Patellar Fracture

Dr Mohd Syafiq Bin Shahbudin

MB BCh (Alex)
Introduction
Patella is a thick, circular-triangular bone which
articulates with the femur (thigh bone) and
covers and protects the anterior articular
surface of the knee joint
Anterior surface
Posterior surface
Course ,flattened
and rough.
(For quadriceps
tendon attachment)
Distal apex
Origin of patella
ligament
Medial
facet
Lateral facet
Incidence

1% of all fractures
common: 20 to 50 years old.
Men > women
Type of patella fracture
Non displaced
- Tranverse
- Stellate
- Vertical
Displaced

-Tranverse
-Stellate
-Multifragmented
-Polar
-Proximal
-Distal
-Osteochondral


Non Displaced fracture

Transverse pattern (50 80% of cases)

80% occur -> middle to lower 3
rd
of patella
>35% injuries are non displaced
Usually minimal damage -> extensor
mechanism remains intact.

Stellate fracture

- From a direct compressive blow
- Account 30% - 35% of patella fracture
- > 50% of these fracture are nondisplaced
- Due to it injury mechanism, damage to
femoral and patellar articular surfaces can
occur

Longitudinal / marginal vertical

- 12 to 17% of patella fractures
- Marginal -> from direct trauma and involve
lateral facet
- The fracture not seen in standard x-ray view.
axial views are necessary
Displaced fracture
Fracture fragment separation more than 3mm
or an articular incongruity of 2mm or more.
Extensor mechanism disruption with displaced
fracture -> indication for operative repair


52% displaced tranverse -> non comminuted

Some patient may demonstrate displaced
fracture fragments but maintain active
extension of the leg

Comminuted fracture
Unstable fracture.
The bone shatters into pieces
Multifragmented fractures

As a result from high energy injuries -> severe
comminution and wide displacement of
fragment.

+ extensive disruption of extensor mechanism
+ injuries may be open
+associated with other
lower extremities
Injuries.
Open fracture
The skin has been broken and exposes the bone.
Involve much more damage to the surrounding
muscles, tendons, and ligaments.
Higher risk of complication and late healing.
Cause
Patellar fractures are most commonly caused
by a direct blow.

The patella can also be fractured indirectly.
Eg: Quadriceps muscle is contracting but the
knee joint is straightening.
(Eccentric contraction)

Symptoms

The major symptoms of a patellar fracture
include pain and swelling of the knee.

Additional symptoms include:
Bruising
Inability to straighten the knee
Inability to walk

Investigations
History taking
c/o by the patient
Test: Straight leg raise test

- To test the function of the the quadriceps
muscle and its attachment to tibia.
- Disruption of quadriceps, patella tendon or
patella itself lead to inability to perform test.


X-ray






- Differentiate other abnormalities such as
bipartite patella.


Bipartite patella
- A congenital fragmentation or synchondrosis
of the patella as the result of developmental
lack of assimilation of the bone during growth.
- Occurs in approximately 1 % of population.


Characteristic x-ray
features:
- Rounded
- Sclerotic lines rather
than the sharp edges of
a fracture.
Treatment

Non surgical treatment

Indications:

- For undisplaced fractures with intact articular surface.
- Preserved extensor mechanism with maintained active
extension against gravity.
- Retinacula on either side of patella should not be torn.
- There should be minimal displacement of fragments (2-
3mm)
- Minimal disruption of the articular surface (2-3mm)
- Tranverse undisplaced fracture of the patella is an
avulsion fracture
- Should aspirate with occurrence of tense hemoarthrosis.




Management:

Intact extensor function:
-knee immobilizer, rest, ice, analgesia

Diminished extensor function:
- Immobilize, rest, ice, analgesia, Non weight
bearing and proceed with ORIF




- A long leg cast or a knee brace or splint usually
applied in stable fracture of patella.
- To keep fracture bone in proper position
while in healing process.
- Non weight bearing for 6-8 weeks
- Ambulate with crutches during
healing period.

Surgical treatment

Indications:

- Extensor mechanism involvement

- Displaced transverse fracture, either simple or comminuted,
with associated disruption of quadriceps retinacula.

- Patella fractures with compromised overlying skin should
undergo delayed fixation.



Disruption of
quadriceps
retinacula
Cerclage wiring
Indicated in:
- Displaced fracture
- Impaired extensor function.
Cerclage wiring may be used alone or
combination with lag screw.

cerclage wire plaster/ thermoplastic/
cylinder treatment of the leg/ removable
splintage as support

Contraindication:
Polytrauma patient in extremis
Medically unfit for surgery
Local soft-tissue compromise



Advantages
Restoration of extensor function
Early mobilization of knee joint
No plaster, or prolonged splintage

Disadvantages
Caution with knee mobilization is needed, if a
single cerclage wire is used
Secondary displacement
Prominent metalwork after fixation
articular malunion
Risks of open operation


Tension band wiring
Commonly indicated in transverse displaced
patella fracture and also comminuted fracture
of patella.


Technique:

- Reduction of fracture with reduction of clamp
- K-wire is inserted perpendicular to the
fracture
- Figure of 8 tension band wire is applied for
compression of the fracture
These tension band wires convert anterior
distractive forces to compressive forces at the
articular surface
(More flexion of the knee will give more
compression to the articular surface)

Wound Closure:
- Following implant insertion, the extensor
retinaculum is repaired
- The superficial retinaculum must be closed
properly in order to maximize coverage over
the implant.


Post Operative Care:

- Patient is immobilized for 2-3 weeks
- begin prone hang exercises at 2-3 weeks
- crutches are discontinued after 6 weeks
Claw plate
Patellectomy
Partial Patellectomy






Involve distal pole of patella


Smaller fragments are excised
The patella tendon is reattached anteriorly
with sutures
Complications: Suture pull out.

Signs:
- Look for proximal migration of upper patellar
pole on radiography or by absence of palpable
quad tendon repair to inferior pole fragment

- Absence or weakness of quadriceps function

- Inability to palpate the patellar ligament or
detection of gap between ligament and pole.
Total Patellectomy






Total patellectomy is reserved for severe
multifragmentary fractures (comminuted and
displaced) of the patella, which may be
combined with significant osteochondral
damage to the patellofemoral joint



Bone fragments are excise before
reattachment to patella tendon
Complication of patella fracture
Infection
Loss of reduction
Failure of internal fixation
Malunion
Quadriceps weakness
Extensor lag
Traumatic arthritis of patellofemoral joint