Updated: 6/13/2021

Tibial Tubercle Fracture

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  • summary
    • Tibial Tubercle Fractures are common fractures that occur in adolescent boys near the end of skeletal growth during athletic activity.
    • Diagnosis can be confirmed with plain radiographs of the knee. 
    • Treatment may be nonoperative or operative depending on location of the fracture, degree of displacement, and any associated injuries.  
  • Epidemiology
    • Incidence
      • less than 1% of pediatric fractures
    • Demographics
      • males >> females
      • ages 12 - 15 (approaching skeletal maturity)
    • Risk factors
      • most common in basketball, football, sprinting and high jump
  • Pathophysiology
    • Mechanisms of injury
      • a concentric contraction of the quadriceps during jumping
      • an eccentric contraction of the quadriceps during forced knee flexion
    • Associated conditions
      • compartment syndrome (4%)
      • meniscal tears with Type III injuries
  • 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, with the tibial tubercle the last to fuse
          • places distal secondary center at greater risk of injury in older children
    • Muscles
      • extensor mechanism exerts great force at secondary ossification center
    • Blood Supply
      • recurrent anterior tibial artery can be lacerated
  • Classification
    • Based on level of fracture and presence of fragment displacement
      • Type III most common
      • 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 proximal between primary and secondary ossification centers
      • Type III
      • Coronal fracture extending posteriorly to cross the primary ossification center
      • Type IV
      • Fracture through the entire proximal tibial physis
      • Type V
      • Periosteal sleeve avulsion of the extensor mechanism from the secondary ossification center
      • Modifier: A (nondisplaced), B (displaced)
  • Presentation
    • Symptoms
      • sudden onset of pain
        • generally occurs during the initiation of jumping or sprinting
      • inability to immediately ambulate
      • knee swelling/hemarthrosis with Type III injuries
    • Physical exam
      • inspection & palpation
        • knee effusion
        • tenderness at the tibial tubercle
        • evaluate for anterior compartment firmness
      • ROM & instability
        • extensor lag or extensor deficiency in Type II or III injuries
          • retinacular fibers may allow for active extension
      • neurovascular exam
        • monitor for increasing pain suggestive of compartment syndrome
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
      • optional views
        • internal rotation view will bring the tibial tubercle into profile
        • comparison views of contralateral knee in younger pediatric patients
      • 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 V injury)
        • patella alta
    • CT
      • can be useful to evaluate for intra-articular or posterior extension
      • arteriogram if concern for popliteal arterty injury
        • should not delay intervention in setting of compartment syndrome
    • MRI
      • generally not indicated
      • useful for determining fracture extension in a nondisplaced Type II injury or type V injury
  • Treatment
    • Nonoperative
      • long leg cast in extension for 6 weeks
        • indications
          • Type I injuries or those with minimal displacement (< 2 mm)
          • acceptable displacement after closed reduction/cast application
    • Operative
      • open reduction internal fixation with arthrotomy +/- arthroscopy, +/- soft tissue repair
        • indications
          • Type II-IV fractures - need to visualize joint surface for perfect reduction and evaluate for intra-articular pathology
          • soft tissue repair for Type V (periosteal sleeve) fracture
  • Techniques
    • Open reduction and internal fixation
      • approach
        • midline incision to the fracture site
      • technique
        • evaluate and clean fracture site
        • remove any soft tissue (periosteum) interposition
        • 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
        • smooth K wires for younger child (>3y from skeletal maturity)
      • postoperative care
        • immobilization
        • non-weightbearing in long leg cast or brace for 4-6 weeks
      • 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
          • incision and associated complications
          • hardware irritation can necessitate implant removal
    • Open reduction and internal fixation with arthrotomy or arthroscopy
      • approach
        • midline approach and 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
        • evacuate intra-articular hematoma
        • visualize joint surface to achieve anatomic reduction
        • evaluate for meniscal tears and repair or debride as appropriate if soft tissue repair indicated
      • postoperative care
        • immobilization
          • long leg cast for 4-6 weeks
          • non-weight bearing
        • rehabilitation
          • progressive extensor mechanism strengthening
          • return to sports at 3 months
        • pros & cons
          • pros
            • addresses intraarticular extension and soft tissue injuries
          • cons
            • arthrotomy may require longer immobilization and/or rehabilitation
    • Soft tissue repair
      • similar to above
      • approach
        • midline incison to fracture 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
        • prolonged healing time given to soft tissue healing
  • Complications
    • Recurvatum deformity
      • more common than leg length discrepancy
      • growth arrest anteriorly and posterior growth continues leading to decrease in tibial slope
    • Compartment syndrome
      • related to injury of anterior tibial recurrent artery
    • Stiffness
    • Bursitis
      • most common complication following surgical repair
      • due to prominence of screws and hardware about the knee, resolved upon hardware removal
    • Vascular Injury
      • to popliteal artery as it passes posteriorly over distal metaphyseal fragment
  • Prognosis
    • High rate of fracture union and return to sports with approriate treatment
    • Low incidence of leg length discrepancy given age at which this injury occurs
Flashcards (2)
Cards
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Questions (13)

