ARTICLE IN PRESS

Current Orthopaedics (2006) 20, 397–404

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MINI-SYMPOSIUM: MANAGEMENT OF FRACTURES AROUND THE KNEE JOINT

(i) Comminuted patellar fractures

Isabella Mehling, Andreas Mehling, Pol M. Rommens!

Department of Trauma Surgery, University of Mainz, Germany

KEYWORDS Summary
Patellar fracture; Purpose of review: This article reviews current best practice for the diagnosis and
Tension-band wiring; treatment of comminuted patellar fractures.
Cannulated screw Recent findings: Patellar fractures make up about 1% of all fractures. As a rule, fractures
fixation; of the patella are caused by direct trauma to the knee. A transverse fracture is the most
Partial and total common fracture type.
patellectomy Open reduction and internal fixation is the treatment of choice for the majority of
displaced patellar fractures. Treatment must achieve anatomic reduction of the articular
surface and reestablish the continuity of the extensor mechanism. Tension-band wiring,
interfragmentary screw fixation and a combination of cerclage wiring and screw fixation
are the most accepted techniques for stabilisation. Partial or total patellectomy is
generally indicated when the patella is so severely comminuted that an accurate reduction
and reconstruction of the retropatellar joint surface cannot be achieved.
Summary: Different methods of stabilisation for patellar fractures are used, depending
mainly on the fracture pattern and the amount of displacement. The aims of operative
treatment are basically accurate reduction and stable fixation that allows early mobilisation.
& 2006 Elsevier Ltd. All rights reserved.

Introduction Kapandji2 reported that maximal forces within the quad-

riceps tendon could be as high as 3200 N, and up to 6000 N in
The patella is the largest sesamoid bone of the human skeleton. the patellar tendon in young, physically fit men.
It is integrated into the extensor apparatus and with its articular Patellar fractures represent 0.5–1.5% of all skeletal
surface, it is also a component of the patellofemoral joint. injuries.3 Typically, patients are between 30 and 60 years
The patella serves as the fulcrum for the extensor old. As a rule, the mechanism for this injury is direct
mechanism between the quadriceps tendon and the patellar trauma, such as an impact onto the knee (‘‘dashboard
tendon. Forces transmitted across the femoropatellar joint injury’’). Indirect trauma mechanisms may produce bony
can reach up to three to seven times body weight.1 In 1985, avulsions of the adjacent tendons, and occur infrequently.
Fractures can also occur as complications after total knee
replacement surgery or after patellar tendon graft trans-
!Corresponding author. plantation for ACL rupture.

0268-0890/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cuor.2006.11.004
 ARTICLE IN PRESS
398 I. Mehling et al.

