Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Patella Complete articular, frontal/coronal multifragmentary fracture

back to skeleton

Glossary

General considerations

34 - C3.2

Multifragmentary fractures with four or more fragments are often caused by a direct blow to the patella and frequently the extensor mechanism is not disrupted.

The degree of comminution determines the difficulty of reconstruction.

The aims of fixation are to reduce articular incongruity and to facilitate early knee mobilization.

Cerclage wire
Indication summary Skill Equipment
Joint surface reconstructable Highly experienced and skilled surgeon Simple surgical and imaging resources

If the extensor mechanism still functions despite the comminuted fracture, one option is to allow healing, institute early mobilization and consider reconstructive arthroplasty at a later stage when warranted by symptoms.

Cerclage wiring may occasionally be used alone, or in combination with tension band wiring and possibly K-wires at the discretion of the surgeon.

Indications

  • Multifragmentary fractures
  • Defective function in the extensor mechanism of the knee

Contraindications

  • Polytrauma patient in extremis
  • Medically unfit for surgery
  • Extensor function preserved

Advantages

  • Early mobilization of knee joint
  • No plaster, or prolonged splintage

Disadvantages

  • Caution with knee mobilization is needed, if a single cerclage wire is used
  • Secondary displacement is possible
  • Prominent metalwork after fixation
  • Risk of articular malunion 
  • Risks of open operation
Salvage techniques
Indication summary Skill Equipment
Patella too fragmented to reconstruct Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction internal fixation (ORIF); salvage techniques

When it is decided that the whole patella is too fragmented to be salvageable, a total patellectomy may be considered. This has long term implications for knee function and it is probably better to allow the fracture to heal and then perform a salvage procedure at a later date for the articular surface, if this becomes a problem.

Indication

  • Multifragmentary fractures that cannot be reconstructed

Contraindications

  • Polytrauma patient in extremis
  • Medically unfit for surgery

Advantages

  • Reduction of articular incongruity
  • May permit early mobilization of the joint

Disadvantages

  • Prominent metalwork after fixation
  • May need later revision of partial patellectomy to total patellectomy, or arthroplasty
  • Risk of malunion
  • Risk of nonunion
  • Risks of open operation
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2008-12-03