What is the treatment for a mild comminuted fracture (fx) of the distal pole of the patella with mild distraction?

Treatment of Mild Comminuted Fracture of the Distal Pole of the Patella with Mild Distraction

For mild comminuted fractures of the distal pole of the patella with mild distraction, open reduction and internal fixation (ORIF) using headless compression screws with additional wiring technique is the recommended treatment to ensure optimal functional outcomes and fracture healing. 1

Assessment and Classification

• Patellar fractures should be classified based on displacement, with significant displacement considered as >3mm 2
• Comminuted distal pole patellar fractures have characteristics of both patellar fracture and avulsion of the patellar tendon, requiring specialized treatment approaches 3

Treatment Algorithm

For Mild Comminuted Distal Pole Patellar Fractures:

1. Surgical Fixation Indications

   • Surgery is indicated for fractures with:
     • Displacement >2-3mm 2
     • Articular step-off >1-4mm 2
     • Disruption of the extensor mechanism 2

2. Recommended Surgical Techniques

   • Primary Option: Headless compression screws with additional vertical wiring

     • Provides direct visual reduction of articular surface 1
     • Results in good clinical outcomes with average ROM of 134.2° 1
     • Allows for stable fixation without implant migration 1

   • Alternative Option: Anterior tension band wiring through cannulated screws

     • Safe and reliable technique with minimal soft tissue irritation 4
     • Provides stable fixation with average healing time of 8 weeks clinically 4
     • Results in good functional outcomes (average Bostman score of 28.7/30) 4

3. Post-Operative Management

   • Active finger motion exercises should be performed to prevent stiffness 5
   • Early weight-bearing and rehabilitation program can be initiated 3
   • Radiographic follow-up at approximately 3 weeks to assess healing 5

Expected Outcomes

• Fracture healing typically occurs within 8-15 weeks 1, 4
• Good functional outcomes can be expected with proper surgical technique 1, 4
• Return to pre-injury level of activities typically by the fourth postoperative month 3

Potential Complications

• Joint stiffness is one of the most functionally disabling adverse effects 5
• Thigh muscle wasting may occur in approximately 33% of patients 1
• Posttraumatic patellofemoral osteoarthritis may develop if articular surface is not properly restored 2

Important Considerations

• Anatomical reconstruction of the articular surface is critical to prevent posttraumatic osteoarthritis 2
• The basket plate technique is another viable option for comminuted distal pole fractures, showing excellent to good results in the majority of patients 6
• CT imaging may be beneficial for better understanding of fracture complexity and could modify treatment approach 2

Pitfalls to Avoid

• Inadequate fixation leading to loss of reduction and implant failure 1
• Failure to restore articular surface contour, resulting in posttraumatic arthritis 2
• Improper rehabilitation protocol leading to knee stiffness and quadriceps weakness 5, 1