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
QUESTIONS 1 of 13 1 2 3 4 5 6 7 8 9 10 11 12 13 Previous Next (OBQ18.73) Which of the following is the likely mechanism of injury shown in Figure A? QID: 212969 FIGURES: A Type & Select Correct Answer 1 Knee flexion with quadriceps contraction 93% (1762/1886) 2 Knee extension with hamstring contraction 3% (62/1886) 3 Direct blow to the anterior knee 1% (14/1886) 4 Knee extension with gastrocnemius contraction 1% (22/1886) 5 Knee flexion with hamstring contraction 1% (15/1886) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 Emergent vascular exploration 1% (16/1794) 2 Emergent fasciotomies with open reduction and internal fixation (ORIF) 96% (1726/1794) 3 Elevation and observation 1% (24/1794) 4 Emergent closed reduction and percutaneous screw placement 1% (14/1794) 5 Urgent ORIF only 0% (6/1794) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A Type & Select Correct Answer 1 Concurrent ACL disruption 12% (290/2360) 2 Compartment syndrome 81% (1909/2360) 3 Popliteal artery disruption 2% (56/2360) 4 Quadriceps tendon tear 2% (45/2360) 5 Patella baja 2% (50/2360) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (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: A B Type & Select Correct Answer 1 MRI. 1% (8/553) 2 a long leg cast. 5% (28/553) 3 fasciotomy of the anterior compartment. 2% (10/553) 4 open reduction and internal fixation. 91% (501/553) 5 patellar advancement. 0% (1/553) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 Peroneal 1% (36/2436) 2 Posterior tibial 4% (103/2436) 3 Middle geniculate 6% (158/2436) 4 Saphenous 1% (16/2436) 5 Anterior tibial recurrent 87% (2116/2436) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 Long leg cast 1% (33/4501) 2 Patella tendon bearing cast 0% (17/4501) 3 Open reduction internal fixation 93% (4168/4501) 4 Closed reduction percutaneous k wire fixation 5% (244/4501) 5 Ligament reconstruction 0% (12/4501) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (1) Podcasts (1) Login to View Community Videos Login to View Community Videos Tibial Tubercle Avulsions Indications and Techniques - Drs Jazrawi Pediatrics - Tibial Tubercle Fracture A 5/15/2016 1568 views 4.8 (9) Pediatrics | Tibial Tubercle Fracture Pediatrics - Tibial Tubercle Fracture Listen Now 19:15 min 10/18/2019 558 plays 5.0 (4)
Pediatric Tibial Tubercle Fracture (C101553) Jacob Triplet Pediatrics - Tibial Tubercle Fracture B 8/5/2020 625 7 1 Bilateral Tibial Tubercle Fractures in 12F (C101392) Panagiotis Poulios Pediatrics - Tibial Tubercle Fracture E 3/3/2020 128 12 0 Tibial Tubercle Fracture in 11M (C2414) Alceu Fornari Chueire Pediatrics - Tibial Tubercle Fracture B 10/27/2015 9474 5 17