Comminuted Displaced Patella Fracture - UK Experience

[CariUK]

I live in the UK and have been reading this forum for 7 weeks since my accident on 27 November 2011. From what I've read here there are some similarities and some differences in the approach to treatment and rehab so I thought I share my story for members to compare with.

I twisted my left ankle on the edge of a low step and fell down onto my right knee cap. It broke into four pieces and the fracture was displaced so I had surgery the following day to pin and wire it back together. I was put in a full cylinder cast for 2 weeks. I was allowed to walk partially weight bearing with crutches from day after my surgery. Walking was uncomfortable but not particularly painful. In fact I didn't experience too much pain overall, but I kept topping up with my range of prescribed painkillers (paracetamol, ibuprofen AND codeine) every six hours, so didn't really give it chance to become noticeable. I was Xrayed after 2 weeks when the cast and staples were removed and then put into a velcro splint. My worse problem mobility wise has been getting my leg from the bed/couch to the floor as I was unable to do a leg lift type of movement. So I've been stuck where I'm put until someone comes to lift my leg up and down for me. I commenced physio therapy after 3 weeks of being in the splint (5 weeks post op). This was just a few quad squeezes and ankle stretches. A week later my physio started me bending my knee with some supported heel slides, but range was almost nil at this time. My quads were still very atrophied and my physio didn't feel they were strong enough to support me yet to try walking without the splint. Last week, 6 weeks post op) I had another Xray which revealed that the fracture had now healed. The doctor said I could ditch the splint now and just use a tubey grip bandage for support. I managed to persuade him to let me keep the splint to get home in as I struggle to get into my car and the walk into the house is a nightmare. Since then, I have left the splint off whilst sitting and lying down and have increased the frequency of my physio exercises at home lots. I haven't tried walking without the splint on yet, partly because I'm terrified of it, and partly because I prefer to check with my physio that my quads are ok to do this first. I am seeing her again tomorrow and hope she will see some improvement in strength and show me how to get on my feet and walk again! I think I would feel more confident if I could use a smaller knee support or something that would hold my knee from giving way whilst allowing a little movement at the same time. I haven't slept without the splint yet, but hope to try that tonight. Again, its the fear of bending or jolting my knee suddenly in my sleep that's stopping me from having a go. Yep, my confidence is in bits and I think until I get over some of my fears my progress will continue to be slow.

Its good to read forums like this and know that I'm not alone, keeping in mind that everyone is different and treatments and progress will depend on the individual and their particular injury and situation.

[MSD]

I had a tpf injury rather than a patella, but I was given a hinged support where I could "dial in" the range of motion allowed. Maybe that would be a good way to get started? The longer you wait with walking, the harder it will be, so you need to get started somehow or other.

Mark

[CariUK]

Thanks Mark. I have seen the type of hinge support that you mentioned and wondered if that would help. I've just had a call from the physio department and my appointment has been postponed until next week. I can't wait another week before doing something so it looks as though I'm on my own with it. Going to try standing and taking a couple of steps later and will see how that goes. Definitely considering buying myself a support to use though, I think that will help psychologically if nothing else. 

[smileyshaz]

Hi, like Mark I had a tpf (horseriding in october last year) and I was also given a hinged splint (after they took the full leg cast off)  mine was a Donjoy TROM, you can get them on ebay if you can't get one from the hospital.

My biggest tip to you would be to do as many of those quad exercises as you can fit into a day, I used to sit watching tv (not a lot else to do at the start of the healing process) and everytime the adverts started I would start my "quad clenching"   When they first took the cast off I couldn't do a straight leg lift, with a day or two of quad exercises I could!  My physio has said that as long as I can straight leg lift then my quads are strong enough to support weight whilst i'm standing (not full weight initially)

My physio took my brace away from me, I asked if I could keep it (just for those days when you feel too weak/wobbly/scared) but she wouldn't let me - proper physioterrorist she is!    Seriously although it's really scary the only way you can get better from this kind of injury is to exercise, exercise, exercise (without overdoing it of course) if you don't use the muscles they just disappear - really fast!
Take care, Shaz

[Rollerblader]

Cari,

Hi, sorry to hear your situation.  It sounds like you are really struggling.  I had a similar experience with a broken patella and my leg was very stiff.  I was FWB from the beginning and my OS gave me a hinged splint that was opened up fully at 16 days post op, however, my knee was very swollen and stiff.  He told me to work on bending at 16 days post op.  At my next follow up appt 7 weeks post op, I was only about 35-45 ROM.  He couldn't believe it and I was scheduled for a manipulation under anethesia which was "not fun"  It did however turn out with a very posative outcome. 

