Fractures of the patella constitute almost 1% of all skeletal injuries, resulting from either direct or indirect trauma.

The anterior subcutaneous location of the patella makes it vulnerable to direct trauma, such as the knee striking the dashboard of an automobile or from a fall on the anterior knee. These injuries often are comminuted or displaced and may include chondral injury to the distal femur or patella. Fractures caused by indirect mechanisms result from a violent contraction of the quadriceps with the knee flexed. These fractures usually are transverse and may be associated with tears of the medial and lateral retinacular expansions. Most patellar fractures are caused by a combination of direct and indirect forces. The most significant effects of fracture of the patella are loss of continuity of the extensor mechanism of the knee and potential incongruity of the patellofemoral articulation. Fractures of the patella can be classified as undisplaced or displaced and subclassified further according to fracture configuration (Fig. 51-69). Transverse fractures usually involve the central third of the patella, but can involve the proximal (apical) or distal (basal) poles. A variable amount of comminution of the poles may be present. Most fractures in reported series are transverse. Vertical fractures usually involve the middle and lateral thirds of the patella. If only the medial or lateral edge of the patella is affected, the fracture is called marginal. Vertical fractures are seen best on axial radiographs of the patella; displacement and retinacular disruption rarely occur in vertical fractures. Another common fracture pattern is the comminuted or stellate patellar fracture, which is associated with a variable amount of displacement Inability of the patient to extend the affected knee actively usually indicates a disruption of the extensor mechanism and a torn retinaculum, which require surgical treatment. Occasionally, if active knee extension is limited by pain, the hemarthrosis can be aspirated under sterile conditions and followed by intraarticular injection of lidocaine. In patients without significant impairment of the extensor mechanism, active knee extension should be restored. An open wound in the vicinity of a patellar fracture may be a sign of an open fracture, which is a surgical emergency. If uncertainty exists as to whether the open wound communicates with the joint, the saline test can be used.
authors recommended open reduction and internal fixation for uncomminuted fractures and partial patellectomy for comminuted fractures Patellar fractures should be radiographically evaluated with anteroposterior, lateral, and axial (Merchant) views. Transverse fractures usually are best seen on a lateral view, whereas vertical fractures, osteochondral fractures, and articular incongruity are best evaluated on axial views. A comparison view of the opposite knee sometimes is necessary to differentiate an acute fracture from a bipartite patella, which is a failure of fusion of the superolateral portion of the patella and usually is bilateral The initial treatment of acute patellar fractures should consist of splinting the extremity in extension or slight flexion and applying ice to the knee. To prevent soft-tissue damage, the ice should not be applied directly to the skin. Closed fractures with minimal displacement, minimal articular incongruity, and an intact extensor retinaculum can be successfully treated

nonoperatively. Nonoperative treatment consists of immobilizing the knee in extension in a cylinder cast from ankle to groin for 4 to 6 weeks, with weight bearing allowed as tolerated. Bostrm considered 3 to 4 mm of fragment separation and 2 to 3 mm of articular incongruity to be acceptable for nonoperative treatment; if either separation or articular incongruity is greater, operative treatment is indicated Fractures associated with retinacular tears, open fractures, and fractures with more than 2 to 3 mm of displacement or incongruity are best treated operatively. The goal is restoration of articular congruity and repair of the extensor mechanism with fixation secure enough to allow early motion. When the skin is normal, the operation should be performed as soon as is practical. Delay retards convalescence and to some extent unfavorably affects the result. If contusion or laceration of the skin is present, it usually is best to perform the indicated operation immediately on admission to the hospital or very soon thereafter. When lacerations or abrasions become superficially infected, surgery must be delayed 7 to 10 days until the danger of contaminating the operative wound is minimal Opinions differ as to the optimal treatment of patellar fractures. Accepted methods include a variety of wiring techniques, screw fixation, partial patellectomy, and total patellectomy. Open fractures of the patella are a surgical emergency and should be treated with immediate dbridement and irrigation. Early soft-tissue coverage (within 5 days) should reduce the incidence of infection. The same surgical techniques used to treat closed patellar fractures can be used successfully for open fractures Wiring techniques are used most often for transverse fractures. They also can be used in comminuted fractures if the fragments are large enough to lag together with screws, converting it to a transverse fracture. Many different wiring techniques have been described, including cerclage wiring, alone or in combination; tension band wiring, alone or modified with longitudinal Kirschner wires or screws; Magnusson wiring; and Lotke longitudinal anterior band wiring most secure fixation was obtained with modified tension band wiring. Weber et al. recommended anchoring the fixation wiring directly in bone, rather than threading it through the soft tissue around the patella if early motion is to be initiated. Arthroscopically assisted percutaneous screw fixation also has been described for fixation of displaced transverse patellar fractures If the amount of comminution and articular damage preclude salvage of the entire patella, partial or total patellectomy may be indicated proper site of insertion of the patellar tendon into the patellar remnant after partial patellectomy also has been controversial. Duthie and Hutchinson found that reinserting the patellar tendon anteriorly on the patella caused excessive tilting of the lower pole of the patella toward the femoral articular surface and led to patellofemoral arthritis. They recommended suturing the patellar tendon as close to the articular surface as possible

Whatever site of reattachment is chosen, intraoperative radiographs should be evaluated carefully to ensure that the extensor mechanism is not excessively shortened, and that the remaining patella is not tilted. Gunal et al. compared the results of simple patellectomy (16 patients) with the results of patellectomy with advancement of the vastus medialis obliquus (12 patients). At a minimum 3-year follow-up, results were significantly better in patients with vastus medialis obliquus advancement

