Tibial Eminence Fracture

Author:

http://upload.orthobullets.com/topic/4022/images/tibial eminence.jpg
http://upload.orthobullets.com/topic/4022/images/tibial eminence classification.jpg
http://upload.orthobullets.com/topic/4022/images/nondisplaced tibial eminence.jpg
http://upload.orthobullets.com/topic/4022/images/tibial eminence classification 2.jpg
http://upload.orthobullets.com/topic/4022/images/type 2.jpg
Introduction
  • A fracture of the bony attachment of the ACL on the tibia
  • Epidemiology
    • rare injuries
    • most common in ages 8-14
  • Mechanism
    • traumatic
      • rapid deceleration or hyperextension of the knee
      • same mechanism that would cause ACL tear in adult
  • Associated conditions
    • occur in 40% of eminence fractures
      • meniscal injury 
      • collateral ligament injury
      • capsular damage
      • osteochondral fracture
Anatomy
  • Osteology
    • tibial eminence
      • non-articular portion of the tibia between the medial and lateral tibial plateau
  • Ligaments
    • anterior cruciate ligament
      • inserts 10-14 mm behind anterior border of tibia and extends to medial and lateral tibial eminence
Classification
 
Meyers and McKeever Classification
Type I Nondisplaced
Type II Minimally displaced with intact posterior hinge

Type III Completely displaced
 
Presentation
  • Symptoms
    • pain in knee
  • Physical exam
    • inspection
      • immediate knee effusion
    • ROM
      • often limited secondary to pain
      • once pain is controlled, lack of motion may indicate
        • meniscal pathology
        • displaced/entrapped fracture fragment
      • positive anterior drawer
Imaging
  • Radiographs
    • recommended views
      • standard knee radiographs
  • CT
    • useful for pre-operative planning
  • MRI
    • better at determining associated ligamentous/meniscal damage than CT or radiographs
Treatment
  • Nonoperative  
    • closed reduction, aspiration of hemarthrosis, immobilization in 0-20° of flexion
      • indications
        • non-displaced type I and reducible type II fractures
      • reduction maneuver = extend the knee to 20° short of full extension to observe for fragment reduction
  • Operative
    • ORIF vs. all-arthroscopic fixation
      • indications
        • Type III or Type II fractures that cannot be reduced
        • block to extension
Sugical Techniques
  • Arthroscopic fixation 
    • approach
      • standard arthroscopic portals
    • technique
      • debride fracture
      • disengage entrapped meniscus or intermeniscal ligament
        • medial meniscus entrapment most common
      • reduce fracture
      • fracture fixation
        • suture fixation
          • pros
            • avoids physis
          • cons
            • technically demanding
        • screw fixation
          • pros
            • less demanding than suture fixation
            • possibly earlier mobilization
          • cons
            • hardware irritation
            • impingement from improperly placed screw
            • physeal damage
    • post-operative care
      • early range of motion
      • length of limited weight bearing is controversial
  • Open fixation
    • same principles as arthroscopic
Complications
  • Arthrofibrosis 
    • more common with surgical reconstruction
  • Growth arrest
  • ACL laxity
    • incidence
      • 10% of knees managed surgically
      • 20% of knees managed non-operatively
    • often not clinically significant
 

Please rate topic.

Average 4.0 of 31 Ratings

Questions (2)

(OBQ11.237) A 19-year-old patient is undergoing an arthroscopic treatment of a right knee with suture fixation via transosseous tunnels shown in the video in Figure V. What is the most likely postoperative complication? Review Topic

QID:3660
FIGURES:
1

Infection

1%

(13/1295)

2

Arthrofibrosis

76%

(979/1295)

3

Spontaneous osteonecrosis of the knee (SONK)

3%

(37/1295)

4

Hardware prominence in the intercondylar notch necessitating removal of implants

15%

(196/1295)

5

Increased posterior tibial excursion

5%

(62/1295)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Intercondylar eminence fractures that occur in adolescent or adult patients need to be counseled as to the risk of development of stiffness and arthrofibrotic scar tissue. This often presents with the inability to achieve full knee extension.

Lubowitz et al present a Level 5 review article emphasizing that early range-of-motion exercises are critical to prevent loss of extension in patients that have been operatively treated for intercondylar eminence fractures.

Montgomery et al present Level 4 evidence of 17 adults treated arthroscopically with suture fixation for displaced anterior cruciate ligament avulsion fractures. They found that 9 (53%) had severe difficulty regaining motion postoperatively and about 25% of the patients required a manipulation under anesthesia for arthrofibrotic scar tissue.

Illustration V demonstrates a tibial intercondylar eminence fracture treated with suture fixation via transosseous tunnels.

ILLUSTRATIONS:

Please rate question.

Average 3.0 of 15 Ratings

Question COMMENTS (5)

(OBQ06.56) The AP radiograph in Figure A demonstrates an injury in a 13-year-old soccer player. What is the equivalent injury in a skeletally mature patient? Review Topic

QID:167
FIGURES:
1

Patella tendon rupture

3%

(10/316)

2

Posterior cruciate ligament tear

2%

(6/316)

3

Anterior cruciate ligament tear

91%

(287/316)

4

Lateral meniscus tear

2%

(5/316)

5

Posteromedial capsular avulsion

2%

(6/316)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The radiograph demonstrates a displaced fracture of the tibial spine. The ACL inserts on the tibial eminence and the lateral aspect of the medial tibial spine. Mid-substance ACL tears are seen in both children and adults, but tibial spine fractures are seen primarily in the skeletally immature. The analogous injury in the adult knee would be an ACL tear, and if associated with a fracture, that would be a lateral capsule avulsion (Segond fracture). The Segond fracture results from excessive internal rotation and varus stress of the knee.

The Campos paper discusses that the iliotibial band and anterior oblique ligaments are thought to be involved in generation of the Segond fracture. Injuries associated with Segond fractures include ACL (75-100%) and meniscal (66-75%) tears.

Kocher et al found that narrower notch width index predisposes patients to ACL tear more than tibial spine fracture.


Please rate question.

Average 3.0 of 23 Ratings

Question COMMENTS (13)
Sorry, this question is available to Virtual Curriculum members only.

Click HERE to learn more and purchase the Virtual Curriculum today!


This is a Never-Been-Seen Question that can only be seen in Milestone Exams
for Virtual Curriculum members.

Click HERE to learn more and purchase the Virtual Curriculum today!


CASES (1)
VIDEOS (2)
GROUPS (1)
EVIDENCE & REFERENCES (21)
Topic COMMENTS (16)
Private Note