A few things you need to do: 

Let your leg hang off the bed or sofa.  Don't be scared, just let the weight of the leg bend your knee.  It may not do much at first, but you need to do this or you are going to have a very difficult recovery.  Once you get used to it try to use your other foot to push your foot down to bend you knee.  Place your good foot on top of your bad leg foot.

Once you get comfortable with that place your foot on the floor and push your body towards your foot to try to force your knee to bend.  You need to do this as much as possible to try to get your leg to bend. 

I used my good leg and would put my good foot under my bad leg angle and lift my foot up and down to get on and off the sofa or couch. 

I went home from the hospital with a walker and I used it off and on until I was able to drive.  My PT did not want me to limp, so she told me to use my walker until I could walk without a limp.  It was a pain to take out, but it really helped with balancing and getting around.  I think it would be good for you to get one.  They are much cheaper than a hinged splint.

If you can truly hardly bend your leg, you've got to work hard and get your knee bending.  If your bone is healed there should be nothing holding you back.  The longer you wait, the more likely the scar tissue will harden and you will have a harder time bending and it is more likely your OS will threaten or schedule you for a MUA.  I hate to be so blunt, but I wish I'd had more direction on my bending than I got from my OS.  I didn't find this website until I was 5 1/2 weeks post op and I was afraid.  Recovering from a broken patella is a lot of work.  Some people get their ROM back quickly and some really struggle and have issues with scar tissue.

Keep a posative attitude and keep working at it.  Be confident, you can do it.

Take Care,

RB

[CariUK]

Thanks for your replies. Yesterday was a bit of a low point, I was disappointed not being able to see the physio for another week and also, disheartened by the fact that my knee seemed to have stiffened up even more in protest! I think I may have pushed it a little too hard in my exercises the day before as it was also quite sore again. So I just plodded on with the quads and heel slides, just as far as I could to stop it from locking up completely. Today its much better again and it feels back to where it was earlier in the week. My hinge brace has arrived this morning (Sharon, its similar to the one you told me about) so I'm going to try standing and walking with that later. I can set it at various points from 0-90 degrees flexion to begin with to see how it goes. I think I have somewhere between 20-30 ROM at the moment, so I'll start with that to get used to walking with the new brace and move up in a few days. The hinge can be removed and it is also quite strong and supportive without that, so hopefully I will be able to progress to that in time.

I'm doing the quad squeezes and heel slides every hour - I set the stop watch on my phone to remind me! I find the quad sets quite tricky as I really have to focus to make sure I'm clenching the right muscles, my butt seems more willing to clench than anything else!! The best way I find is to put something under my knee and focus on pushing down on that and holding for 5-10 seconds. It helps me to focus on the right area. I wondered if anyone has suggestions for how to make sure the right muscles are being worked?

Rollerblader - thanks for your suggestions! The idea of hanging my leg off the bed without support terrified me at first, but when I read it again and thought about it, it makes sense. Will certainly give it a try. When I sit with my leg off the sofa it just wants to stick out straight in front of me, but I am able to raise my knee slightly in that position by flexing my ankle towards me to just work it a little. I've tried to do some heel slides like that too but at the moment they're not really working. I've also tried using my other leg to hook my bad leg down to the floor, but am useless at that too!

Now that my "bad day" yesterday is over with I'm feeling much more positive again, and determined to have a go at the things suggested here. I certainly don't want to be faced with the threat of MUA, I think I would turn into a wreck at the thought of it!

