Updated: 11/17/2018

Tibial Tubercle Fracture

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Introduction
  • Overview
    • tibial tubercle fractures are a common fracture that occurs in adolescent boys near the end of skeletal growth during athletic activity
    • treatment is casting or surgical fixation depending on the degree of displacement
  • 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 jumpimg
      • an eccentric contraction of the quadriceps during forced knee flexion 
  • Associated conditions
    • compartment syndrome (4%)  
    • meniscal tears with Type III injuries
  • 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
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    
  • Vascular injury
    • to popliteal artery as it passes over distal metaphyseal fragment posteriorly
  • Stiffness
  • Bursitis
    • most common complication following surgical repair
    • due to prominence of screws and hardware about the knee, resolved upon hardware removal
  • Vascular Injury
    • popliteal artery as it passes posteriorly over distal metaphyseal fragment
 

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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? Review Topic

QID: 857
FIGURES:
1

Peroneal

2%

(32/1700)

2

Posterior tibial

5%

(79/1700)

3

Middle geniculate

6%

(107/1700)

4

Saphenous

1%

(10/1700)

5

Anterior tibial recurrent

86%

(1467/1700)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 1487
FIGURES:
1

Long leg cast

1%

(27/3746)

2

Patella tendon bearing cast

0%

(16/3746)

3

Open reduction internal fixation

92%

(3458/3746)

4

Closed reduction percutaneous k wire fixation

6%

(215/3746)

5

Ligament reconstruction

0%

(8/3746)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 470
FIGURES:
1

Concurrent ACL disruption

13%

(219/1665)

2

Compartment syndrome

79%

(1322/1665)

3

Popliteal artery disruption

3%

(44/1665)

4

Quadriceps tendon tear

2%

(32/1665)

5

Patella baja

2%

(41/1665)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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