Classification systems The clinical examination should include an inspection of

the whole extremity. Clinical signs of a patellar fracture are
There are different classification systems for patellar swelling and pain in the knee joint. Fracture blisters, skin
fractures: based on the trauma mechanism in direct or lacerations, abrasions or contusions are signs of direct
indirect injuries, on the grade of displacement in displaced trauma and should be documented. Wounds should be
or non-displaced fractures and on the basis of the config- checked to confirm whether the fracture is open or closed.
uration of the fracture lines in transverse, vertical, margin- In displaced patellar fractures, a defect zone between the
al, osteochondral or comminuted fractures. These systems fragments may be palpable. Often there is a hemarthrosis of
are too imprecise for scientific use. The OTA classification, the knee. Flexion and extension in the knee joint is limited
similarly to the AO classification,1,4 describes the different and painful. Active extension and lifting of the leg is ususally
fracture types in extra-articular (A), partial articular (B) and impossible. However, the ability to extend the knee does not
complete articular fractures (C) (Fig. 1). Each fracture rule out a patellar fracture, because the medial and lateral
type has its own code, consisting of three elements, e.g., retinacula may be still intact.1 The stability of the knee
45-C1.3. The first element, 45, identifies the bone: the joint should be carefully examined. Of course a check of the
patella. The second element describes the fracture type: peripheral pulses, the compartments of the leg, and a
neurological examination should always be performed.
Special interest should be paid to potential ipsilateral
(A) extra-articular, extensor mechanism disrupted,
concomitant injuries, e.g. acetabular fractures, femoral
(B) partial articular, extensor mechanism intact, for exam-
fractures or tibial fractures, which are signs of serious
ple, often vertical fractures,
trauma.
(C) complete articular, disrupted extensor mechanism.
For radiographic examinations, a standard X-ray of the
knee in two planes as well as a 301 tangential view of the
The classification of Speck and Regazzoni5 also differ- patella should be performed. In the anteroposterior (AP)
entiates the fracture in three types (A, B, C), with three view, the patella is normally centred on the medullary axis
subgroups for each fracture type. The classification of Rogge of the femur. In the lateral view, the patellar fracture is best
et al.6 differentiates seven fractures types. visible: displacement, intra-articular involvement and de-
gree of comminution can be assessed. Vertical patellar
fractures are best seen on the axial view. With the Insall7
Diagnosis method of relating the greatest diagonal lengths of the
patella and the patellar tendon, abnormal position of
The medical history is the first step of the diagnostic work- the patella, e.g., patella alta or patella baja or a rupture
up. Information on the mechanism of trauma helps for of the patellar ligament are recognisable.
estimation of the severity of injury and the fracture pattern. Evaluation of the true degree of damage of the patellar
The activity level of the patient and his/her current medical fracture in the conventional radiographic examinations is
problems are also important for decision making on further not always possible due to the cancellous bone structure of
treatment. the patella. An additional CT-scan is seldom necessary.

Figure 1 OTA classification for patellar fractures (J Orthop Trauma, 1996).4

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Comminuted patellar fractures 399

However, a CT-scan can be helpful for the evaluation of not permit safe surgical intervention, are contraindications.
articular incongruity in cases of non-union, malunion and Open fractures of the patella are treated as other open joint
patellofemoral alignment disorders. Special attention injuries. Open fractures are surgical emergencies; other
should be paid to bipartite or tripartite patellae, which lesions are best treated as soon as possible, depending on
occur due to a lack of convergence of the bone during the condition of the local soft tissues.
growth. Bipartite and tripartite patellae have characteristic
signs on the radiographs, with rounded, sclerotic lines in
contrast to the sharply edged lines of a fractured patella. Therapy
For differentiation it can be helpful to compare the
radiographs with the contralateral side. Magnet resonance The aim of the therapy is an anatomic reduction and stable
imaging is only recommended in special cases, for example fixation of the fracture, which allows early mobilisation.
in stress fractures. Stable fractures without dislocation or minimally dis-
Differential diagnoses for patellar fractures are contusion placed stable fractures can be treated conservatively. We
of the knee, tendon ruptures (rupture of the quadriceps prefer immobilisation in a semicircular plaster cast, with the
tendon or the patellar ligament), injuries of the capsular knee extended. In longitudinal fractures, full weight bearing
ligament of the knee and patellar dislocation or growth is allowed. In transverse fractures, in the first 4 or 6 weeks,
abnormalities. only half weight bearing is allowed because of the risk of
secondary loss of reduction. Physiotherapy should be
performed out of the plaster cast. Active and passive knee
Non-operative versus operative treatment mobilisation are limited in the beginning up to 601 of flexion,
later on up to 901 of flexion. After 6 weeks, increased weight
Operative management is the treatment of choice for the bearing and free knee motion are allowed. The immobilisa-
majority of patellar fractures, especially those with dis- tion in the plaster cast should be not longer than 6 weeks.
placement and intra-articular involvement. The AO recom-
mends the following treatment method, depending on the
fracture type3 (see Table 1). Surgical technique
Displacement of more than 3 mm or articular incongruity
of more than 2 mm is considered an indication for surgical The patient is positioned supine on a radiolucent operation
treatment. The grade of dislocation can be checked in the table. To avoid external rotation of the leg, a cushion is used
radiographic examination whereas stability can be proven by under the ipsilateral hip. With cushioning below the lower
clinical examination. The extensor apparatus is intact if the leg, a knee flexion of 30–401 is achieved. This is the optimal
patient can lift up the extended leg. A secondary loss of position for Kirschner-wire drilling. A tourniquet can be
position is unlikely. placed high around the involved thigh and inflated to about
Contraindications and relative contraindications for sur- 300 mmHg, depending on the size of the leg and on the
gical treatment include non-displaced or minimally dis- patient’s blood pressure. Use of a tourniquet is not
placed stable fractures. These fractures can be treated non- absolutely necessary. The surgeon should take into account
operatively. Contused or injured skin areas, which preclude the fact that the inflated tourniquet can complicate the
a safe surgical approach to the fracture, active infection on reduction of the fracture, as under tourniquet pressure the
the extremity or medical conditions of the patient, which do patella can be displaced proximally due to contraction of

