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Case of the Month - June 2014

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OIC Medical Director

on 1 July 2014

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Transcript of Case of the Month - June 2014

6+6 y/o boy-Clinical Exam UCC
Tenderness around the knee
Significant soft tissue swelling
Does not cooperate to actively extend the right knee
Pain with flexion of the knee
CRP: 0.8; ESR: 24; WBC: 10,000
Case of the Month - June 2014

6+6 y/o boy
Fell down 3 steps, onto the right knee
Patient seen by his PCP
Diagnosed with patella dislocation

Referred to an orthopaedic UCC
All of the diagnoses are possible
1. Patient is afebrile and labs are normal. While possible, an infection is unlikely.
Pre-patellar bursitis
, an entity that is commonly associated with local infection, will not present with inability to actively extend the knee.
3. An
ACL injury might
have a similar clinical appearance, but the mechanism of injury will be different and the patient will be able to extend the knee.
4. A
knee contusion
is rarely associated with the amount of soft tissue injury seen on this patient's x-rays. The patient will be able to perform a straight-leg raise against resistance.
5. Although a
patellar dislocation
is a possibility, it is not very common in this age range. It is not commonly associated with the amount of soft tissue swelling seen on this patient

In this particular case, you should have suspected a patellar sleeve fracture (PSF)
Did you noticed how high is the patella with respect to the Blumensaat's line?
What is your diagnosis?
1. Septic arthritis of the right knee
2. Pre-patellar bursitis
3. ACL injury
4. Knee contusion
5. Patella dislocation
6. Patella fracture
Normally, this line intersects the distal pole of the patella when the knee is flexed 30 degrees
This is a similar case, but it is easier to diagnose because the distal pole is better ossified. It was managed with ORIF
There is a sleeve of periosteum attached to the distal pole of the patella
Small flecks of bone adjacent to the poles in a patient with an acute injury may indicate the presence of this fracture
Lateral x-rays of both knees at 30° of flexion may be helpful to confirm a high-riding patella on the injured side
MRI or ultrasound may be helpful for detecting a sleeve fracture when the diagnosis is not clear from the clinical and plain x-rays

PSF - Management
While some fractures can be managed without surgery, a patient with a patellar sleeve fracture who has a compromised extensor mechanism should receive early surgical fixation
Back to our 6.6 y/o boy
X-rays taken 6 weeks later demonstrated the ossifying distal pole separated from the main body of the patella, confirming the presence of a sleeve fracture
Recommended Reading
Fractures Around the Knee in Children
Zionts, LE.
J Am Acad Orthop Surg. 2002; 10(5):345-55
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