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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?
Open reduction and suture fixation
Open reduction and internal fixation with plating and wire cerclage technique
Partial patellectomy and advancement of patellar tendon
Patellar tendon midsubstance rupture repair with nonabsorbable suture
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Patella sleeve fractures occur most commonly in children aged 8-12. This injury involves an avulsion of cartilage (and sometimes a small piece of bone) from the inferior pole of the patella. Sleeve fractures should be accurately reduced and stabilized using suture fixation thru bone tunnels in the patella. K wires can be added if the fracture fragment is large enough.
These fractures may be missed on plain radiographs if there is no obvious bony injury. Radiographs will typically show an effusion, patella alta, and possibly a bony avulsion. In uncertain cases, an MRI is useful to define the extent of injury.
The article by Zionts reviews the diagnosis and management of fractures about the distal femur, proximal tibia, and patella in children.
Figures A and B demonstrate patella alta and a small amount of bone that is avulsed from the patella. Illustration A is a cartoon demonstrating patellar sleeve fractures and Illustration B is a second example of a radiograph with a patellar sleeve fracture.
J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):345-55.PMID: 12374485 (Link to Abstract)
Zionts, JAAOS 2002
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