Tibial Tubercle Fracture

Author: Anay Patel

Topic updated on 02/12/13 10:52pm

Introduction

A common fracture pattern that occurs in adolescent boys near end of growth period
Epidemiology
- incidence is less than 1% of pediatric fractures
- males >> females
- ages 12 - 17 (approaching skeletal maturity)
Mechanism
- active quadriceps extension with knee flexed (jumping, sprinting)
- common in basketball players, football players, and sprinters
Associated conditions
- monitor for compartment syndrome
- evaluate for extensor lag
Prognosis

Anatomy

Osteology
- proximal tibia has two ossification centers
  - primary ossification center (proximal tibial physis)
  - secondary ossification center (tibial tubercle physis)
    - insertion of patellar tendon
  - physeal closure occurs from posterior to anterior and proximal to distal
  - places distal secondary center at greater risk of injury in older children
Muscles
- extensor mechanism can exert great force at secondary ossification center
Blood Supply
- recurrent anterior tibial artery can be torn with these injuries

Classification

Ogden Classification (modification of Watson-Jones)
Type I	fracture of the secondary ossification center near the insertion of the patellar tendon
Type II	fracture propagates to proximal to the junction with the primary ossification center
Type III	fracture extend posteriorly to cross the primary ossification center
Modifier: A (nondisplaced), B (displaced)

Newer descriptions have been added to the original system
- Type 4 is a fracture through the entire proximal tibial physis
- Type 5 is a periosteal avulsion of the extensor mechanism from the secondary ossification center

Presentation

Symptoms
- pain
  - generally occurs during the initiation of running or sprinting
- swelling of the knee
- extensor mechanism deficiency or lag with Type 2 and 3 injuries
- possible hemarthrosis
  - usually only with Type 3 injuries
Physical exam
- inspection & palpation
  - swelling at the knee
  - tenderness at the tibial tubercle
  - evaluate for anterior compartment firmness
- ROM & instability
  - extensor lag or extensor deficiency in Type 2 or 3 injuries
- neurovascular exam
  - monitor for increasing pain suggestive of compartment syndrome

Imaging

Radiographs
- recommended views
  - required
    - lateral of the knee
  - optional
    - internal rotation view will bring the tibial tubercle into profile
- findings
  - anterior swelling may be the only sign in the setting of a periosteal sleeve avulsion (type 5 injury)
  - evaluate for possible patella alta
CT
- can be useful to evaluate for intraarticular extension
- arteriogram can be helpful if concern for anterior tibial artery injury
  - should not delay intervention in setting of compartment syndrome
MRI
- generally not indicated
- useful for determining fracture extension in a nondisplaced Type 2 injury

Treatment

Nonoperative
- long leg cast in extension for 4-6 weeks
  - indications
    - rarely indicated
    - minimal displacement (< 2 mm)
    - extensor lag
Operative
- closed reduction and internal fixation
  - indications
    - Type 1, 2, and 4 fractures
- open reduction internal fixation
  - indications
    - Type 1, 2, and 4 fractures
- open reduction with arthrotomy and internal fixation
  - indications
    - Type 3 fractures
- open reduction and soft tissue repair
  - indication
    - Type 5 fractures

Techniques

Closed reduction and internal fixation
- approach
  - closed reduction and manipulation
  - percutaneous clamping
- technique
  - internal fixation with 4.0 cancellous partially threaded screws
  - larger screws can be used but may cause soft tissue irritation in the long-term
- postoperative care
  - immobilization
    - long leg cast for 4-6 weeks
    - prolonged immobilization needed in Type 2 and 3 injuries
    - non-weight bearing
  - rehabilitation
    - progressive extensor mechanism strengthening
    - return to sports no sooner than 3 months
  - pros & cons
    - pros
      - no open reduction
      - excellent healing potential
    - cons
      - inability to clean fracture site or removal soft tissue interposition
      - hardware irritation can necessitate implant removal
Open reduction and internal fixation
- approach
  - midline incision to the fracture site
- technique
  - evaluate and clean fracture site
  - remove any soft tissue interposition (periosteum)
  - anatomic reduction of fracture fragments
  - internal fixation with 4.0 cancellous partially threaded screws
  - larger screws can be used but may cause soft tissue irritation in the long-term
- postoperative care
  - immobilization
    - long leg cast for 4-6 weeks
    - prolonged immobilization needed in Type 2 and 3 injuries
    - non-weight bearing
  - rehabilitation
    - progressive extensor mechanism strengthening
    - return to sports no sooner than 3 months
  - pros & cons
    - pros
      - anatomic reduction and stable fixation
      - excellent healing potential
    - cons
      - hardware irritation can necessitate implant removal
Open reduction with arthrotomy and internal fixation
- approach
  - midline approach or median parapatellar arthrotomy
  - joint surface must be visualized to assure anatomic reduction
- technique
  - same as above
  - evaluate for meniscal tears and repair or debride as appropriate
  - evacuate intraarticular hematoma
  - visualize joint surface to achieve anatomic reduction
- postoperative care
  - immobilization
    - long leg cast for 4-6 weeks
    - prolonged immobilization needed in Type 2 and 3 injuries
    - non-weight bearing
  - rehabilitation
    - progressive extensor mechanism strengthening
    - return to sports no sooner than 3 months
  - pros & cons
    - pros
      - addresses intraarticular extension and soft tissue injuries
    - cons
      - arthrotomy may require longer immobilization and/or rehabilitation
Open reduction and soft tissue repair
- approach
  - midline incision to the soft tissue injury site
- technique
  - evaluate soft tissue injury
  - remove any soft tissue interposition (periosteum)
  - heavy suture repair of periosteum back to the secondary ossification center
- postoperative care
  - immobilization
    - long leg cast for 8-10 weeks
    - prolonged immobilization needed due to soft tissue (rather than bone) healing
  - rehabilitation
    - progressive extensor mechanism strengthening
    - return to sports no sooner than 3 months
- pros & cons
  - cons
    - prolonged healing time due to soft tissue healing

