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Introduction
  • A common fracture pattern that occurs in adolescent boys near end of growth
  • Epidemiology
    • incidence is less than 1% of pediatric fractures
    • males >> females
    • ages 12 - 15 (approaching skeletal maturity)
  • Mechanism
    • eccentric quadriceps contraction, such as coming down from a jump with knee flexed 
    • common in basketball players, football players, and sprinters
  • Associated conditions
    • monitor for compartment syndrome
    • evaluate for extensor lag
  • Prognosis
    • high rate of return to sports when appropriately treated
    • low incidence of leg length discrepancy
Anatomy
  • Osteology
    • proximal tibia has two ossification centers 
      • primary ossification center (proximal tibial physis)
      • secondary ossification center (tibial tubercle physis or apophysis)
        • 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 IV is a fracture through the entire proximal tibial physis  
    • Type V is a periosteal avulsion of the extensor mechanism from the secondary ossification center 
Presentation
  • Symptoms
    • sudden onset of pain
      • generally occurs during the initiation of jumping or sprinting
    • extensor mechanism deficiency or lag with Type 2 and 3 injuries
    • knee swelling
      • hemarthrosis 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
        • consider contralateral knee views in pediatric fractures
    • findings
      • widening or hinging open of the apophysis
      • fracture line may be seen extending proximally and variable distance posteriorly 
      • 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 intra-articular or posterior 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
        • usually Type 1 and 2 injuries
        • minimal displacement (< 2 mm)
        • acceptable displacement after closed reduction
  • Operative
    • closed reduction and percutaneous fixation vs 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 percutaneous fixation 
    • approach
      • closed reduction often done under anesthesia
      • 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 or brace 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 remove 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 or brace 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
          • may allow for earlier range of motion
        • 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
      • alternatively, arthroscopy can be used to directly assess the articular 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
    • more common than leg length discrecancy
    • growth arrest anteriorly as posterior growth continues leading to decrease in tibial slope
  • 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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Questions (3)

(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 concomitant diagnosis should be particularly observed for with this injury pattern? Review Topic

QID:470
FIGURES:
1

Concurrent ACL disruption

14%

(180/1317)

2

Compartment syndrome

79%

(1041/1317)

3

Popliteal artery disruption

2%

(29/1317)

4

Quadriceps tendon tear

2%

(21/1317)

5

Patella baja

3%

(39/1317)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.


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Question COMMENTS (6)

(SBQ07.2) 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? Review Topic

QID:1487
FIGURES:
1

Long leg cast

1%

(20/2790)

2

Patella tendon bearing cast

0%

(10/2790)

3

Open reduction internal fixation

93%

(2589/2790)

4

Closed reduction percutaneous k wire fixation

5%

(152/2790)

5

Ligament reconstruction

0%

(5/2790)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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.

Incorrect Answers:
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.

ILLUSTRATIONS:

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Question COMMENTS (6)

(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? Review Topic

QID:857
FIGURES:
1

Peroneal

2%

(29/1390)

2

Posterior tibial

5%

(70/1390)

3

Middle geniculate

7%

(91/1390)

4

Saphenous

1%

(7/1390)

5

Anterior tibial recurrent

86%

(1190/1390)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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:

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Question COMMENTS (5)
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