1. Sleeve Fractures of the Patella
A Case report
Dr. V. Singh Chauhan
Dr. Michael Maru

2. Outline History and Physical Examination Preop and Post op info
Dr. V Singh Chauhan
Orthopedic Registrar University of Nairobi
Dr. Michael Maru
Consultant Orthopedic Surgeon, PCEA Kikuyu Rehab Hospital
History and Physical Examination
Preop and Post op info
Discussion

3. History A.K, 12yr old Boy PCEA Kikuyu Rehab Hospital, Feb 2016
Rt Knee pain & inability to extend knee
Fall while playing football………jumping
Knee ‘gave way’

4. Physical Exam Swelling Rt knee, tender
Palpable gap inferior aspect of patella
High riding Patella
Difficulty raising leg

5. Xrays Patella Alta Small Distal fragment Insal Salvati index >1.4
Intact Patella Tendon

6. What was done Midline incision Confirmation of diagnosis intra op
Repair of Sleeve # with 2-0 fibre suture
Construct secured with backslab

7. Intra-op showing the fracture

8. Intra-op showing repair of the fracture with fibre 2-0 sutures with repair of retinaculum

9. Post-op Xray

10. Discussion Patella #s rare in skeletally immature (1%)
Sleeve #s – 57% of the patella #s here
Highly mobile
Surrounded by protective layer of cartilage
Chondral/osteochondral avulsion at either pole of patella
Commonest ……………….Distal
Avulsion occurs with articular cartilage, periosteum & retinaculum that’s pulled off the main body

11. Discussion

12. Why missed? Much of the fragment is unossified
Missed on radiograph
Rare ………The eyes will not see what the brain doesn’t know
Lack of knowledge amongst primary clinicians
Usually misinterpreted for small bone avulsion of patella pole
May be unrecognised if no ossified bone in the sleeve
-Normal ossification 3-6yrs and is completed at puberty. -

13. So what if its missed Motion resistance in extension
Development disturbances in patella
Double patella / Mega patella / AVN

14. What aids in initial clinical diagnosis?
Understand the anatomy of the immature patella
High index of suspicion
Knee swelling without direct trauma esp in sports
Unable to perform straight leg raise
Patella Alta on xray for distal pole #s
…………………….Do MRI if suspicious

15. What can be done Conservative mx Operative Minimal displacement……….MRI
Anatomical repositioning and stable fixation
Figure of 8 suturing technique
Anchors
TBW
Protect with cast 4-6wks
Complications
Infection
Limited Knee flexion
Ectopic Bone formation
Ischaemic necrosis of patella

16. References
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Schmal H, Strohm P. Fractures of Patella in children and Adolescents. Acta Orthop. Belg., 2010, 76,
Kameyamu O, Ogawa R. Sleeve fractures of patella in children: a review of 2 cases. J Kansai Med Univ., 1991, 43
Shu-Yuan Lin, Wei-Chun Lin, Jing-Wein Wang. Inferior Sleeve Fractures of Patella: A case report. Journal of the Chinese Medical Association 74 (2011) 98e101
Tom VAN ISACKER, Hugo DE BOECK, Sleeve fractures of the upper pole of the patella: A case report. Acta Orthop. Belg., 2007, 73,
Guy S, Marciniak J, Tulwa N, Cohen A. Bilateral Sleeve Fracture of the Inferior Poles of the Patella in a Healthy Child: Case Report and Review of the Literature. Advances in Orthopedics Volume 2011, Article ID 428614, 4 pages Labronici P. J, Fernandes H. J. A, AraujoGoes R, Dos Reis F. Patella Fractures in Children(Sleeve Type Fractures. ACTA ORTOP BRAS., 2005, 13(5)
Gao GX, Mahadev A, Lee EH. Sleeve fracture of the patella in children. J Orthop Surg 2008;16:43e6.
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Dai LY, Zhang WM. Fractures of the patella in children.Knee Surg Sports Traumatol Arthrosc 1999 ; 7 :
P. D. Sponsellar and J. H. Beaty, “Fractures and dislocations of the knee,” in Fractures of the Patella in Children, C. A. Rockwood Jr., K. E. Wilkins, and J. H. Beaty, Eds., vol. 3, pp. 1284–1290, Lippincott Williams & Wilkins, Philadelphia, Pa, USA, 1996
Grogan DP, Carey TP, Leffers D, Ogden JA. Avulsion fractures of the patella. J Pediat Orthop 1990;10:721e30