Complications

Recurvatum deformity
- proximal tibia physis is very sensitive to trauma
- growth is arrested anteriorly with this fracture pattern
- posterior growth continues leading to a recurvatum deformity
Compartment syndrome
- related to injury of anterior tibial recurrent artery
Loss of range of motion
Bursitis
- due to prominence of screws and hardware about the knee

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Qbank (2 Questions)

TAG

(OBQ08.84) A 15-year-old male complains of pain and swelling of the right knee immediately after landing a ski jump. Radiographs are shown in Figure A. Which of the following potential complications is most common with this injury pattern? Topic

Review Topic

FIGURES: A

1. Concurrent ACL disruption
2. Compartment syndrome
3. Popliteal artery disruption
4. Quadriceps tendon tear
5. Patella baja

PREFERRED RESPONSE ▶

DISCUSSION: Radiographs show a type III tibial tubercle avulsion fracture. Anterior compartment syndrome is at risk as anterior tibial recurrent artery may be disrupted. Meniscal tears have been reported in this population as well.

The referenced article by Pape et al reports tibial tubercle fractures to be uncommon physeal fractures that are predisposed to anterior compartment syndrome due to the proximity of the anterior tibial recurrent artery. Mosier reviews 19 tibial tubercle physeal fractures finding the fracture to occur in athletic participation 77% of the time specifically with an eccentric quadriceps contraction during flexion of the knee. Fifteen of the 19 fractures were treated with open reduction and all had good outcomes.

REFERENCES:

1. Pape JM, Goulet JA, Hensinger RN. Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop Relat Res. 1993 Oct;(295):201-4. PMID:8403649 (Link to Abstract)

2. Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop. 2004 Mar-Apr;24(2):181-4. PMID:15076604 (Link to Abstract)

Question Authors:

John Badylak MD, Eric Shirley MD, Ben Taylor MD,

Please Rate Educational Value!

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TAG

(OBQ07.196) A 14-year-old boy sustains the injury shown in figure A. He subsequently develops compartment syndrome and requires fasciotomy. Injury to what artery is most likely responsible? Topic

Review Topic

FIGURES: A

1. Peroneal
2. Posterior tibial
3. Middle geniculate
4. Saphenous
5. Anterior tibial recurrent

PREFERRED RESPONSE ▶

DISCUSSION: The anterior tibial artery lies on the anterior surface of the interosseous membrane and supplies the anterior compartment of the leg. The anterior tibial recurrent artery arises superiorly over the tibial tubercle to supply the anterior knee and can be injured by displaced fractures of the tubercle.

Pape et al stress that soft tissue disruption associated with tibial tubercle injuries are often under appreciated and compartment syndrome should be considered, especially in adolescent boys.

Incorrect Answers:
Answer 1: The peroneal artery is a branch off the posterior tibial artery distal to the knee joint, and descends in the posterior compartment.
Answer 2: The posterior tibial artery is a branch of the popliteal artery and carries blood to the posterior compartment of the leg and plantar surface of the foot.
Answer 3: The middle geniculate artery comes off of the popliteal artery and supplies the ACL.
Answer 4: The saphenous branch of descending genicular artery pierces the aponeurotic covering of the adductor canal, and accompanies the saphenous nerve to the medial side of the knee.

Illustrations: A

REFERENCES:

1. Pape JM, Goulet JA, Hensinger RN. Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop Relat Res 1993 PMID:8403649 (Link to Abstract)

2. Zionts LE in Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children, 2003.

Question Authors:

Derek Moore, Derek Moore, Patrick McCulloch MD,

Please Rate Educational Value!

3.0

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Groups

ABOS II: Tibial Tubercle Fracture

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Pape JM, Goulet JA, Hensinger RN. Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop Relat Res. 1993 Oct;(295):201-4. PMID:8403649 (Link to Abstract)
Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop. 2004 Mar-Apr;24(2):181-4. PMID:15076604 (Link to Abstract)
Pape JM, Goulet JA, Hensinger RN. Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop Relat Res 1993 PMID:8403649 (Link to Abstract)
Zionts LE in Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children, 2003.

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Tibial Tubercle Fracture

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