OR2.10 | Patella and Peri-knee Fracture Management — Summary & Reflection

KEY TAKEAWAYS

Peri-knee fractures — patellar, distal femur, and proximal tibia — share common themes of high-energy mechanism, extensor mechanism disruption, and proximity to the popliteal artery and peroneal nerve. Patellar fractures are classified by pattern (transverse, comminuted, vertical) and managed non-operatively if the gap is <3 mm and active extension is preserved; displaced fractures require operative fixation with tension band wiring. Distal femur fractures follow the AO/OTA A/B/C classification; type C (bicondylar) fractures require articular reconstruction before shaft fixation and are at high risk for popliteal artery injury. Tibial plateau fractures follow Schatzker I–VI; Types IV–VI are high-energy and carry the greatest risk for compartment syndrome and neurovascular compromise. Compartment syndrome is diagnosed clinically: pain out of proportion + pain on passive stretch are the earliest signs; a present pulse does NOT exclude the diagnosis; ΔP <30 mmHg mandates four-compartment fasciotomy. All peri-knee fractures require thorough neurovascular documentation on arrival and reassessment every 1–2 hours.

REFLECT

A patient comes to the casualty at 2 AM with a tibial plateau fracture after falling from a two-wheeler. Initial neurovascular exam is normal. At 5 AM, the nursing staff notes he is pressing the call bell every few minutes complaining of increasing pain 'worse than on arrival'. The duty intern reassures him that 'it is normal to hurt after a fracture' and increases the analgesic dose. By 8 AM the surgical registrar finds a tense anterior compartment, absent toe extension, and numb first web space. Consider: at what point did the window for fasciotomy close? What are the likely long-term consequences of the delayed diagnosis? As the duty intern, what specific assessment should have been performed at 5 AM, and what findings would have mandated an immediate senior call?