Outline:  
Fracture of patella is usually caused by a sudden fall in which the patella is pulled by contracture of quadriceps muscle of thigh or bumps against the ground. Fracture caused by contracture of muscle is often transverse, with fragments separated from each other (see Fig. 18). Fracture caused by direct force is often comminuted, but with no marked displacement because of restraint of aponeurosis. This fracture often occurs in young and the middle aged people.

Major points for diagnosis  
1. There is an evident traumatic history of fall.
 
2. The patient has a sharp pain in the knee after fall, and can not move the knee.

3. There is an apparent swelling in the injured knee with ecchymoses and tenderness. Fracture with displacement is characterized by a palpable transverse groove and bony crepitus in the anterior aspect of the knee. There is also dysfunction of extending the knee actively.
 
4. X-ray film can determine the type and displacement of fracture. An axial film of patella may be taken to exclude the fracture of patella border.

Treatment:   
In the treatment of fracture of patella, it is essential that the function of extending the knee should be restored and the articular surface should be kept smooth and integral so as to prevent the development of traumatic arthritis.

Reduction:
Anesthesia is generally not needed. The diseased knee joint is stretched. The operator fixes the distal end of fracture with one hand and   grasps the two sides of the proximal end with the other hand, then slowly pushes and squeezes them towards the middle to make the fragments meet together. As soon as the two fracture ends are in contact, the operator's hands work in cooperation and gently move the two fragments leftward and rightward. When the bony crepitus disappears, the operator holds firmly the whole patella with one hand and palpates the anterior border of patella up and down with the thumb and the index finger of the other hand. If he feels even and smooth under his fingers, it indicates that the reduction has been achieved.

Fixation:
For fissure fracture, a long splint lined with cushion is put on the posterior side of the leg with the posterior aspect of the knee being slightly padded, then wrapped it up with bandage for fixation. The upper border of the splint should reach the middle-upper segment of the thigh and the lower border should reach the heel. For fresh fracture with displacement, reduction, a long splint is put on the posterior side lowing of the leg. The upper border of the splint should get at the middle-lower segment of the thigh and the lower border should reach the heel. A cotton pad is put on the posterior part of the knee and another cotton pad covers the anterior side of the knee.

A horse-shoe paperboard or bone-holding pad is placed on the proximal end and another horse-shoe-shaped paperboard or bone-holding pad on the distal end. Then wrap it with strips for fixation. In addition, two broad adhesive tapes are used to stick to the two paperboards or bone-holding pads respectively, and pulled to the correspondingly opposite side to achieve a precise paraposition of the two fragments. Finally, an∞-shaped bandage for knee is used to wrap the fragments for fixation. A knee-holding ring or a patella-grasping device may be applied for fixation. In the case of fracture with wide separation space, pressure fixation with transcutaneous needle may be used.

Functional exercise:
Following reduction and fixation, the patient is encouraged to do functional activities of ankle and toe joints, but the activity of contraction of quadriceps muscle of thigh should be avoided. After the removal of the fixation, the patient should practice contraction of quadriceps muscle of thigh to gradually increase the scope of movements of the knee joint, but precaution should be taken against squatting down blindly. The functional exercises should take the active motion as the principal and the passive motion as the auxiliary.

Herbal therapy  
Internal treatment based on syndrome differentiation  

1. In the early stage  
Main symptoms and signs:
Swelling and pain in the knee with ecchymoses, dysfunction in stretching the knee.
 
Therapeutic methods:
Promoting blood flow to remove the stasis, relieving the swelling to stop pain.
 
Recipe and herbs:
Modified Huoxue Zhitong Decoction. Specifically, Danggui ( Radix Angelicae Sinensis )10 g, Chishaoyao (Radix Paeniae Rubrae)10 g, Chuanxiong (Rhizoma Ligustici Chuanxiong)10 g, Honghua (Flos Carthmi )6 g, Zhechong (Eapolyphaga seu Steleophaga)10g, Sanqi (RadixNotoginseng)9 g, Huainiuxi (Radix Achyranthis Bidentatae )10 g, Chenpi ( Pericarpium Citri Reticulatae )10 g, Luodeda ( Herba Centellae)10 g, Ruxiang ( Gummi Olibanum )6 g and Gancao (Radix Glycyrrhizae)5 g.

2. In the middle stage  
Main symptoms and signs:
Subsided swelling and pain, unhealed fracture.

Therapeutic methods:
Uniting bones and promoting the growth of fresh bone.

Recipe and herbs:
Modified Xugu Huoxue Decoction. The herbs see the treatment of fracture of femoral shaft in the middle stage.

3. In the late stage  
Main symptoms and signs:
Adhesion of tendons and bones, muscular atrophy, rigidity of the knee, impaired movement of flexion and extension.
 
Therapeutic methods:
Relaxing tendons and activating collaterals, and freeing joint movement.

Recipe and herbs:
Modified Kuanjin Powder. Specifically, Qianghuo ( Rhizoma seu Radix Notopterygii )10 g, Fangfeng ( Radix Ledebouriellae Divaricatae )10 g, Xuduan (Radix Dipsaci)10 g, Chishaoyao (Radix Paeniae Rubrae )10 g, Guizhi ( Ramulus Cinnamomi Cassiae)6 g, Danggui (RadixAngelicae Sinensis)10 g, Dilong (Lumbricus)15 g, Ruxiang (Gummi Olibanum)10 g, Moyao (Myrrha)10 g, Duhuo (RadixAngelicae Pubescentis )10 g, Chenpi ( Pericarpium Citri Reticulatae)10 g and Gancao ( Radix Glycyrrhizae )5g.