Executive Editor: Rick Buckley, Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Patella Complete articular, frontal/coronal multifragmentary fracture

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Glossary

General considerations

Multifragmentary fractures may need a combination of fixation techniques, such as screw fixation with tension band wiring, patellar plating, or tension band stitch.

Stable anatomical restoration of the articular surface may not be possible. In these cases, excision of the patella 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 later for the articular surface, if this becomes a problem.

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.

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

Cerclage wiring may occasionally be used alone, or in combination with tension band wiring, plating 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 prolonged splintage

Disadvantages

  • Caution with knee mobilization is needed, if a single cerclage wire is used
  • Secondary displacement is possible
  • Prominent metalwork after fixation requiring removal
  • Risk of articular malunion 
  • Risks of open operation
Patellar plating
Indication summary Skill Equipment
Joint surface reconstructable Highly experienced and skilled surgeon Simple surgical and imaging resources

Plating may occasionally be used alone, or in combination with tension band wiring, cerclage 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 prolonged splintage

Disadvantages

  • Very prominent metalwork after fixation requiring removal
  • Risk of articular malunion 
  • Risks of open operation
Salvage techniques
Indication summary Skill Equipment
Distal fragment too fragmented to repair Highly experienced and skilled surgeon Simple surgical and imaging resources

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
  • Osteoarthritis may develop, which then requires later revision of partial patellectomy to total patellectomy, or arthroplasty
  • Risk of malunion
  • Risk of nonunion
  • Risks of open operation
Tension band stitch
Indication summary Skill Equipment
All displaced frontal/coronal (transverse) fractures in elderly osteoporotic patients Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Impaired extensor function
  • Additional knee injuries

Contraindications

  • Polytrauma, in extremis
  • Medically unfit for surgery
  • Local soft-tissue compromise
  • Undisplaced fractures in the elderly patient 

Advantages

  • Restoration of the extensor mechanism
  • Restoration of articular congruity
  • Early mobilization of knee joint
  • No prolonged splintage
  • Less prominent hardware for later removal

Disadvantages

  • 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

v2.0 2019-03-21