Introduction Overview patellar sleeve fractures are a rare injury seen in children between 8 and 12 years of age characterized by separation of the cartilage "sleeve" from the ossified patella most fractures are displaced and require treatment with open reduction and internal fixation Epidemiology incidence <1% of pediatric fractures accounts for >50% of patella fractures in children demographics more common in males (5:1) occurs in children 8-12 years old when patellar ossification is nearly complete Pathophysiology mechanism of injury indirect injury caused by powerful contraction of the quadriceps muscle applied to a flexed knee pathoanatomy separation between the cartilage "sleeve" and main part of the patella and ossific nucleus Prognosis higher risk of complications associated with greater degree of comminution displacement Anatomy Osteology patella is largest sesamoid bone in body ossification begins at 3-5 years old superior 3/4 of posterior surface covered by articular cartilage articular cartilage thickest in body (up to 1cm) posterior articular surface comprised of medial and lateral facets lateral facet is larger facets separated by vertical ridge Soft tissue attachments quadriceps tendon and fascia lata attach to anterosuperior margin quadriceps tendon comprised of 3 layers superficial layer formed from rectus femoris tendon middle layer formed by vastus medialis and vastus lateralis tendons deep layer formed by vastus intermedius tendon patellar tendon attaches to inferior margin Blood Supply derived from anastomotic ring originating from geniculate arteries most important blood supply to the patella is located at the inferior pole Classification Anatomic superior pole least common inferior pole most common Presentation History indirect injury not associated with a direct blow to the knee Symptoms severe knee pain inability to bear weight Physical exam inspection soft tissue swelling diffuse tenderness hemarthrosis of the knee joint is often present high-riding patella or palpable gap at the distal end of the patella indicates disruption of the extensor mechanism motion difficulty with active extension of the knee, especially against resistance Imaging Radiographs recommended views AP lateral tangential findings small flecks of bone adjacent to superior or inferior pole diagnosis may be missed because the distal bony fragment is not readily discernible on radiographs slight anterior tilt of superior pole seen with proximal fractures patella alta seen with distal fractures patella baja seen with proximal fractures MRI or ultrasound indications may be useful for identifying a sleeve fracture when the diagnosis is not clear from the clinical and radiographic findings Treatment Nonoperative cylinder cast for 6 weeks indications nondisplaced fractures with intact extensor mechanism rare (most require ORIF) Operative open reduction and internal fixation indications > 2-3mm displacement > 2-3mm articular step-off disrupted extensor mechanism Technique Open reduction and internal fixation approach medial parapatellar approach to knee soft tissue repair torn medial/lateral retinaculum and/or quadricept/patellar tendon instrumentation stabilize fracture using transosseous sutures modified tension band wiring intraosseous suture anchors interfragmentary screws post-operative care cylinder cast in extension for 2-3 weeks Complications Patella alta Extensor lag Quadriceps atrophy Malunion Nonunion Painful hardware
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.77) A 10-year-old female presents to the emergency department complaining of anterior knee pain after a fall from her bicycle. Exam reveals ecchymosis and swelling over the patella and an extensor lag. Radiographs are shown in Figures A and B. What is the most appropriate next step in treatment? Review Topic QID: 2890 FIGURES: A B 1 Open reduction and suture fixation 76% (894/1172) 2 Open reduction and internal fixation with plating and wire cerclage technique 5% (59/1172) 3 Cylinder cast 5% (54/1172) 4 Partial patellectomy and advancement of patellar tendon 3% (38/1172) 5 Patellar tendon midsubstance rupture repair with nonabsorbable suture 11% (125/1172) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Patella sleeve fracture in a 12M (C101038) Pediatrics - Patella Sleeve Fracture HPI - Fall on bent knee Would you order further imaging in this patient? 2/9/2018 201 6 1