1 Principles topenlarge
The patella is the largest sesamoid bone in the human body. It is located within the extensor apparatus of the knee. Anatomical features include the proximal articular body, with an extraarticular anterior surface and a posterior articular surface, and the extraarticular distal pole. The rectus femoris and vastus intermedius muscles insert at the superior pole of the body and the vastus medialis and vastus lateralis muscles on either side. The patellar tendon originates from the inferior pole and inserts into the tibial tuberosity. The articular surface has the thickest layer of cartilage in the body, up to 5 mm, reflecting the very high resultant loads across the patello-femoral joint, rendering it susceptible to chondromalacia and degenerative joint disease.
History and examination
Patellar fractures comprise about 1% of all fractures and are mostly caused by direct trauma to the front of the knee, for example, a direct fall, or a blow onto the flexed knee.
Bony avulsions of the adjacent tendons, or pure ruptures of the quadriceps and patellar tendons, are caused by indirect forces.
Typical signs are swelling, tenderness and limited, or lost, function of the extensor mechanism.
Preservation of active knee extension does not rule out a patellar fracture if the auxiliary extensors of the knee - the medial and lateral parapatellar retinacula - are intact.
If displacement is significant, it is possible to palpate a defect between the fragments, if present. The hemarthrosis is usually obvious. The examination must include assessment of the soft tissues, so as not to confuse with an injury to the prepatellar bursa, or to omit grading the injury if the fracture is open.
In addition to the standard x-rays of the knee in two planes, a tangential ("skyline") view of the patella is useful. In the AP view, the patella normally projects into the midline of the femoral sulcus. Its lower pole is located just above a line drawn across the distal profile of the femoral condyles. In the lateral view the proximal tibia must be visible to exclude a bone avulsion of the patellar tendon from the tibial tuberosity. A rupture of the patellar tendon, or an abnormal position of the patella like patella alta (high-riding patella), or patella baja (shortening of the tendon), can be recognized with the help of the Insall-Salvati method. This is the relationship between the length of the patella (B) and of the patellar tendon (A) on the lateral x-ray, r = A/B. This ratio is normally r = 1+/-0.2, i.e. 0.8-1.2. A ratio r > 1.2 suggests a high-riding patella (patella alta), or patellar tendon rupture.
The third important x-ray projection is the 30° tangential view, which is obtainable in 45° knee flexion. If a longitudinal, or osteochondral fracture, is suspected, the 30° tangential view is a helpful diagnostic adjunct.
Special imaging is helpful in certain cases, such as stress fractures, in elderly patients with osteopenia and hemarthrosis, and in cases of patellar nonunion, or malunion.
Computed tomography is recommended only for the evaluation of articular incongruity in cases of nonunion, malunion and patello-femoral alignment disorders.
Scintigraphic examination (or MRI) can be helpful in the diagnosis of stress fractures; a leukocyte scan can reveal signs of osteomyelitis.
MRI can be helpful to diagnose cartilage defects and lesions.
Tendon ruptures and patellar dislocation must be ruled out. Isolated rupture of the quadriceps, or patellar, tendon must be excluded by clinical evaluation (palpation) and ultrasound scan (or MRI). Dislocation, most commonly occurring to the lateral side, may result in osteochondral shear fractures with lesions of the medial margin of the patella, and occasionally impaction fractures of the lateral lip of the patellar groove of the femur.
X-ray by courtesy of Spital Davos, Switzerland, Dr C Ryf and Dr A Leumann.
Bipartite patella is an anatomical variant that results from developmental lack of assimilation of the bone during growth. Located on the proximal lateral quadrant of the patella, the condition is without clinical relevance, is usually bilateral and has a characteristic x-ray feature with rounded, sclerotic lines rather than the sharp edges of a fracture.
In fractures with several large fragments and disruption of the extensor mechanism, cerclage wiring may be used alone, or in combination with lag screw fixation.
Cerclage wiring may also be indicated in relatively undisplaced fragmented fractures. These types of fractures, especially in osteoporotic bone, are difficult to stabilize and cerclage wiring does not provide adequate biomechanical stability, although cerclage wiring may be the only technique that will give any stability at all.
If this surgical technique is used alone, it must be supplemented with a period of postoperative plaster, or thermoplastic, cylinder treatment of the leg, or removable splintage.
Cerclage wires may be used in combination with tension band wiring. Tension band technique is described in the dedicated section.
2 Reduction and fixation top
Reduction techniques and tools
The knee joint and fracture lines must be irrigated and cleared of blood clot and small debris to allow exact reconstruction. The larger fragments are reduced using a pointed reduction forceps. In frontal/coronal (transverse) fractures, reduction is easier with the knee extended. Sagittal fractures are more easily reduced with the knee flexed. Anatomical reduction of the articular surface is monitored by palpating the joint from inside, as neither inspection nor the x-ray will reveal a minor step off. If an inside-out technique is planned, K-wires are inserted in an open manner before the reduction is done. The wires can also be used as joysticks to help in reducing the fragments. Reduction is held by one or two reduction forceps.
An image intensifier should always be available so that the reduction can be checked in the AP and lateral planes.
Inserting the cerclage wire
Pass the wire around the superior pole of the patella, close to the bone. The use of a curved large bore injection needle is helpful.
The wire is then similarly threaded around the circumference of the body of the patella and its lower pole, as illustrated.
Carefully tighten the wire. Avoid over-tightening as this may distort the overall shape of the patella. When the correct tension is achieved, twist and trim the wire ends.
The major fragment may additionally be fixed using a lag screw. A detailed description of the lag screw technique is available in the dedicated section.
Pearl: correct wire-tightening technique
Loosely prepare the wire twist ensuring that each end of the wire spirals equally - the twist should not comprise one spiral around a straight wire.
To tighten the wires in this fashion, pull away from the patella as the wires are twisted.
The wires should be twisted at least 5 times to prevent fixation failure. When stainless steel wires tighten they will lose the surface sheen and if tightened further the wire may break.
Care should be taken finally to position the twisted wire into deeper soft-tissue muscle layers, if possible.