Fractures of The Patella:: - Discussion

Fractures of the Patella:
- See:
- Anatomy
- Biomechanics
- Classification of Patellar Fractures
- Osteochondral Frx
- Pediatric Patellar Avulsion Fractures
- Discussion:
- classification of patellar fractures
- mechanism:
- direct trauma frequently produces stellate frx pattern and may be assoc w/
compromised anterior skin and subcutaneous tissue;
- Radiographs:
- AP view:
- patella may be difficult to see on AP view;
- peripheral fractures (osteochondral frx) may be confused w/ bipartite patella;
- radiographs of contralateral knee can help in this differentiation because bipartite
patella rarely occurs unilaterally;
- lateral view:
- best reveals the comminution of frx or separation of fragments;
- w/ separation of the fracture more than 3-4 mm may is usually associated w/
retinacular disruption and loss of active extension;
- w/ patellar comminution at the inferior pole, consider partial patellectomy;
- some vertical frxs are best seen on tangential or Merchant radiographs;
- CT or other advanced imaging techniques are usually unnecessary;
- bone scans have been used to help to identify stress fractures;
- Non Operative Rx:

- indications:
- for undisplaced frxs w/ intact articular surface;
- preserved extensor mechanism w/ maintained active extension against gravity;
- retinacula on either side of patella should not be torn, as evidenced by pt's ability
to maintain knee extended against gravity;
- there should be minimal displacement of fragments (2-3 mm)
- minimal disruption of the articular surface (2-3 mm)
- transverse undisplaced fracture of the patella is an avulsion frx;
- should aspirate with occurrence of tense hemotoma;
- Operative Treatment Options:

- indications:
- extensor mechanism is avulsed from the patella;
- displaced transverse fracture, either simple or comminuted, w/ associatted disruption
of quadriceps retinacula;
- patellar frxs w/ compromised overlying skin should undergo delayed fixation;
- treatment options:
- tension band technique:
- partial patellectomy
- consider advancement of the fibers of the vastus medialis over the repair site;
- reenforment of the repair may be achieved by turning down half the thickness of
the rectus tendon;
- screw fixation:
- Post Op Care:
- joint in immobilized in 40-60 deg flexion for 2-3 days & extremity is elevated;
- on POD 4, begin ROM exercises;
- ROM is required to enhance cartilage healing and for physiologic frx compression
thru figure of 8 apparatus;
- consider using prone hangs: patient lies in the prone position and flexes and extends
the knee;
- these exercises avoid active knee extension and avoid excessive stress at the
fracture site;
- wt bearing is allowed at 4-6 wks;
- Complications of Patella Fracture:

- infection (which communicates with the knee joint)
- loss of reduction
- failure of internal fixation
- avascular necrosis:
- patella has two main areas of blood supply (see blood supply)
- one penetrates middle third of anterior surface, & other enters at lower pole behind
patellar ligament;
- delayed union
- non union
- delayed union is recognized by failure of trabeculae to bridge between patellar frags,
as noted on x-rays 2 mo after injury;
- typically frxs will have > 2 mm of gap between fracture fragments;
- non union can be diagnosed after 3-4 months of treatment;
- occassionally elderly patients tolerate nonunions well, however, younger patients do
not tolerate nonunion;
- nonunion is most common in transverse frxs, but may be seen in comminuted frxs
that have failed to acheive internal fixation;
- partial or total patellectomy is preferred in most pts w/ non union, esp if disuse
osteoporosis or AVN is present
- malunion
- chondromalacia
- traumatic arthritis of the patellofemoral joint
- quadriceps weakness
- extensor lag
- avascular necrosis of the polar fragments
- arthrofibrosis of the knee joint;
Fracture of the patella treated by open reduction and external compressive skeletal fixation.
Efficacy of various forms of fixation of transverse fractures of the patella.
Indications and results of nonoperative treatment of patellar fractures.
Transverse fractures of the patella.
Scapinelli R: Blood supply of the human patella. J Bone Joint Surg

1967;49B:563-570.
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Classification of Patellar Fractures
- Discussion:
- classified according to both the mechanism of injury and morphology.
- two major mechanisms of injury:
- direct and indirect trauma;
- Direction Trauma:
- patella may be fractured by direct blow during fall onto
knee or when it hits dashboard in an MVA;
- because of small amount of prepatellar soft tissue &
direct contact with the distal aspect of femur posteriorly,
nearly all of force of direct blow is delivered to patella;
- such direct trauma frequently causes considerable comminution, but
often there is little displacement of frx fragments.
- w/ certainty, articular cartilage of contact area is damaged by this
mechanism of injury.
- Indirection Trauma:
- indirect trauma that causes fractures can be due to jumping or,
more frequently, to unexpectedly rapid flexion of the knee against
fully contracted quadriceps.
- natural anatomy and biomechanics of knee, as previously described,
create tension, three-point bending, and compressive strains in
patella that exceed values sufficient to cause a fracture.
- frx resulting from indirect injury tend to be < comminuted than those
from direct trauma, but they are displaced and are often transverse.
- articular cartilage is less damaged than with direct trauma.
- Combined Mechanism:
- most patellar fractures occur as a result of a combination of direct
and indirect trauma.
- rarely does anyone hit a dashboard w/ relaxed quadriceps.
- in addition, Thompson et al clearly demonstrated that direct blows to
patella of magnitudes < those sufficient to cause patellar frx
predictably damage contacting articular cartilage of patella & femur
& that early biochemical and histological changes after such blows
are consistent with the initiation of post-traumatic osteoarthrosis.
- Osteochondral Frx:
- Transverse Frx:
- fractures that occur in medial-lateral direction are called transverse.
- these fractures are usually in central or distal third of the patella.
- Vertical Fractures:
- are in superiorinferior direction, and they are rare.
- frx of edge of the patella that do not extend across patella and that
are not associated with disruption of extensor mechanism are called
marginal fractures.
- displaced frxs are those w/ articular incongruity (step-off) of more
than two mm or separation of fragments of more than 3 mm;
- frx w/ multiple fragments are called comminuted fractures;
- some comminuted fractures can be characterized as stellate fractures;
- some transverse frx also demonstrate comminution of one or both poles;

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Fractures of The Patella:: - Discussion

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Fractures of the Patella:

- Non Operative Rx:

- Operative Treatment Options:

- Complications of Patella Fracture:

Indications and results of nonoperative treatment of patellar fractures.

Transverse fractures of the patella.

Scapinelli R: Blood supply of the human patella. J Bone Joint Surg

Main Menu Home Page

Classification of Patellar Fractures

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