Modifier: A (nondisplaced), B (displaced)
Modifier: A (nondisplaced), B (displaced)
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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 concomitant diagnosis should be particularly observed for with this injury pattern?
Concurrent ACL disruption
Popliteal artery disruption
Quadriceps tendon tear
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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.
Pape JM, Goulet JA, Hensinger RN.
Clin Orthop Relat Res. 1993 Oct;(295):201-4. PMID: 8403649 (Link to Abstract)
Mosier SM, Stanitski CL
J Pediatr Orthop. 2004 Mar-Apr;24(2):181-4. PMID: 15076604 (Link to Abstract)
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A 14-year-old boy develops an acutely swollen right knee playing volleyball. During the examination, he is unable to perform a straight leg raise due to pain. Figure A shows a lateral radiograph of his right knee. What would be the most appropriate management of this injury?
Long leg cast
Patella tendon bearing cast
Open reduction internal fixation
Closed reduction percutaneous k wire fixation
The lateral radiograph shows a displaced tibial tuberosity fracture, and the treatment of choice would be open reduction and internal fixation.
Tibial tubercle avulsion fractures typically occur in late adolescent boys that participate in jumping sports, such as basketball and volleyball. Attention must be directed to assessment for other associated injuries, including patellar and quadriceps tendon avulsions, collateral and cruciate ligament tears, and meniscal injuries. Non-displaced fractures may be treated nonoperatively with casting or splinting. Displaced fractures are best treated with open reduction and internal fixation.
McKoy et al. reviewed the presentation and management of acute tibial avulsion fractures. They recommend three to four weeks of immobilization for non-displaced fractures. In displaced fractures, the use of cannulated screw fixation of the avulsed fragment show best results. In skeletally immature patients (Tanner 1-2), periosteal sutures can be considered.
Abalo et al is a review detailing treatment and results based upon the Ogden modification of the Watson-Jones Classification of tibial tubercle fractures. Similar to McKoy et al, non-displaced fractures were treated with cast treatment and immobilization and displaced fractures with open reduction and internal fixation demonstrating favorable results.
Figure A is a lateral knee radiograph of late adolescent boy with a type II tibial tubercle fracture.
Illustration A shows the fracture following fixation with two cannulated screws. Illustration B shows the Ogden classification of tibial tuberosity fractures in children.
Answer 1: Long leg cast would be appropriate for non-displaced avulsions
Answer 2: Patella tendon bearing casting is not recommended for displaced avulsion fractures
Answer 4: The use of cannulated screw fixation has shown to be superior to closed reduction, percutaneous pinning for these displaced fractures
Answer 5: This fracture pattern may be associated with ligament injury but is not suggested by the this patient scenario.
McKoy BE, Stanitski CL.
Orthop Clin North Am. 2003 Jul;34(3):397-403. PMID: 12974489 (Link to Abstract)
Abalo A, Akakpo-numado KG, Dossim A, Walla A, Gnassingbe K, Tekou AH
J Orthop Surg (Hong Kong). 2008 Dec;16(3):308-11. PMID: 19126896 (Link to Abstract)
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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?
Anterior tibial recurrent
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.
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.
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HPI - Acute knee pain after an injury during a soccer match.
How would you treat this injury?
Tibial Tubercle Avulsions Indications and Techniques - Drs Jazrawi Drs Jazrawi...