Circumferential Wire Loop Fixation :-Circumferential wire loop fixation

was formerly the most popular technique. With the loop threaded through the soft tissues around the patella, rigid fixation is not achieved, so a delay of 3 to 4 weeks in starting knee motion is necessary if this technique is used. It has largely been replaced by more rigid fixation techniques to permit early motion of the joint, although it can be used in conjunction with other techniques for fixation of comminuted fractures
AFTERTREATMENT :-A posterior splint from groin to ankle provides sufficient

immobilization during the early postoperative period. The patient is encouraged to perform quadriceps-setting exercises and within a few days should be lifting the leg off the bed. At 10 to 14 days, the sutures are removed, and a cylinder cast is applied with the knee in extension. The patient is allowed to be ambulatory, using crutches when active muscular control of the leg has been obtained. In transverse fractures, the immobilization can be removed at 3 weeks, and gentle active and active-assisted exercises are begun. As muscle power returns, the crutches are discarded, usually at 6 to 8 weeks. After fracture union, the wire should be removed in most instances; if not, it eventually may break, become painful, and be difficult to remove. The twisted ends usually can be located through a small stab incision under local anesthesia; the wire is cut near the ends and is withdrawn with little difficulty

Tension Band Wiring Fixation :-The AO group has used and recommended
a tension band wiring principle for fixation of fractures of the patella. By proper placement of the wires, the distracting or shear forces tending to separate the fragments are converted into compressive forces across the fracture site (see Fig. 51-70), resulting in earlier union and allowing immediate motion and exercise of the knee. Generally, two sets of wire are used, one passed transversely through the insertion of the quadriceps tendon immediately adjacent to the bone of the superior pole, then passing anteriorly over the superficial surface of the patella and in a similar way through the insertion of the patellar tendon. This wire is tightened until the fracture is slightly overcorrected or opened on the articular surface. The second wire is passed through transverse holes drilled in the superior and inferior poles of the anterior patellar surface and tightened. The capsular tears are repaired in the usual manner. The knee is immobilized in flexion, and early active flexion produces compressive forces to keep the edges of the articular surface of the patella compressed together. Early active flexion exercises are essential for the tension band principle to work

. Carefully clean the fracture surfaces of blood clot and small fragments. Explore the extent of the retinacular tears, and inspect the trochlear groove of the femur for damage. Thoroughly lavage the joint. If the major proximal and distal fragments are large, reduce them accurately, with special attention to restoring a smooth articular surface. With the fracture reduced and held firmly with clamps, drill two 2-mm Kirschner wires from inferior to superior through each fragment. Place these wires about 5 mm deep to the anterior surface of the patella along lines dividing the patella into medial, central, and lateral thirds. Insert the wires as parallel as possible. In some cases, it is easier to insert the wires through the fracture site into the proximal fragment in a retrograde manner before reduction. This is made easier by tilting the fracture anteriorly about 90 degrees. Withdraw the wires until they are flush with the fracture site, accurately reduce the fracture and hold it with clamps, and drive the wires through the distal fragment. Leave the ends of the wires long, protruding beyond the patella and quadriceps tendon attachments to the inferior and superior fragments. Pass a strand of 18-gauge wire transversely through the quadriceps tendon attachment, as close to the bone as possible, deep to the protruding Kirschner wires, over the anterior surface of the reduced patella, transversely through the patellar tendon attachment on the inferior fragment and deep to the protruding Kirschner wires, and back over the anterior patellar surface; tighten it at the upper end. Alternatively, place the wire in a figure-ofeight fashion. Check the reduction by palpating the undersurface of the patella with the knee extended. If necessary, make a small longitudinal incision in the retinaculum to allow insertion of the finger. Bend the upper ends of the two Kirschner wires acutely anteriorly, and cut them short. When they are cut, rotate the Kirschner wires 180 degrees; with an impactor, embed the bent ends into the superior margin of the patella posterior to the wire loops. Cut the protruding ends of the Kirschner wires short inferiorly

Repair the retinacular tears with multiple interrupted sutures. In patients with good bone stock, lag screws can be used instead of Kirschner wires; 3.5mm cortical screws are adequate in most patients, but 4.5-mm screws may be needed in large patients. Lag screws also can be placed horizontally to join comminuted fracture fragments, converting a comminuted fracture to a transverse fracture pattern. A modified anterior tension band technique can be used. If the anterior cortex is split from the articular surface in the coronal plane, the fragment usually can be secured with the anterior tension band wire. If this is unsuccessful, the fragment can be excised.

AFTERTREATMENT :-The limb is placed in extension in a posterior plaster splint

or removable knee brace. The patient is allowed to ambulate while bearing weight as tolerated on the first postoperative day. Isometric and stiff-leg exercises are encouraged, beginning on the first postoperative day. In patients with stable fixation and limited retinacular tears, continuous passive motion can be initiated immediately after surgery if desired. Active range-of-motion exercises can be performed when the wound has healed, at approximately 2 to 3 weeks. Progressive resistance exercises can be begun and the brace discontinued at 6 to 8 weeks if healing is evident on radiograph. Unrestricted activity can be resumed when full quadriceps strength has returned, at approximately 18 to 24 weeks. In patients with less stable fixation or extensive retinacular tears, active motion should be delayed until fracture healing has occurred. Initiating range-of-motion exercises by the sixth postoperative week is desirable, but not always possible. A controlled motion knee brace can be used, allowing full extension and flexion to the degree permitted by the fixation as determined intraoperatively