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Updated: Jun 13 2021

Tibial Tubercle Fracture


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Images ttfx 4.jpg
  • 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
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