Table 1 Recommended therapy from the AO1 for each fracture pattern.

Patella #45- Therapy

45-A Extra-articular Pole fractures Extensor mechanism disrupted Operative:

! Lag srew+tension-band wire or

cerclage
! Transosseous suture+cerclage

45–B Partial articular Vertical fractures ! Non-displaced ! Non-operative

! Displaced, simple- ! Transverse lag screw+cerclage
multifragmentary ! Circumferential cerclage+tension
band

45-C Complete Transverse fractures Disrupted extensor mechanism ! K-wire+tension-band wire

articular ! Lag screw or K-wire+tension-band
! + Third fragment wire
! Four or more fragments ! K-wires, screws+tension-band
! Comminuted fracture ! Partial or total patellectomy
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400 I. Mehling et al.

the quadriceps muscle. Therefore, the knee should be to torsion forces.1 Nevertheless, both the figure-zero and
carefully flexed and the patella manually pulled distally the figure-of-eight wire enhance total stability and com-
before inflating the tourniquet. press the superficial parts of the fracture fragments.
The incision can either be longitudinal or transverse. We Especially the frontal wire changes distraction into com-
prefer the longitudinal incision over the patella, because, if pression during knee flexion. For symmetrical tensioning
necessary, it can be enlarged distally and proximally and of the wire, a double-loop technique is recommended.
does not interfere in case of later revision. For the best (Figs. 2–5 show examples of tension-band wiring). Then, the
cosmetic result, the transverse incision is preferable ends of the two cerclage wires are hand-tightened by lifting
because it lies within the Langer’s lines. However, one them up on the clamp. The proximal pins of the two
should consider that this approach may injure the infra- Kirschner wires are bent, shortened and turned towards the
patellar branch of the saphenous nerve. quadriceps tendon and put into the patella to avoid skin
Care should also be taken of the vessels of the geniculate irritation and loosening. The distal pins are cut at short
arteries, and an en-bloc preparation of the fasciocutaneous length so that they are not prominent within the patellar
layers under the bursa prepatellaris should follow. Under tendon. Finally, the quality of reduction should be checked
direct vision, an anatomical reconstruction is performed again and the knee gently flexed to assess the stability of the
with the aid of one or several bone reduction forceps. By fixation.
reducing smaller fracture fragments to each other, we Before wound closure, the tourniquet is deflated and
convert a complex fracture pattern into a simple one.8 haemostasis is achieved with electrocoagulation. A suction
Anatomical reduction of the articular surface is checked by drain is placed into the knee joint and closure of the
digital palpation of the patellofemoral joint inside the knee. wound can be performed in layers. First, closure of the
The most common osteosynthesis technique is tension- prepatellar bursa with 2–0 resorbable sutures is performed.
band wiring. The principle of this technique is to transform Then the subcutaneous tissues are closured with simple
distraction forces into compression forces. Two different inverted 2–0 resorbable sutures, and finally skin closure is
techniques of tension-band wiring are in use: the outside-in performed.
technique and the inside-out technique. In the outside-in With the tension-band wiring technique even comminuted
technique, the fracture is first reduced and then fixed with fractures can be reduced and stabilised.1 In these fractures,
two Kirschner wires (1.6 mm stainless-steel wire), which are the first step of internal fixation after fragment reduction is
drilled in the axial direction through the reduced fragments. the placement of the circumferential cerclage wire in order
In the inside-out technique, first the Kirschner wires are to avoid recurrent displacement of the fragments. An
drilled into one of the unreduced fragments, and then additional figure-of-eight cerclage wire must be combined
reduction and completion of the fixation follows. We prefer with the tension-band wiring technique. Screw osteosynth-
to drill the Kirschner wires from the distal to the proximal esis is an alternative to the tension-band wiring technique.
pole because it is easier to find the optimal entry portal in Depending on the thickness and bone quality of the patellar
the distal patellar pole for Kirschner-wire drilling. Following bone, 6.5 mm cancellous bone screws or 3.5 mm cortical
Kirschner-wire fixation, a 30 cm segment of a 1.25 mm wire screws can be used.9 Also, fractures of the superior or
should pass adjacent to and behind the Kirschner wires. inferior pole of the patella or fractures with small fragments
Close approximation of the wire to the proximal and distal can be stabilised by lag screws (see Fig. 6).
pole of the patella is recommended. The cerclage wire is In vertical patellar fractures, transverse lag screw fixation
placed in the form of a figure-zero or figure-of-eight fashion. in combination with a cerclage wire is a sufficient fixation
The figure-zero fashion in comparison seems more resistant technique (see Fig. 7).

