Chronic Bilateral Sleeve Fracture of the Patellae in a Healthy Child: A Case Report
Sleeve fracture of the patella is a unique type of patellar injury that predominantly affects the pediatric population. It is characterized by an avulsion fracture in which the avulsed fragment consists of a small bony portion from the patella accompanied by a large segment of articular cartilage. This type of injury accounts for approximately half of all patellar fractures in children. However, the occurrence of bilateral sleeve fractures is extremely rare, and there is limited literature on the treatment and prognosis of such injuries, especially in their chronic phase. This report presents the first documented case of chronic bilateral sleeve fracture of the patellae in a healthy 13-year-old boy, providing valuable insights into the diagnosis, management, and outcomes of this rare condition.
Case Presentation
The patient was a 13-year-old boy who sustained an injury during a running competition. He suddenly felt weakness in both knees and fell to the ground. Initially admitted to a local hospital, magnetic resonance imaging (MRI) revealed bilateral discontinuities of the patellar tendons, prompting the decision for surgical intervention. However, the surgery was delayed due to the patient developing a fever with a high temperature of 39.0°C. Blood tests indicated an extremely low lymphocyte count, with CD4 levels at 144/mL, although other laboratory results were unremarkable. After a week of antibiotic treatment, his temperature normalized, and CD4 levels increased to 400/mL.
The patient was subsequently transferred to our hospital for further management. Clinical examination revealed quadriceps atrophy, swelling of both knees, and high-riding patellae (patella alta). Palpation identified a tender palpable gap at the inferior poles of both patellae. The patient had difficulty straightening his legs, and the active range of motion (ROM) of both knees was limited to 40° to 110°. Lateral radiographs showed small avulsed bony fragments of the bilateral patellae and patella alta. Computed tomography (CT) and MRI confirmed the diagnosis of bilateral patellar sleeve fractures.
Hospital Course and Surgical Management
During his hospital stay, the patient developed an upper respiratory infection, necessitating antibiotic treatment and further postponing the surgery. The operation was finally performed two months after the initial injury. The surgical procedure involved open reduction and internal fixation of both knees. Prophylactic antibiotics were administered during the perioperative period. A midline incision was made, and the avulsed fragments of bone and cartilage were removed. Three 2-mm diameter transosseous tunnels were drilled from the inferior pole to the anterior side of the middle part of the patella. Orthocord sutures (DePuy Mitek, USA) were used to rigidly fix the patellar tendons.
Postoperative Management and Follow-Up
Postoperatively, the patient was immobilized in bilateral straight splints for three weeks, followed by routine physical therapy. At the one-year follow-up, the patient had regained full and painless ROM in both knees. MRI at this time showed good continuity of the bilateral patellar tendons and complete healing of the fractures.
Discussion
Sleeve fracture of the patella is a unique injury in children, involving an avulsion fracture with a small bony fragment and a large portion of articular cartilage. Treatment options for this injury include both nonoperative and operative approaches. Conservative treatment is typically reserved for minimally displaced fractures, while surgical intervention is necessary for more severe cases. Early treatment is associated with a good prognosis, whereas delayed treatment can lead to chronic complications such as nonunion of the fracture, patellar pain, quadriceps atrophy, restricted ROM, and patella alta. Additionally, the avulsed cartilaginous fragment may undergo ossification or ectopic bone formation within the patellar tendon.
For patients with symptomatic chronic sleeve fractures, conservative treatment such as cast immobilization may result in continued quadriceps atrophy, soft tissue healing, persistent patellar deformity, and restricted ROM. Therefore, surgical intervention is often required. Surgical techniques for acute patellar sleeve fractures include transosseous suturing, tension band wiring, absorbable sutures, and suture anchors. However, there is no consensus on the optimal treatment for chronic sleeve fractures. In our case, transosseous non-absorbable suturing was used to achieve solid fixation, resulting in excellent outcomes at the one-year follow-up.
Surgical Complications and Prevention
Potential complications of surgery for patellar sleeve fractures include avascular necrosis of the patella, wound infection, and knee flexion limitations. In our case, the patient had a history of infection prior to surgery, necessitating the use of prophylactic antibiotics during the perioperative period. No signs of infection were observed postoperatively.
Conclusion
Chronic bilateral sleeve fracture of the patellae is an extremely rare injury in the pediatric population. This case report describes the successful management of a 13-year-old boy with chronic bilateral sleeve fractures using transosseous suturing two months after the initial injury. The patient achieved excellent outcomes at the one-year follow-up, with full and painless ROM and complete healing of the fractures. This report highlights the importance of timely surgical intervention and the effectiveness of transosseous suturing in managing chronic patellar sleeve fractures.
doi.org/10.1097/CM9.0000000000000926
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