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https://upload.orthobullets.com/topic/4022/images/tibial eminence.jpg
https://upload.orthobullets.com/topic/4022/images/tibial spine key image.jpg
https://upload.orthobullets.com/topic/4022/images/nondisplaced tibial eminence.jpg
https://upload.orthobullets.com/topic/4022/images/type 2.jpg
Introduction
  • Overview
    • a tibial eminence fracture, also known as a tibial spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity
      • treatment is closed reduction and casting or open reduction and fixation depending on the degree of displacement and whether it can be reduced
  • Epidemiology
    • incidence
      • 2-5% of knee injuries with effusion in the pediatric population 
    • demographics
      • most common in ages 8-14
  • Pathophysiology
    • traumatic mechanism
      • rapid deceleration or hyperextension/rotation of the knee, as in sports
      • same mechanism that would cause ACL tear in adult 
      • fall from bike or motorcycle (typically resulting in hyperextension) 
  • Associated conditions
    • occur in 40% of eminence fractures
      • meniscal injury 
      • collateral ligament injury
      • capsular damage
      • osteochondral fracture
  • Prognosis
    • overall prognosis is good with 85% returning to prior level of sport 
Anatomy
  • Osteology
    • tibial eminence
      • non-articular portion of the tibia between the medial and lateral tibial plateau
      • Consists of two spines: ACL attaches to medial spine 
      • ACL insertion is 9mm posterior to the intermeniscal ligament and adjacent to anterior horns of meniscus
      • PCL does not attach to tibia spines 
    • Pediatric specific
      • Intercondylar eminence in incompletely ossified and is more prone to failure than ligamentous structures
      • Failure occurs through deep cancellous bone 
      • Fracture usually confined to intercondylar eminence, but it may propagate to tibial plateau, medial is most common 
  • 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
    • severe swelling and pain in the knee
    • inability to bear weight 
  • Physical exam
    • inspection
      • immediate knee effusion due to hemarthrosis
      • Knee usually in flexed position
    • 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
      • AP
      • lateral
        • most useful for determining fracture displacement
      • intercondylar
      • oblique 
        • helpful in determining the extent of tibial plateau involvement 
  • CT
    • useful for pre-operative planning
    • used when fracture displacement cannot be determined by plain radiographs
  • MRI
    • better at determining associated ligamentous/meniscal damage than CT or radiographs
    • Majority of fractures show no additional internal derangement (meniscus injuries)
      • 15-37% of cases have associated intra-articular pathology 
Treatment
  • Nonoperative  
    • closed reduction, aspiration of hemarthrosis, immobilization in full extension
      • indications
        • non-displaced type I and reducible type II fractures
      • reduction technique
        • see techniques below 
      • immobilization
        • cast in extension for 3-4 weeks 
          • patients get extremely stiff with prolonged immobilization
          • allows for gradual rehab program 
  • Operative
    • ORIF vs. all-arthroscopic fixation
      • indications
        • Type III or Type II fractures that cannot be reduced
          • type II fractures may fail to reduce due to the entrapped medial meniscus, entrapped intermeniscal ligament, or the pull of the lateral meniscus attachment
        • block to extension
Techniques
  • Closed Reduction
    • aspiration
      • when tense hemarthrosis is present, needle aspiration with the injection of lidocaine may help extend the knee
    • reduction
      • extend the knee to full extension or hyperextension to observe for fragment reduction
    • immobilization
      • cast is placed at 0 degrees of flexion
      • cast in extension for 3-4 weeks 
    • confirmation
      • lateral radiograph to confirm reduction, and then serial radiographs to observe maintenance of reduction
      • CT or MRI may be used when the adequacy of reduction is unclear 
  • Arthroscopic fixation 
    • approach
      • standard arthroscopic portals
    • technique
      • reduction
        • debride fracture
        • disengage entrapped meniscus or intermeniscal ligament
          • medial meniscus entrapment most common
        • reduce fracture
      • fracture fixation
        • suture fixation
          • Large avulsed fragments may be repaired directly
          • Smaller avulsed fragments (usually in an older patient) may require sutures through the base of the ACL
          • pros
            • minimal damage to physis
            • growth at level of physis will disrupt non-absorbable sutures to allow for continued growth 
          • cons
            • technically demanding
        • screw fixation
          • pros
            • less demanding than suture fixation
            • possibly earlier mobilization
          • cons
            • requires larger osteochondral fragment 
            • hardware irritation
            • not possible for small, comminuted fragments
            • impingement from an improperly placed screw
            • risk of iatrogenic comminution 
            • requires removal only if malpositioned 
            • physeal damage
    • post-operative care
      • immobilize with cast in extension for 7-10 days and repeat radiographs to ensure no displacement
        • This is variable, some surgeon allow immediate ROM
      • early controlled range of motion
      • length of limited weight bearing is controversial
  • Open fixation
    • same principles as arthroscopic
Complications
  • Loss of motion
    • very common, especially loss of extension
    • may be due to displaced fragment impinging on femoral notch
  • Arthrofibrosis 
    • more common with surgical reconstruction
  • Growth arrest
    • from iatrogenic injury during surgery 
  • ACL laxity
    • incidence
      • 38-100%, more common in operatively treated knees 
    • Lachman's laxity may be noted compared to contralateral limb
      • functional instability is uncommon
    • Rate of ACL reconstruction following this injury is 15-25% 
 
 
 

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(OBQ11.237) A 19-year-old patient is undergoing an arthroscopic treatment of a right knee with suture fixation via transosseous tunnels shown in the video in Figure V. What is the most likely postoperative complication? Review Topic

QID: 3660
FIGURES:
1

Infection

1%

(22/1634)

2

Arthrofibrosis

73%

(1197/1634)

3

Spontaneous osteonecrosis of the knee (SONK)

4%

(60/1634)

4

Hardware prominence in the intercondylar notch necessitating removal of implants

16%

(259/1634)

5

Increased posterior tibial excursion

5%

(84/1634)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ06.56) The AP radiograph in Figure A demonstrates an injury in a 13-year-old soccer player. What is the equivalent injury in a skeletally mature patient? Review Topic

QID: 167
FIGURES:
1

Patella tendon rupture

3%

(16/614)

2

Posterior cruciate ligament tear

2%

(13/614)

3

Anterior cruciate ligament tear

92%

(562/614)

4

Lateral meniscus tear

1%

(7/614)

5

Posteromedial capsular avulsion

2%

(10/614)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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