What are the treatment options for a patella fracture?

Treatment Options for Patella Fractures

The treatment of patella fractures should be based on fracture displacement and extensor mechanism integrity, with surgical intervention recommended for fractures with >2mm displacement or disruption of the extensor mechanism to reduce morbidity and optimize functional outcomes. 1

Initial Assessment and Classification

• Diagnosis is made through evaluation of injury mechanism, physical examination, and radiographic findings 2
• Standard radiographs should include anteroposterior and lateral views to assess fracture pattern, displacement, and articular congruity 3
• CT may be used when radiographs are inconclusive, especially with metal artifact reduction techniques to detect occult fractures 4, 3
• Fractures are classified based on location (proximal, distal) and pattern (transverse, comminuted, polar) 5

Treatment Algorithm

Conservative Management

• Indicated for undisplaced fractures (<2mm displacement) with intact extensor mechanism 1
• Treatment typically involves immobilization with cast or brace 6
• For patella fractures with minimal displacement, conservative treatment may yield satisfactory results 5

Surgical Management

• Indicated when displacement exceeds 2-3mm or step-off >1-4mm, or when extensor mechanism is disrupted 1
• Surgical options include:

1. Tension Band Wiring

• Most commonly employed surgical technique for patella fractures 1
• Can be used for almost every type of fracture 2
• Modified tension band wiring techniques may provide better outcomes than conventional AO tension band wiring 6

2. Cannulated Lag Screws with Tension Band

• Treatment of choice for horizontally displaced two-part fractures due to superior biomechanical stability 2
• Provides better fixation for certain fracture patterns 2

3. Percutaneous Osteosynthesis

• Alternative to open surgery, though evidence quality is very low regarding differences in outcomes 6
• May have benefits in selected cases, but uncertainty remains about clinical advantages 6

4. Partial or Total Patellectomy

• Reserved for severely comminuted fractures where reconstruction is not feasible 2
• Should be considered a salvage procedure due to loss of quadriceps power and poor functional outcomes 2, 7
• Despite concerns, some long-term follow-up studies suggest patients who underwent total patellectomy fared at least as well as others requiring surgical intervention 7

Special Considerations

• In elderly patients with poor bone quality, conservative treatment or patella-enclosing wiring techniques are preferred 5
• For sleeve fractures in children, exact reconstruction of the joint surface is necessary 5
• Hardware removal is often required after fracture healing due to implant-related pain 1

Rehabilitation

• Early rehabilitation is recommended regardless of treatment method to prevent stiffness and optimize outcomes 2
• Failure to restore articular surface contour may result in posttraumatic arthritis 1

Complications to Monitor

• Knee stiffness, loss of extension, and patellofemoral osteoarthritis are common complications 1
• Blue, purple, or pale extremities may indicate poor perfusion requiring immediate medical attention 4
• For open fractures with severe bleeding, emergency treatment of bleeding should take priority 4

Fracture Immobilization in First Aid Setting

• Splinting can reduce pain, prevent further injury, and facilitate transport 4
• Deformed fractures should generally be treated in the position found unless straightening is necessary for safe transport 4
• Open fractures should be covered with clean dressing to reduce contamination risk 4