What is the treatment plan and recovery process for an adult patient with no significant medical history and a fractured patella?

Treatment Plan and Recovery for Fractured Patella

For an adult with a fractured patella, surgical treatment with open reduction and internal fixation (ORIF) using tension band wiring is recommended for displaced fractures (>2-3mm step-off or >1-4mm displacement) or those with disrupted extensor mechanism, while undisplaced fractures with intact extensor mechanism can be managed conservatively with immobilization. 1

Initial Assessment and Diagnosis

Confirm the diagnosis with standard knee radiographs (anteroposterior and lateral views at minimum), ensuring the lateral view is obtained with the knee at 25-30 degrees of flexion to visualize the patella in profile. 2 Consider CT imaging pre-operatively for complex or comminuted fractures, as this frequently modifies both classification and treatment planning by revealing fracture complexity not apparent on plain films. 1

The critical clinical decision point is assessing extensor mechanism integrity—have the patient attempt active straight leg raise. 3 If the patient cannot extend the knee against gravity, the extensor mechanism is disrupted and surgical repair is mandatory. 3

Treatment Algorithm

Conservative Management (Non-operative)

Reserve conservative treatment exclusively for:

• Undisplaced fractures (<2mm step-off, <1-4mm displacement) AND
• Intact extensor mechanism (patient can perform straight leg raise) 1

Conservative protocol includes:

• Immediate multimodal analgesia with acetaminophen; add opioids as needed but avoid NSAIDs if renal function unknown (approximately 40% of trauma patients have moderate renal dysfunction) 4
• Immobilization in full extension with cast or brace 5
• Early mobilization as pain allows 4
• Serial radiographs at 1-2 weeks to confirm no displacement has occurred

Surgical Management (Operative)

Indications for surgery:

• Displacement >2-3mm step-off OR >1-4mm fragment separation 1
• Disrupted extensor mechanism (inability to perform straight leg raise) 3, 1
• Open fractures 3

Surgical technique—tension band wiring remains the gold standard:

• Open reduction with internal fixation using anterior tension band wiring is the most commonly employed technique 1
• For comminuted fractures, supplement with interfragmentary screws, cerclage wire/suture, or plate-and-screw constructs to enhance stability 3
• Anatomical reconstruction of the articular surface is mandatory to prevent posttraumatic osteoarthritis 1

Alternative surgical options for specific scenarios:

• Partial patellectomy with quadriceps or patellar ligament advancement may be considered for severely comminuted polar fragments not amenable to fixation 3, 6
• Total patellectomy is rarely indicated but may be necessary for unreconstructable comminution; long-term outcomes are comparable to other surgical interventions 6

Perioperative Management

Provide comprehensive preoperative assessment:

• Appropriate pain management before diagnostic investigations 2
• Preoperative investigations including chest X-ray, ECG, full blood count, renal function 2
• Surgery should ideally occur within 48 hours when possible to minimize complications from immobility 2

Implement orthogeriatric comanagement for elderly patients to reduce mortality, improve functional outcomes, and reduce length of hospital stay. 2 This includes comprehensive geriatric assessment for malnutrition, electrolyte disturbances, anemia, cardiac/pulmonary diseases, and cognitive function. 2

Postoperative Recovery Protocol

Immediate postoperative phase:

• Begin active range-of-motion exercises immediately after stable fixation 7
• Early mobilization with weight-bearing as tolerated to prevent recumbency complications 8
• Continue multimodal analgesia 4

Expected timeline:

• Fracture healing typically occurs over 8-12 weeks 5
• Hardware removal is frequently required after fracture healing due to implant-related pain 1

Long-term rehabilitation:

• Progressive strengthening of quadriceps and hamstrings
• Gradual return to activities as pain and function improve
• For elderly patients, implement balance training and fall prevention programs 7

Common Complications and Pitfalls

Be aware that complications are common despite optimal treatment:

• Symptomatic hardware requiring removal 1, 9
• Posttraumatic patellofemoral arthritis (very common even with anatomical reduction) 3, 1
• Arthrofibrosis and knee stiffness 9
• Nonunion, infection, extensor mechanism insufficiency 9
• Substantial functional deficits may persist long after fracture healing 3

Critical pitfall to avoid: Failure to achieve anatomical articular surface reconstruction results in inevitable posttraumatic arthritis. 1 Accept nothing less than <2mm step-off in the articular surface. 1

Secondary Fracture Prevention

For all patients over 50 years with fragility fractures:

• Order vitamin D, calcium, and parathyroid hormone levels 7
• Schedule outpatient DEXA scan and refer to bone health clinic 7
• Consider initiating calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 4
• For confirmed osteoporosis, initiate bisphosphonate therapy as first-line pharmacologic treatment 2

Do not treat this as an isolated knee injury—failure to address underlying osteoporosis leaves the patient at substantially increased risk of subsequent hip or vertebral fractures. 7