure that the joint is in extension when normal flexion cannot be guaranteed. Other exercises can be set up as described in various articles on this website.