What is the treatment for a patella fracture?

Treatment of Patella Fractures

Surgical fixation is recommended for displaced fractures (>2-3 mm step-off or >1-4 mm displacement) or those with disrupted extensor mechanism, while undisplaced fractures with intact extensor mechanism can be treated conservatively with immobilization. 1, 2, 3

Initial Assessment and Emergency Management

Immediate Evaluation

• Assess for vascular compromise (blue, purple, or pale extremities) requiring immediate intervention 1
• For open fractures with severe bleeding, control hemorrhage as priority 1
• Apply splinting to reduce pain, prevent further injury, and facilitate transport 1
• Cover open fractures with clean dressing to minimize contamination 1

Diagnostic Imaging

• Obtain anteroposterior and lateral radiographs to assess fracture pattern, displacement, and articular congruity 1, 2, 4
• Use CT imaging when radiographs are inconclusive, particularly with metal artifact reduction techniques for occult fractures 1, 4
• CT imaging often modifies both classification and treatment planning by revealing fracture complexity not apparent on plain films 3

Treatment Algorithm

Non-Displaced Fractures

• Conservative treatment with immobilization is appropriate for fractures with <2-3 mm displacement and intact extensor mechanism 3
• Verify extensor mechanism integrity clinically before selecting non-operative management 2

Displaced Fractures Requiring Surgery

Indications for surgical intervention include: 2, 3

• Displacement >2-3 mm step-off
• Displacement >1-4 mm separation
• Disrupted extensor mechanism
• Transverse fractures with patellar maltracking 1, 2
• Vertical fractures through fixation holes in post-arthroplasty patients 1

Surgical Technique Selection

For simple transverse (2-part) fractures:

• Modified anterior tension band wiring is the treatment of choice 5
• Combine with cannulated screw fixation for biomechanical superiority 5
• Additional circular cerclage wiring (metal or FiberWire) increases stability and decreases re-dislocation risk 5

For comminuted/multi-part fractures:

• Angular stable locking patella plates provide superior stability and are preferred over tension band wiring 6, 3
• Open reduction with small fragment screws or angular stable plates achieves anatomical restoration of retropatellar surface 5
• Stabilize all displaced fragments whenever possible to restore articular congruity 1, 2

For distal avulsion fractures:

• Fix with small fragment screws protected by transtibial McLaughlin cerclage 5

For fractures near cartilage or bony processes:

• Use specialized fixation techniques such as spanning plates 1
• Repair if reliable fixation can be obtained on proximal fragment 1

Critical Technical Considerations

• Anatomical reconstruction of the articular surface is mandatory to prevent posttraumatic osteoarthritis 3
• Locking plates reduce implant-related complications compared to tension band wiring, particularly in osteoporotic bone or comminuted fractures 6
• Tension band wiring frequently requires hardware removal after healing due to implant-related pain 3

Postoperative Management

• Implement appropriate pain management protocols 2
• Perform systematic wound assessment and care 2
• Initiate early rehabilitation to avoid knee joint capsule contractures and cartilage degeneration 5
• Evaluate patients aged ≥50 years for osteoporosis and subsequent fracture risk 2

Common Pitfalls

Avoid partial or complete patellectomy except as rare salvage operation due to severe functional impairment 5

Recognize high complication potential: 7

• Nonunion, infection, posttraumatic arthritis, arthrofibrosis, symptomatic hardware, and extensor mechanism insufficiency all occur following patellar ORIF
• Patient-, injury-, and treatment-related factors augment complication risk
• Advanced reconstructive techniques often required when complications arise

Failure to restore articular surface contour results in posttraumatic arthritis - anatomical reconstruction is the only prevention 3