(OBQ18.73) Which of the following is the likely mechanism of injury shown in Figure A?

QID: 212969
FIGURES:

Knee flexion with quadriceps contraction

93%

(1762/1886)

Knee extension with hamstring contraction

3%

(62/1886)

Direct blow to the anterior knee

1%

(14/1886)

Knee extension with gastrocnemius contraction

1%

(22/1886)

Knee flexion with hamstring contraction

1%

(15/1886)

N/A A

Select Answer to see Preferred Response

(OBQ18.54) A 13-year-old male sustains the injury shown in Figure A. He is admitted at 10 pm with plans for surgical treatment in the morning. Overnight, he requires an increase in narcotics to control his pain. On physical examination, he has diffuse tenderness to palpation and is unable to comply with the examination. He appears distressed and his leg appears more swollen than when he was admitted. What is the next best step in management?

QID: 212950
FIGURES:

Emergent vascular exploration

1%

(16/1794)

Emergent fasciotomies with open reduction and internal fixation (ORIF)

96%

(1726/1794)

Elevation and observation

1%

(24/1794)

Emergent closed reduction and percutaneous screw placement

1%

(14/1794)

Urgent ORIF only

0%

(6/1794)

L 1 A

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(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?

QID: 470
FIGURES:

Concurrent ACL disruption

12%

(290/2360)

Compartment syndrome

81%

(1909/2360)

Popliteal artery disruption

2%

(56/2360)

Quadriceps tendon tear

2%

(45/2360)

Patella baja

2%

(50/2360)

L 2 B

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(SAE07PE.2) A 13-year-old boy injured his knee playing basketball and is now unable to bear weight. Examination reveals tenderness and swelling at the proximal anterior tibia, with a normal neurologic examination. AP and lateral radiographs are shown in Figures 1a and 1b. Management should consist of

QID: 6062
FIGURES:

MRI.

1%

(8/553)

a long leg cast.

5%

(28/553)

fasciotomy of the anterior compartment.

2%

(10/553)

open reduction and internal fixation.

91%

(501/553)

patellar advancement.

0%

(1/553)

L 1 E

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(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?

QID: 857
FIGURES:

Peroneal

1%

(36/2436)

Posterior tibial

4%

(103/2436)

Middle geniculate

6%

(158/2436)

Saphenous

1%

(16/2436)

Anterior tibial recurrent

87%

(2116/2436)

L 1 B

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(SBQ07PE.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?

QID: 1487
FIGURES:

Long leg cast

1%

(33/4501)

Patella tendon bearing cast

0%

(17/4501)

Open reduction internal fixation

93%

(4168/4501)

Closed reduction percutaneous k wire fixation

5%

(244/4501)

Ligament reconstruction

0%

(12/4501)

L 1 C

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Evidence (17)
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