Avulsion fractures of the tibial tuberosity in the adolescent athlete. Risk factors, mechanism of injury, and treatment

Isolated Avulsion Fracture of the Tibial Tuberosity in an Adult Treated with Suture-Bridge Fixation: A Rare Case and Literature Review

Background and objectives: Isolated tibial tuberosity avulsion fractures are exceptionally uncommon among adults, with limited instances documented in published literature. Here, we describe a case of an isolated tibial tuberosity avulsion fracture in an adult that was treated successfully with the suture bridge repair technique. Patient concerns: A 65-year-old female visited the outpatient department with left knee pain after a slip and fall. Lateral radiographs and sagittal MR images of the left knee revealed the tibial tuberosity avulsion fracture, but the fracture line did not extend into the knee joint space. Surgical intervention was performed on the patient's knee using an anterior midline approach, involving open reduction and internal fixation. The avulsed tendon was grasped and pulled, and an appropriate suture location was identified. Using a suture hook, the suture was guided through the patellar tendon as near to its uppermost point of the fragment as achievable, and tied over tendon. A single suture limb from each anchor was fastened over the tibial tuberosity to the distally positioned foot print anchor, effectively anchoring the tibial tuberosity using the suture bridge technique. The patient started walking on crutches after one week and was able to walk independently with a brace after two weeks from the operation day. After three months, the patient had regained her mobility to the level prior to the injury and exhibited painless active range of motion from 0 to 130 degrees. Hardware positioning and bony union were maintained at the one-year follow-up. Conclusions: In our case, the open suture bridge fixation method for tibial tuberosity avulsion fractures produced satisfactory results. Open suture bridge fixation may be considered for isolated tibial tuberosity avulsion fractures in adults, especially when the avulsion tip is too small for screw fixation.

Fracture-avulsion of tibial tubercle apophyseal in two Cameroonian adolescents

Introduction

Avulsion-fractures of the tibial tubercle apophysis are a rare lesion of active adolescent. They are relatively uncommon injuries that occur in the active adolescent. We described cases of tibial tubercle apophysis avulsion-fractures in two Cameroonian adolescents.

Cases

We observed 2 cases which occurred in boys after contraction of the quadriceps during sports activity (high jump and football). The lesions were classified as Type IV by Ryu and Debenham (case 1) and type IA by Ogden (Case 2). The treatment was surgical by double screwing (case 1) and orthopedic by plaster knee brace (Case 2). The functional result was excellent without complications.

Discussion

Non-displaced fracture of the anterior tibial tubercle I type IA Ogden has good prognosis and responding very well to non-surgical treatment. It should be considered as a separate entity. The other cases of displaced fracture generally require surgery which enables an assessment of often associated lesions. Type IV can required supplemental plate fixation to stabilize the proximal tibia. The prognosis of displaced fractures is poor due to the associated lesions and potential complications. Functional results are excellent despite a few cases of previous pain limiting sports activity.

Conclusion

Avulsion fractures of the anterior tuberosity in adolescents remain rare in Africa and worldwide. The circumstances of the occurrence are stereotypical. If treated properly, the outcome is usually good.

Biomechanical Comparison of Three Stabilization Methods for Tibial Tuberosity Fractures in Dogs: A Cadaveric Study

OBJECTIVE

 The aim of this study was to compare the biomechanical properties of a hybrid external skeletal fixator (HESF) construct to the placement of paired interfragmentary Kirschner wires alone, and pin and tension band wire (PTBW) fixation for the stabilization of simulated tibial tuberosity fractures in dogs.

STUDY DESIGN

 Tibias were harvested from 12 skeletally mature dog cadavers weighing 20 to 30 kg. An osteotomy was made through the base of the tibial tuberosity, which was subsequently repaired with either paired Kirschner wires, PTBW fixation or a HESF. A tensile load was applied to the tibial tuberosity until failure occurred. Mode of failure was described and biomechanical parameters obtained were compared between fixation groups.

RESULTS

 The PTBW fixation and HESF construct afforded greater stiffness and load at 3 mm of axial displacement compared with fixation with Kirschner wires alone. There was no significant difference in stiffness and load at 3 mm displacement between PTBW and HESF fixation. Failure occurred by bending and pullout of the Kirschner wires for all fixation groups, preceded by untwisting of the knot in PTBW specimens.

CONCLUSION

 The HESF may provide a favourable alternative to PTBW fixation for tibial tuberosity avulsion fracture stabilization in dogs with substantial remaining growth potential.

Tibial Tuberosity Fracture in an Elderly Gentleman: An Unusual Injury Pattern

Avulsion fracture of the tibial tuberosity is an infrequent injury in adolescents and an extremely rare occurrence in adults. We describe the case of an 86-year-old gentleman presenting after a fall, sustaining injury to the left knee. Radiographs of the left knee showed avulsion fracture of the tibial tuberosity. The purpose of this study was to present a rare case of tibial tuberosity avulsion fracture in an adult, the treatment performed, and the challenges faced. The case is discussed with the review of the literature.

Outcomes and Complications of Tibial Tubercle Fractures in Pediatric Patients: A Systematic Review of the Literature

BACKGROUND

Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients.

METHODS

A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded.

RESULTS

Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common.

CONCLUSIONS

Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected without a significant effect on final outcome. Finally, there is a need for longer follow-up to determine long-term outcomes.

LEVEL OF EVIDENCE

Level III-systematic review of level III/IV studies.

