What are the treatment recommendations for a patient with a patella fracture, considering their overall health and medical history, including pre-existing conditions such as diabetes or cardiovascular disease?

Patella Fracture Management

Treatment Decision Algorithm

For displaced patella fractures with disruption of the extensor mechanism, operative management with open reduction and internal fixation (ORIF) is the treatment of choice to restore function and enable unassisted gait. 1, 2

Initial Assessment

Determine fracture displacement and extensor mechanism integrity:

• Assess ability to perform straight leg raise against gravity (indicates intact extensor mechanism) 2
• Obtain anteroposterior and lateral knee radiographs with lateral view at 25-30 degrees of flexion to visualize patella in profile 1
• Evaluate for open fracture (occurs in ~1% of cases, typically from high-energy vehicular trauma) 3

Treatment Selection Based on Fracture Pattern

Non-displaced fractures (<2-3mm displacement, intact extensor mechanism):

• Conservative management with immobilization 1
• Multimodal analgesia: acetaminophen first-line, add opioids as needed; avoid NSAIDs if renal function unknown (40% of trauma patients have moderate renal dysfunction) 1
• Serial radiographs at 1-2 weeks to confirm no displacement 1
• Early mobilization as pain allows 1

Displaced 2-part transverse fractures:

• Modified anterior tension band wiring combined with two parallel cannulated lag screws (biomechanically superior) 4, 5
• Additional circular cerclage wiring with metal or FiberWire increases stability and decreases re-dislocation risk 4

Comminuted fractures:

• Open reduction with small fragment screws or angular stable plates for anatomic restoration of retropatellar surface 4
• Supplemental cerclage wiring for added stability 4, 2
• Partial patellectomy only if comminution precludes fixation (provides similar results to ORIF in highly comminuted cases) 3

Distal avulsion fractures:

• Small fragment screw fixation protected by transtibial McLaughlin cerclage 4

Open fractures (Type I-II):

• Immediate rigid internal fixation (NOT cerclage wiring alone—29% infection rate) 3
• Primary wound closure for Type I-II injuries 3
• Individualize timing of wound closure for Type III injuries 3

Perioperative Management for Patients ≥50 Years or Multiple Comorbidities

Preoperative optimization:

• Comprehensive assessment including chest X-ray, ECG, full blood count, renal function 1
• Surgery within 48 hours when possible to minimize immobility complications 1
• Orthogeriatric comanagement for elderly/frail patients to reduce mortality and improve functional outcomes 6, 1

Assess for malnutrition, electrolyte disturbances, anemia, cardiac/pulmonary disease, and cognitive function in elderly patients 1

Postoperative Protocol

Immediate rehabilitation:

• Begin active range-of-motion exercises immediately after stable fixation 1
• Early mobilization with weight-bearing as tolerated 1
• Continue multimodal analgesia 1

For elderly patients, implement balance training and multidimensional fall prevention programs 6, 1

Secondary Fracture Prevention (Age ≥50 Years)

Systematic evaluation for osteoporosis:

• Order vitamin D, calcium, parathyroid hormone levels 1
• Schedule outpatient DEXA scan of spine and hip 6, 1
• Refer to bone health clinic 1

Pharmacologic management:

• Initiate calcium 1000-1200 mg/day and vitamin D 800 IU/day (associated with 15-20% reduction in non-vertebral fractures and falls) 6, 1
• For confirmed osteoporosis: bisphosphonates (alendronate or risedronate) as first-line therapy 6
• Alternative agents for oral intolerance/non-compliance: zoledronic acid (IV) or denosumab (subcutaneous) 6

Common Pitfalls to Avoid

• Avoid cerclage wiring alone for open fractures (high infection rate of 29%) 3
• Avoid total patellectomy except as salvage procedure due to severe loss of quadriceps power and poor functional outcomes 4, 5
• Do not delay surgery beyond 48 hours in medically stable patients, as immobility increases complications 1
• Do not neglect osteoporosis screening in patients ≥50 years, as this represents a fragility fracture requiring secondary prevention 6, 1

Expected Complications

Common complications include: nonunion (especially with nonrigid fixation), infection (10.7% in open fractures), posttraumatic arthritis, arthrofibrosis, symptomatic hardware, and extensor mechanism insufficiency 3, 7

Substantial functional deficits and patellofemoral arthrosis are very common long-term sequelae even after successful fracture healing 2