Review Question - QID 219550

Pediatric tibial spine fractures are at risk for inciting the development of arthrofibrosis, and the presence of a concomitant ACL injury has been shown to be an independent predictor for the need to return to the operating room for MUA.

Tibial eminence fractures represent intra-articular fractures of the bony attachment of the ACL on the tibia and most commonly occur in children aged 8-14 during an athletic activity. Given that the intercondylar notch is incompletely ossified in children, it is more prone to failure than the surrounding ligamentous structures. The primary failure occurs through deep cancellous bone and is usually confined to the eminence but may propagate to the tibial plateau, with medial propagation being most common when this occurs. It is important to note that in incompletely displaced fractures with an intact posterior hinge, the medial meniscus or intermeniscal ligament can act as blocks to reduction. In ~40% of cases, a concomitant injury is present, either meniscal, collateral ligamentous, capsular, or osteochondral in nature, with concomitant ACL injuries being a specific indicator of likely post-operative arthrofibrosis and possible need for return to the OR for MUA.

Bram et al. performed a national 10-site multicenter study to identify risk factors for arthrofibrosis in tibial spine fractures (TSF). The authors reviewed 249 patients less than 18 years of age with a TSF and found that a total of 58 (23.3%) of patients developed post-operative arthrofibrosis, with 19 (7.6%) requiring a return to the OR for MUA. They concluded that concomitant ACL injury is associated with a higher return to the operating room for MUA and recommend that post-operative immobilization in a cast be avoided, given the high risk of arthrofibrosis.

Vander et al. reviewed the rate of arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents. The authors reviewed 32 patients with displaced tibial eminence fractures and found that 24 required re-operation for loss of flexion (n = 9), loss of extension (n = 4), or both (n = 11). They concluded that children with tibial spine fractures are at risk for arthrofibrosis and that stabilization of the fracture is important to allow early postoperative rehabilitation.

Figure A is an AP radiograph of the knee demonstrating a displaced tibial eminence fracture in a skeletally immature individual.

Incorrect Answers:
Answers 1-4: Only the presence of a concomitant ACL injury has been shown to be an independent risk factor for a return to the OR for MUA.