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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
 
Modified Meyers and McKeever Classification
Type I Nondisplaced (<3mm)
Type II Minimally displaced with intact posterior hinge

Type III Completely displaced
Type III+ Type III fracture with rotation   
Type IV Completely displaced, rotated, comminuted  
 
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 full extension
      • indications
        • non-displaced type I and reducible type II fractures
      • reduction maneuver = extend the knee to 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
  • Los of motion
    • very common, especially loss of extension
  • 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
 

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