Orthopaedic Emergencies 305
Injuries to the Lower Femur, Knee and Upper Tibia
Supracondylar and condylar fractures of the femur
DIAGNOSIS AND MANAGEMENT
1 These injuries are caused by direct trauma or a fall in an elderly person with
osteoporotic bones.
2 A condylar fracture often causes a tense haemarthrosis, and rarely the
popliteal artery is damaged by a supracondylar fracture.
3 Give the patient analgesics and refer immediately to the orthopaedic team for
aspiration of any tense haemarthrosis and operative fixation in certain cases.
Fractures of the patella and injury to the quadriceps apparatus
DIAGNOSIS
1 Damage is caused by direct trauma as in a traffic crash or fall, or by indirect
force from violent quadriceps contraction.
2 Patients typically present with acute knee pain, swelling, bruising and loss of
function. There is inability to extend the knee in most cases, associated with
the local pain.
3 Remember to always examine the shaft of femur and the hip at the same time.
4 There may be a palpable defect in the suprapatellar region if the quadriceps
mechanism is torn, with a low-lying patella.
5 Request an X-ray to demonstrate the patella fracture.
(i) Confusion may arise from a congenital bipartite or tripartite
patella, although these are often bilateral, unlike a fracture, so if
in doubt X-ray the other knee.
(ii) Look for a lipohaemarthrosis causing a horizontal line fluid level
on the lateral X-ray view of the knee, which is a useful indicator
of an intra-articular fracture.
(iii) Request a ‘skyline’ X-ray view in subtle patellar fractures.
(iv) Consider a CT scan when a suspected fracture is not visible on
plain X-ray.
MANAGEMENT
1 Refer distracted or comminuted patella fractures, and patients with disrup-
tion of the knee extensor mechanism directly to the orthopaedic team.
2 Otherwise, place the leg in a padded plaster cylinder from the thigh to the
ankle if there is a stable, undisplaced fracture of the patella, and refer the
patient to the next fracture clinic.
