FRACTURE OF PATELLA

Anatomy
The patella is a sesamoid bone in continuity with thequadriceps tendon and the patellar ligament (also called the patellar tendon). There are additional insertions from the vastus medialis and lateralis into the medial and lateral edges of the patella.

The extensor strap is completed by the medial and lateral extensor retinacula (or quadriceps expansions), which bypass the patella and insert into the proximal tibia.

The mechanical function of the patella is to hold the entire extensor strap away from the centre of rotation of the knee, thereby lengthening the anterior lever arm and increasing the efficiency of the quadriceps.

The key to the management of patellar fractures is the state of the entire extensor mechanism. If the extensor retinacula are intact, active knee extension is still possible, even if the patella itself is fractured.

Mechanism of injury and pathological anatomy

Direct injury usually a fall onto the knee or a blow against the dashboard of a car causes either an undisplaced crack or else a comminuted (stellate) fracture without severe damage to the extensor expansions.

Indirect injury occurs, typically, when someone catches the foot against a solid obstacle and, to avoid falling, contracts the quadriceps muscle forcefully. This is a transverse fracture with a gap between the fragments.

Clinical Features

Following one of the typical injuries, the knee becomes swollen and painful. There may be an abrasion or bruising over the front of the joint. The patella is tender and sometimes a gap can be felt.

Active knee extension should be tested. If the patient can lift the straight leg, the quadriceps mechanism is still intact. If this manoeuvre is too painful, active extension can be tested with the patient lying on his side. If there is an effusion, aspiration may reveal the presence of blood and fat droplets

X-ray. The x-ray may show one or more fine fracture lines without displacement, multiple fracture lines with irregular displacement or a transverse fracture with a gap between the fragments (Fig. 30.14). Comparative x-rays of the opposite knee may help to distinguish normal from abnormal appearances in undisplaced fractures

Patellar fractures are classified as 1. Transverse 2. Longitudinal 3. Polar or comminuted (stellate) Any of these may be either undisplaced or displaced. Separation of the fragments is significant if it is sufficient to create a step on the articular surface of the patella or, in the case of a transverse fracture, if the gap is more than 3 mm wide.

A fracture with little or no displacement can be treated conservatively by a posterior slab of plaster that is removed several times a day for gentle active exercises.

With severe comminutions, patellectomy is arguably the best treatment, although some surgeons would consider preserving as many useful fragments as possible

A fracture line running obliquely across the superolateral corner of the patella should not be confused with the smooth, regular line of a (normal) bipartite patella. Check the opposite knee; bipartite patella is often bilateral

Undisplaced or minimally displaced fractures. If there is a haemarthrosis it should be aspirated. The extensor mechanism is intact and treatment is mainly protective. A plaster cylinder holding the knee straight should be worn for 34 weeks, and during this time quadriceps exercises are to be practised every day.

Comminuted (stellate) fracture The extensor expansions are intact and the patient may be able to lift the leg However, the undersurface of the patella is irregular and there is a serious risk of damage to the patellofemoral joint. For this reason some people advocate patellectomy, whatever the degree of displacement.

To others it seems reasonable to preserve the patella if the fragments are not severely displaced (or to remove only those fragments that obviously distort the articular surface); a hinged brace is used in extension but unlocked several times daily for exercises to mould the fragments into position and to maintain mobility.

Fractured patella transverse The separated fragments (a) are transfixed by K-wires; (b) malleable wire is then looped around the protruding ends of the K-wires and tightened over the front of the patella

Displaced transverse fracture The lateral expansions are torn and the entire extensor mechanism is disrupted. Operation is essential.

Through a longitudinal incision the fracture is exposed and the patella repaired by the tension-band principle. The fragments are reduced and transfixed with two stiff K-wires; flexible wire is then looped tightly around the protruding K-wires and over the front of the patella

The tears in the extensor expansions are then repaired. A plaster backslab or hinged brace is worn until active extension of the knee is regained; either may be removed every day to permit active knee-flexion exercises.