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Updated: Jun 13 2021

Tibial Eminence Fracture

Images
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
https://upload.orthobullets.com/topic/4022/images/type iii.jpg
  • summary
    • 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.
    • Diagnosis can be confirmed with radiographs of the knee. MRI studies can be helpful for determining associated ligamentous/meniscal damage.
    • Treatment is closed reduction and casting or open reduction and fixation depending on the degree of displacement and success of closed reduction. 
  • Epidemiology
    • Incidence
      • 2-5% of knee injuries with effusion in the pediatric population
    • Demographics
      • most common in ages 8-14
  • Etiology
    • 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
  • 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
      • 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%
  • Prognosis
    • Overall prognosis is good with 85% returning to prior level of sport
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