Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Patella Complete articular, frontal/coronal simple fracture of the distal third

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Glossary

General considerations

Fractures of the lower third of the body of the patella involve the articular surface and the fracture plane is transverse and therefore perpendicular to the pull of the extensor apparatus. These fractures are usually due to a sudden quadriceps contraction when the weight-bearing knee is held in flexion. If the fragments are separated, the extensor mechanism is usually disrupted. Displaced fractures should be fixed surgically.

Tension band wiring
Indication summary Skill Equipment
Distraction with impaired extensor function Some specialized surgical experience Simple surgical and imaging resources

Displaced frontal/coronal (transverse) fractures of the body of the patella interrupt the function of the extensor mechanism and require operative stabilization. These fractures are intraarticular and anatomical reduction of the joint surface, when possible, is important.

Indications

  • Displaced fractures
  • Impaired extensor function
  • Additional knee injuries

Contraindications

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

Advantages

  • Restoration of the extensor mechanism
  • Restoration of articular congruity
  • Early mobilization of knee joint
  • No plaster, or prolonged splintage

Disadvantages

  • Prominent metalwork after fixation
  • Risk of malunion
  • Risk of nonunion 
  • 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

Displaced frontal/coronal (transverse) fractures of the body of the patella will interrupt the function of the extensor mechanism and will require operative intervention.

When a small fragment has been avulsed (usually the lower pole) it may be easier to excise this fragment and reattach the soft tissues directly to the main fragment.

Indication

  • Displaced fractures which are associated with inability to actively extend the knee

Contraindications

  • Polytrauma patient in extremis
  • Medically unfit for surgery

Advantages

  • Preservation of the majority of the patella
  • Early mobilization of knee joint

Disadvantages

  • Prominent metalwork after fixation
  • Loss of the lower third of the patella
  • Risks of open operation
Suture repair
Indication summary Skill Equipment
Distraction with impaired extensor function Some specialized surgical experience Simple surgical and imaging resources

Displaced frontal/coronal (transverse) fractures of the body of the patella will interrupt the function of the extensor mechanism and will require operative stabilization.

These intraarticular fractures occur when the distal third of the patella is avulsed from the body of the patella.

Indication

  • Displaced fractures which are associated with inability to actively extend the knee

Contraindications

  • Polytrauma patient in extremis
  • Medically unfit for surgery
  • Local soft-tissue compromise

Advantages

  • Restoration of extensor function
  • Early mobilization of knee joint
  • No plaster, or prolonged splint

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

v1.0 2008-12-03