What is the appropriate treatment for a patellar fracture in an 87-year-old female?

Treatment for Patellar Fracture in 87-Year-Old Female

In an 87-year-old female with a patellar fracture, surgical treatment with open reduction and internal fixation should be performed if the extensor mechanism is disrupted (inability to perform straight leg raise) or if there is >2mm displacement of fracture fragments, as this approach restores function and independence better than conservative management in elderly patients. 1

Initial Assessment and Decision Algorithm

Determine Fracture Characteristics and Extensor Mechanism Integrity

• Obtain standard radiographs (AP, lateral, and axial views) to assess fracture pattern, displacement, comminution, and articular congruity 2, 3
• Test the extensor mechanism by asking the patient to perform a straight leg raise against gravity 1, 3
• Measure any articular step-off on radiographs—displacement >2mm is a surgical indication 3, 4

Surgical Indications (Operate on 85% of Elderly Patients)

In elderly patients with patellar fractures, 85% will have disruption of the extensor mechanism requiring surgical intervention 1. Specific indications include:

• Inability to perform straight leg raise (disrupted extensor mechanism) 1, 3
• Articular step-off ≥2mm 3, 4
• Fracture displacement >2mm 3, 5
• Open fractures 3

Conservative Treatment (Only 15% of Elderly Patients)

Conservative management is appropriate only if displacement is <2mm, articular step is <2mm, AND the extensor mechanism is intact (patient can perform straight leg raise) 3, 4, 5. However, this approach yields inferior functional outcomes in elderly patients compared to surgery 1.

Surgical Approach for Elderly Patients

Fracture Pattern-Specific Fixation

• For simple two-part transverse fractures: Use two parallel cannulated lag screws combined with anterior tension band wiring, as this provides superior biomechanical stability 6, 4
• For comminuted fractures (present in 66% of elderly patients): Use small fragment screws or angular stable plates with additional circumferential cerclage wiring (metal or FiberWire) to restore the retropatellar surface and prevent re-dislocation 1, 4
• For distal avulsion fractures: Fix with small fragment screws protected by transtibial McLaughlin cerclage 4

Avoid Total Patellectomy

Total patellectomy should be considered only as a salvage procedure due to severe loss of quadriceps power and poor functional outcomes 6, 4, 5. Even in elderly patients with severe comminution, attempt anatomic reconstruction first.

Critical Geriatric-Specific Perioperative Management

Timing and Anesthesia

• Take the patient to surgery within 24-48 hours of admission to optimize outcomes 2
• Use spinal or general anesthesia—both are appropriate for elderly patients 2
• Administer tranexamic acid at the start of the case to reduce blood loss and transfusion need 2

Multimodal Pain Control

• Provide immediate multimodal analgesia including acetaminophen and consider peripheral nerve blocks (femoral or adductor canal block) 2, 7
• Avoid NSAIDs in elderly patients due to renal and gastrointestinal risks 8, 7

Orthogeriatric Co-Management

Implement interdisciplinary care with hospitalist or geriatrician involvement to decrease complications and improve outcomes 2. This is particularly important given that 50% of elderly patients with patellar fractures have significant background diseases 1.

Osteoporosis Evaluation and Secondary Fracture Prevention

Immediate Laboratory Assessment

Order vitamin D, calcium, and parathyroid hormone levels during the initial hospitalization, and schedule outpatient DEXA scan with referral to bone health clinic 8. In an 87-year-old, 82% of patellar fractures result from simple falls, indicating underlying fragility 1.

Initiate Anti-Osteoporotic Therapy

Consider starting anti-osteoporotic medication even before DEXA results in this patient with a typical fragility fracture pattern, as she has extremely high subsequent fracture risk 8, 7.

Fall Prevention

Implement comprehensive fall prevention programs including balance training and environmental modifications, as this reduces subsequent falls by 20% 9, 7.

Rehabilitation Protocol

Early Mobilization

• Allow weight-bearing as tolerated immediately postoperatively 2
• Begin active range-of-motion exercises of the knee within 3 days to prevent debilitating stiffness and contractures 8, 6, 4
• Instruct the patient to move all non-immobilized joints regularly through complete range of motion starting immediately 7

Expected Functional Outcomes

With surgical treatment, 82% of elderly patients achieve the same independence and mobility status they had pre-fracture, compared to only 50% with conservative treatment 1. However, 9% of surgically treated patients may have a residual extension lag of 10-30 degrees, compared to 30% of conservatively treated patients 1.

Common Pitfalls to Avoid

• Do not treat this as an isolated knee injury—failure to address underlying osteoporosis leaves the patient at 2-4 times increased risk of subsequent hip or vertebral fracture within the next year 8, 7
• Do not delay mobilization waiting for pain to completely resolve—stiffness becomes extremely difficult to treat after fracture healing 7, 4
• Do not use NSAIDs for pain control in this 87-year-old patient 8, 7
• Do not perform total patellectomy unless absolutely necessary as a salvage procedure 6, 4, 5

Follow-Up Requirements

• Monitor for wound healing, extensor mechanism function, and knee range of motion at 2 weeks, 6 weeks, and 3 months 1
• Assess for pressure sores, nutritional status, and cognitive function at each visit given advanced age 8
• Ensure systematic follow-up for osteoporosis treatment adherence through a dedicated coordinator 9
• Monitor for unremitting pain during follow-up, which warrants re-evaluation for complications 7