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ULY CLINIC

22 Septemba 2025, 00:16:07

Cleeman’s sign

Cleeman’s sign is a slight linear depression or wrinkling of the skin superior to the patella, typically indicative of a femoral fracture with overriding bone fragments. This clinical finding helps in identifying displaced fractures of the distal femur, especially when swelling or deformity obscures the usual bony landmarks.

Pathophysiology

A femoral fracture, particularly of the distal femur, may result in overriding of bone fragments due to muscle pull (quadriceps and hamstrings).
The skin and subcutaneous tissues above the patella are drawn inward or wrinkled, producing the characteristic linear depression.
This visual and palpable change reflects underlying skeletal misalignment and soft tissue adaptation to displaced fragments.

Examination Technique

Patient Positioning

The patient may be supine with the knee extended or slightly flexed if tolerated.

Inspection

Observe the skin just superior to the patella for a linear depression, wrinkling, or abnormal contour.

Palpation

Gently palpate the area to assess for underlying step-off, tenderness, crepitus, or abnormal mobility.

Assessment

Document the location, length, and depth of the depression.
Compare with the contralateral knee to assess asymmetry.

Clinical utility

Indicator of distal femoral fracture: Suggests overriding bone fragments even if gross deformity is minimal.
Adjunct to radiologic evaluation: Guides the need for X-ray or CT imaging to confirm fracture pattern and displacement.
Early detection: Helps prevent missed diagnosis in trauma cases with soft tissue swelling.

Differential Diagnosis

Cause / Condition	Key Features	Notes
Distal femoral fracture	Pain, swelling, depression above patella, limited knee movement	Cleeman’s sign supports diagnosis; imaging required
Patellar fracture	Localized pain, tenderness, possible skin depression	Fracture may mimic Cleeman’s sign but usually involves patella itself
Quadriceps tendon rupture	High-riding patella, inability to extend knee	Linear skin depression absent; tendon gap may be palpable
Prepatellar bursitis	Swelling, tenderness, limited knee flexion	Typically diffuse swelling; no linear depression

Pediatric considerations

Rare in children due to different fracture patterns and bone elasticity.
May be more subtle; careful palpation required.

Geriatric considerations

Older adults with osteoporotic bones may present with minimal trauma.
Cleeman’s sign can be a critical visual cue in detecting occult fractures.

Limitations

May be absent in fractures without overriding fragments.
Swelling, hematoma, or obesity can obscure the linear depression.
Not definitive; radiographic confirmation is mandatory.

Patient counseling

Explain that the skin change may indicate an underlying bone fracture.
Emphasize the importance of immobilization, imaging, and orthopedic follow-up.
Discuss potential interventions including casting, traction, or surgical fixation, depending on fracture severity.

Conclusion

Cleeman’s sign is a subtle but valuable clinical indicator of distal femoral fractures with overriding bone fragments. Recognition of this sign, combined with careful palpation and imaging, enhances early diagnosis and appropriate orthopedic management.

References

Rockwood CA, Green DP. Fractures in Adults. 9th ed. Philadelphia: Wolters Kluwer; 2019.
Bucholz RW, Heckman JD. Rockwood and Wilkins’ Fractures in Children. 8th ed. Philadelphia: Wolters Kluwer; 2019.
Court-Brown CM, McQueen MM. Trauma and Orthopaedic Surgery: Fracture Diagnosis and Management. London: Elsevier; 2017.
Beaty JH, Kasser JR. Rockwood and Wilkins’ Fractures in Children. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010.
Canale ST, Beaty JH. Campbell’s Operative Orthopaedics. 14th ed. Philadelphia: Elsevier; 2021.