1 Principles top
The patello-femoral joint is the heaviest-loaded joint in the body. Any compromise of the joint surface is likely to lead to degenerative joint disease. It is, therefore, highly desirable, in patellar fractures to strive for anatomical reduction of the joint surface and stable fixation.
In partial articular patellar fractures, there is little, if any, tendency to distraction and the extensor mechanism is functionally intact. The treatment goal is articular surface restoration and stable fixation with interfragmentary compression, using lag screws. In addition, a treatment goal is restoration of function of the knee extensor mechanism.
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.
Although most patellar fractures have transverse fracture lines that require a tension band construction with either K-wires, or lag screws, occasionally patellar fractures consist of simple vertical splits. Patellar fractures may also consist of a large corner piece. In either of these two scenarios, lag screw fixation alone, following anatomical reduction, provides absolute stability. The reason a tension band is not necessary is that the longitudinal integrity of the extensor mechanism is not disrupted by these fracture patterns. The fractures simply need to be repaired to restore anatomical congruity to the articular surface and to prevent nonunion.
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.
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. Sagittal fractures are better 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 ouside-in technique is planned, 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.
In sagittal fractures, cannulated screw systems are useful.
Fixation of main fragments with lag screws
Use a pointed bone reduction forceps to reduce the major fracture fragments.
If available, a partially threaded cannulated screw is inserted as lag screw to reduce the joint anatomically. Alternatively, a standard lag screw may be used. If possible digital palpation, through a small arthrotomy, is performed to ensure that there is anatomical restoration of the joint surface.
Fixation of small fragment with cerclage wire
Preliminarily fix the small fragment with bone reduction forceps.
Use a circular cerclage wire to secure its reduction.