Bilateral sleeve fracture of the inferior poles of the patella in a healthy child: case report and review of the literature.

The initial diagnosis of a sleeve fracture of the patella is key to a successful outcome with poor results well documented in the literature from delayed management. Diagnosis is difficult due to the rarity of this injury and thus the low likelihood the admitting junior doctor would think of this injury in their differential. They are very uncommon in incidence and have features on plain radiography that are difficult to interpret unless the surgeon is familiar with the anatomy of the immature patella. Missing the diagnosis can be disastrous for the patient. In this paper we describe the presentation of bilateral sleeve fractures in a healthy child, our initial investigations and subsequent management. We chose to repair with 5 Ethibond via 3 transosseous tunnels, initially reinforced with a circlage wire. On last review the boy maintains stable, pain-free knees with a full range of motion. The authors hope that this case and literature review will provide a valuable teaching aid and so assist in early, accurate diagnosis and cover the management options to achieve a positive outcome.

Lateral entry fixation using three divergent pins for displaced paediatric supracondylar humeral fractures.

Background. Supracondylar fractures are the commonest elbow injury in children. Most displaced supracondylar fractures are manipulated and held with a medial/lateral entry or two lateral Kirschner wires. This clinical study has results purely from a three lateral divergent wire technique. Methods. Displaced supracondylar fractures were manipulated closed and three lateral divergent wires inserted. Primary study end points were range of movement and carrying angle relative to the contralateral uninjured elbow (Flynn's grading system) and presence of iatrogenic nerve or vessel injury. Results. 25 children between 3 and 10 years (median 5, range 3-10) suffered a displaced fracture (15 type III, 10 type IIB). 15 left-, 10 right-sided fractures, 14 boys and 11 girls). 23 were fixed primarily, of these 21 in the first 24 hours. 2 were delayed due to swelling. 2 were fixed secondarily with lateral k-wires after loss of position (from a primarily fixed crossed wire technique). One radial and one median nerve palsy sustained at injury settled. No iatrogenic nerve injuries occurred. 21 Excellent, 3 good and 1 poor result on Flynn's grading. Conclusions. The use of three wires on the lateral side in this cohort showed no evidence of slip in fracture position and no iatrogenic nerve injury.