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Tibial Tubercle Fracture

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Topic updated on 01/24/14 7:02pm
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
    • 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
    • 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 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
    • 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
      • 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 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 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
          • 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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Qbank (2 Questions)

TAG
(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? Topic Review Topic
FIGURES: A          

1. Long leg cast
2. Patella tendon bearing cast
3. Open reduction internal fixation
4. Closed reduction percutaneous pinning
5. Ligament reconstruction

PREFERRED RESPONSE ▶
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 concomitant diagnosis should be particularly observed for 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 ▶
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 ▶



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Mosier SM, Stanitski CL
J Pediatr Orthop. 2004 Mar-Apr;24(2):181-4. PMID: 15076604 (Link to Pubmed)
1/22/2014
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