Thanks again for your input everyone, it really is great to hear from people who have been through this or similar situations and know what I'm going through ... I think other people tend to underestimate just how much hard work recovery from a knee injury really is 

[Rollerblader]

Hi Cari,

It sounds like you are working really hard and very similar in some ways to what I experienced as far as ROM and stiffness.  I didn't start hanging my leg off until my OS scheduled me for a MUA and I think I gained 10 ROM in the week before my MUA.  I just didn't realize how far behind I was because I wasn't in PT yet.  I could barely do a heel slide.  My OS didn't even give me any excercises, just told me to work on bending.

Once you get comfortable hanging you leg, you should hang some weight on it, maybe your purse.  Also put on a rubbery sole shoe sit in a chair with your foot on the ground and push you knee forward. 

I forgot to mention the recumbent static bike.  It was my best friend.  I didn't get it until the day before my MUA.  The seat is comfortable and you can sit and watch tv or read.  You just go around as far as you can go and hold it, then go the opposite direction till it hurts and hold it.  Do this for about 5-8 min for 5 times a day.  It's kind of like a CPM machine.  My PT had me doing this.

Also hot baths with Epsom salts help loosen the tightness.

Wishing you well!!  Keep us updated.

Take care,

RB

[CariUK]

Rollerblader - hanging-leg-off-bed is the business! What a difference it makes! I have just sat there for half an hour, edging further bit by bit and by the time I'd finished I could bend my knee further and without assistance too! I tried it yesterday but didn't hang that far off, and I didn't check the ROM when I'd finished. Today my leg has been particularly stiff during exercises so I decided to "hang" a bit further to try to loosen it a bit ... and it obviously worked. Thanks for this tip, it really makes so much sense to use gravity to help do the work.

Update re hinge brace - the first attempt walking with the new brace was almost shameful, I was so scared I tensed up so much my good leg would hardly move, never mind my bad one! I held my bad leg so stiff that it jolted backwards when I took a step with my good leg and although it didn't hurt it shocked me and I gave up! The next day I tried again and focused on relaxing this time. I let my knee bend slightly, as far as the locked brace allowed and this helped to prevent the backwards jolt so that I could actually move. I walked around the living room a few times singing nursery rhymes to take my mind off the possibility of falling and by the time I made it back to my downstairs bedroom I felt as though I had just run a marathon. But the bottom line was, I made it, and now all I need to do before I unlock the splint is practice, practice, practice .....

[floridanightingale]

Keep up the good work Cari! You are in a difficult and slow time of the recovery process right now, so hang in there.  It will only keep getting better. 

[CariUK]

After a week of rubbish attempts at walking without my splint i finally got to see my physio. She confirmed that there is a slow progress with my ROM (now at 40) but was concerned to see how wobbly I was on my crutches. The problem was that I was so scared of my leg giving way, I was trying to compensate with the rest of my body and holding myself way too stiff to make any decent attempt at walking.

She decided to try me out walking between parallel bar in the gym, which I managed surprisingly well, without panicking too! So from there she suggested i tried a walking frame until I build my confidence up a little more. This worked great and I was even able to walk with my brace let out to 90% ... I'd still been trying to walk with it locked until then!

I've been using the walker at home for 4 days now and have progressed from a stooping dithering wreck, to being confident enough to stand up straight and tall and take "real" steps, with one foot in front of the other, instead of mini shuffle steps. Today I actually sat at the table to eat a meal instead of having it on my lap, first time in 2 months! Best achievement of the week though has to be making it to the loo on my own ... time to start regaining some dignity at last!

The exercises are still very hard work and a few extras have been added. Now that I can sit with my leg to the floor I can do some heel slides from that position, and I also have a bolster for under my leg to try short leg raises when I sitting on my bed. I'm still not able to get my leg from bed/sofa to floor and vice versa without some help, but I guess as my confidence continues to build I will experiment with some ways to achieve this.

What a difference a week makes ... this time last week i was ready to give up and feeling very sorry for myself, ... this week I can see some of the light at the end of the tunnel ...even if it is a long way off yet.

Thanks again for your support, this site is invaluable!

[CariUK]

Link to 14 week update and MUA discussion.....

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=58986.0