Figure 2 Left patellar fracture in an 86-year-old female. The fracture has a transverse component with smaller additional fracture
fragments: (a, b) preoperative X-rays ap and lateral and (c, d) postoperative X-rays of fracture healing ap and lateral. The fracture is
stabilised with two K-wires and tension-band wiring with steel cable in double-loop technique.
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Comminuted patellar fractures 401

Figure 3 Right transverse patellar fracture in a 56-year-old female stabilised with three K-wires and tension-band wiring with
braided cable in figure-of-eight fashion: (a, b) preoperative X-rays AP and lateral and (c, d) postoperative X-rays of fracture healing
AP and lateral.

Figure 4 A minimally displaced multi-fragment fracture of the right patella in a 64-year-old female: (a, b) preoperative X-rays AP
and lateral, (c, d) postoperative X-rays AP and lateral showing slight distal migration of one of the K-wires and (e, f) X-rays AP and
lateral after hardware removal 1 year after osteosynthesis.

Another variation of the tension band technique in cannulated screws and tightened in a double-loop technique.
combination with screws is the use of 4.0 mm cannulated Berg10 described equivalent clinical results for transverse
screws with the tension-band wire passed through the patellar fractures for fixation with a tensioned anterior
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402 I. Mehling et al.

Figure 5 A comminuted patellar fracture in a 46-year-old female stabilised with three K-wires and double-loop tension-band
wiring: (a, b) preoperative X-rays AP and lateral, (c, d) postoperative X-rays AP and lateral with two visible suction drains, (e, f)
postoperative X-rays AP and lateral after 1 week showing a failure of the circular loop cable, (g, h) postoperative X-rays AP and
lateral after 4 months after removal of the broken cable and (i, j) postoperative X-rays AP and lateral 8 months after stabilisation.
Complete hardware removal was performed; the patellar fracture was completely healed.

figure-of-eight wire placed through parallel cannulated biomechanical comparison in transverse non-comminuted
screws in comparison to reports of fixation with modified patellar fractures, a better fixation with two Kirschner wires
tension-band wiring. and a 1.0 mm braided cable tension loop as opposed to a
Burvant et al.11 and Carpenter et al.12 showed, in monofilament wire tension loop.
biomechanical studies, a significantly higher stability for Fortis et al.14 demonstrated in an experimental investiga-
osteosynthesis with screws only or for the combination of tion that tension-band wiring is highly effective for the
cannulated screws with a tension-band wire compared to a fixation of the fractured patella but is improved by an
single tension-band wire. Scilaris et al.13 described, in a additional circular wire.
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Comminuted patellar fractures 403

Figure 6 Avulsion fracture of the distal pole of the patella in a 23-year-old male. Osteosynthesis was performed with two cancellous
bone screws: (a, b) preoperative X-rays AP and lateral and (c, d) postoperative X-rays of fracture healing AP and lateral.

