Clinical and Radiographic Differentiation of Pediatric Patellar Sleeve Fractures and Other Inferior Pole Pathologies.

Abstract

Inferior pole patellar sleeve fractures (PSFs) are rare injuries that occur in skeletally immature patients that may be missed or falsely diagnosed as an inferior pole fracture (IPF) or Sinding-Larsen-Johansson syndrome (SLJS). The objective of this study was to evaluate and compare clinical and radiographic features of patients with PSF, IPF, and SLJS. Cross-sectional study; Level of evidence, 3. Retrospective review of skeletally immature patients diagnosed with PSF, IPF, and SLJS between 2011 and 2019 at a single urban academic center was performed. Chart and radiographic review was completed. Between-group differences were assessed using analysis of variance, Kruskal-Wallis test, and Fisher exact test, as appropriate to variable distributions. In total, 125 patients (82% male) were included, with a mean (SD) age of 10.7 (2) years (16 PSF, 51 IPF, 58 SLJS). There were no significant differences in patient characteristics between the 3 groups. One hundred percent of the patients with PSF (<i>P</i> < .001) and IPF (<i>P</i> < .001) had acute trauma, compared with 24% of patients with SLJS. Fewer patients with PSF had an intact straight leg raise (38%) compared with those with IPF (94%; <i>P</i> < .001) and SLJS (98%; <i>P</i> < .001). Fewer patients with SLJS had knee swelling (41%) compared with those with PSF (93%; <i>P</i> < .001) and IPF (94%; <i>P</i> < .001). More patients with PSF had knee effusion (81%) compared with those with IPF (37%; <i>P</i> = 0.011) and SLJS (3%; <i>P</i> < .001). More patients with SLJS were able to bear weight (88%) compared with those with IPF (12%; <i>P</i> < .001) and PSF (0; <i>P</i> < .001). Radiographically, compared with those with IPF and SLJS, patients with PSFs had increased mean prepatellar swelling (6.1 [<i>P</i> < .001] and 6.5 [<i>P</i> < .001] vs 12.9 mm), intra-articular effusion (6.1 [<i>P</i> = .014] and 4.9 [<i>P</i> = .001] vs 9.2 mm), maximum fragment size (26 [<i>P</i> = .004] and 17.7 [<i>P</i> < .001] vs 45.3 mm), and maximum fragment displacement (1.24 [<i>P</i> = .002] and 1.45 [<i>P</i> = .003] vs 13.30 mm), respectively. Compared with those with SLJS (1.10), patients with PSF (1.92; <i>P</i> < .001) and IPF (1.22; <i>P</i> < .001) had patella alta with higher mean Insall-Salvati ratios >1.2. Differences in clinical features such as ability to straight leg raise, knee swelling, knee effusion, ability to bear weight, and radiographic features, such as prepatellar swelling, intra-articular effusion, fragment displacement/size/shape/location, and patellar height, can all be helpful in recognizing rare pediatric inferior patellar pathology, thus increasing efficiency in indicating for higher-level imaging to reach a prompt diagnosis and provide appropriate treatment.