Osteochondral fragments can be fixed with biodegradable flexion is most important for transforming distraction forces
pins. There are implants of polyglycolic acid (PGA), into compression forces, and this supports bone healing.
polydioxanone (PDS) or polylactic acid (PLA). These implants Continuous passive motion (CPM) is helpful in the early days
are only recommended for adaptation of unloaded frag- after surgery. Drains are removed on the second post-
ments and not in areas of high mechanical stress. Their operative day or depending on the amount of wound
advantage is that implant removal is not necessary.1,15 drainage. The patient begins with isometric exercises and
A new stabilisation technique for comminuted patellar out of bed mobilisation with the help of a physiotherapist.
fractures is described by Yammis et al.16 Instead of the For protection of the osteosynthesis, we prefer mobilisation
tension-band technique, they used a circular external with a semicircular plaster cast. Normally, full weight
fixator, which is placed under arthroscopic control. The bearing is allowed. Walking exercises begin with partial
authors suggested that this treatment can provide enough weight bearing of 15–20 kg or half body weight bearing and
stability to allow active knee motion in the early post- the help of two crutches for a 6-week duration. Actively
operative period. In addition, arthroscopic examination of assisted motion of the knee is allowed from full extension to
the knee allows assessment of other intra-articular lesions. 901 of flexion. Total weight bearing without the plaster cast
With a comminuted patellar fracture, a partial patellect- and free motion are allowed after the seventh postoperative
omy may be necessary if adequate anatomic reduction of week, provided that the patient has a good clinical feeling
the displaced fragments is not possible. Whenever possible, and that X-rays show ongoing bony healing. Implant removal
partial patellectomy is preferred to total patellectomy is possible after 1 year, on average.
because it keeps the fulcrum function of the patella intact.
A comminuted upper or lower pole or a comminuted zone in
the middle of the patella can be managed by removing the Complications and prognosis
small fragments. Non-resorbable transosseous sutures have
to be used after resection of the upper pole for fixation of Feared complications are disturbed wound healing and deep
the quadriceps tendon and after lower pole resection for infection. Careful soft tissue debridement, spared resection
fixation of the patellar tendon, securing the suture with a and secondary wound closure are recommended to reduce
tension-band wire. A tilt of the remaining patella should be wound healing disturbances. In cases of larger skin defects,
avoided in all cases. split skin grafting or gastrocnemius rotation flaps covered
In cases of severe comminution and extended cartilage with split skin grafts may be necessary. Infection should be
damage a patellectomy may be the only option. However, treated aggressively with radical debridement with drainage
one should be aware that this always means a decrease in and with antibiotics.
muscle strength of the quadriceps muscle. All bony Bowing of the Kirschner wires or failure of the figure-zero
fragments and the damaged tissue should be removed or figure-of-eight fashion wire may happen in patients who
leaving as much extensor apparatus as possible. If the perform unlimited and aggressive early active mobilisation.
defect zone is more than 4 cm wide and a direct adaptation When fracture displacement occurs in relation to the above,
is not possible, an inversion of the quadriceps tendon in re-osteosynthesis is mandatory. Sometimes, rupture of the
accordance to Miyakawa17 may be necessary. wire is discovered later on. There is no need for intervention
when the patellar fracture is already healed.
Another possible complication after surgical treatment of
Postoperative treatment patellar fractures is loss of fixation and reduction. If there is
a loss of fixation without loss of reduction, the leg should
The postoperative treatment depends on the fracture type temporarily be immobilised. If there are signs of loss of
and the stability of surgical fixation. In patients with stable fixation and reduction, a revision of internal fixation should
fractures, knee motion exercises begin immediately. Knee be performed.
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404 I. Mehling et al.

remaining steps or gaps. Nevertheless, an unsatisfactory

outcome is also possible when the radiographic examination
shows an anatomical healing.
As with other articular lesions, there is evidence that
optimal reduction will give the best long-time results. Steps
and gaps in the articular surface will be responsible for knee
complaints such as swelling, pain and diminution of move-
ment.

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