Tibial Tuberosity Avulsion Fracture and Open Proximal Tibial Fracture in an Adult: A Case Report and Literature Review

A displaced tibial tuberosity avulsion fracture associated with an open extra-articular proximal tibial diaphyseal fracture is an uncommon fracture pattern. This case report describes the successful management of such a fracture pattern in a 45-year old male using an open reduction and lag screw fixation of the tuberosity with a minimally invasive reduction and plate fixation of the proximal tibial diaphyseal fracture. A literature search was done to determine the expected clinical outcome of this fracture pattern. This is the first reported adult case of an avulsion fractures of the tibial tuberosity associated with an open proximal tibial diaphyseal fracture successfully treated by an anatomical reduction and fixation of the avulsion fracture of the tibial tuberosity combined with minimally invasive percutaneous plate osteosynthesis of the proximal tibial diaphyseal fractures.

Assessment and treatment of knee pain in the child and adolescent athlete

Knee pain in children and adolescents is one of the most prevalent complaints in a pediatric practice, accounting for at least a third of musculoskeletal complaints. Accurate diagnosis requires an understanding of knee anatomy and patterns of knee injuries and skill in physical examination. This review covers the most common causes of knee pain in children and adolescents, including overuse issues, such as Osgood-Schlatter and osteochondritis dissecans, as well as traumatic injuries, including tibial spine fractures and anterior cruciate ligament injuries.

Tibial tuberosity fractures in adolescents: is a posterior metaphyseal fracture component a predictor of complications?

BACKGROUND

Tibial tuberosity fractures have been described as uncommon injuries, but their frequency appears to be increasing. Because of the relatively few cases reported in the literature, little is known regarding risk factors for complications. In a large group of adolescents with tibial tuberosity fractures, we noted more frequent complications in patients who had posterior metaphyseal fractures in addition to tibial tuberosity avulsion fractures. The purpose of this study was to examine the outcomes associated with this fracture pattern and compare them with tibial tuberosity fractures without the posterior component.

METHODS

All patients who had closed or open reduction and internal fixation of a tibial tuberosity fracture between January 2003 and December 2010 were identified. All radiographs and medical records were reviewed.

RESULTS

Fifty-three tibial tuberosity fractures had radiographs available for review; 15 (28%) fractures had a posterior component identified by either radiograph or computed tomography scan. Four of these combined injuries had an adverse event: 1 patient had compartment syndrome affecting all 4 compartments and 3 patients had refractures after closed reduction and casting. None of the 38 tibial tuberosity fractures without a posterior metaphyseal component had these complications. All patients had complete fracture healing and had returned to full activity at last follow-up.

CONCLUSIONS

In this study, a posterior metaphyseal fracture associated with a tibial tuberosity fracture was a marker for potential complications. If radiographs suggest that a fracture line extends through the posterior metaphysis, computed tomography imaging is recommended to confirm the fracture pattern. Open reduction and internal fixation that includes both the anterior and posterior fragments is recommended for all fractures with these combined components, including nondisplaced fractures, because of an increased risk of refracture.

LEVEL OF EVIDENCE

Level IV (case study).

Tibial tubercle fractures in children with intra-articular involvement: surgical tips for technical ease

BACKGROUND

Tibial tubercle fractures often occur in athletic adolescents close to skeletal maturity. These fractures can present with marked displacement of the apophysis, intra-articular extension, and associated soft tissue injuries, such as tibial meniscal ligament tears. Here, we present our surgical technique which focuses on recreating the meniscal-articular relationship (using suture anchors) in severely displaced fractures.

METHODS

We retrospectively reviewed all tibial tuberosity fractures treated with this technique over the last 2.5 years. Fractures with a minimum of a 12-month follow-up post-fixation were identified. Clinical records and radiographs were reviewed. Data included patient age, gender, involved side, injury classification (modified Ogden), mechanism of injury, treatment, return to activity, and complications.

RESULTS

Six patients met the inclusion criteria. Mean age at time of surgery was 14.9 (range 13.2-16.8) years. All patients were male and the mean follow-up period was 14 (12-26) months. Range of motion was started at 4 weeks post-operatively in a hinged knee brace, and return to sports occurred at an average of 3.75 months postoperatively (range 3-5 months). No evidence of growth disturbance of the proximal tibia or recurvatum at final follow-up was evident.

CONCLUSION

We speculate that patients who sustain a tibial tubercle avulsion fracture types III or V will likely have intra-articular pathology, specifically capsular avulsion or coronary ligament disruption. By utilizing suture anchors, our technique emphasizes renewing the anatomic articular environment to ensure better long-term results and maintaining these active individuals in sports.

Atypical tibial tuberosity fracture in an adolescent

Avulsion fractures of the tibial tuberosity are typically sustained by adolescent males during sporting activities. Tibial tuberosity avulsions with simultaneous proximal tibial epiphyseal fractures are rare injuries. We present an unusual case of Ogden type IIIA avulsion fracture of tibial tuberosity with a Salter Harris type IV posterior fracture of proximal tibial epiphysis in a 13-year-old boy. We believe that the patient sustained the tibial tuberosity avulsion during the take-off phase of a jump while playing basketball due to sudden violent contraction of the quadriceps as the knee was extending. This was then followed by the posterior Salter Harris type IV fracture of proximal tibial physis as he landed on his leg with enormous forces passing through the knee. Although standard radiographs were helpful in diagnosing the complex fracture pattern, precise configuration was only established by computed tomography (CT) scan. The scan also excluded well-recognized concomitant injuries including ligament and meniscal injuries. Unlike other reported cases, our patient did not have compartment syndrome. Anatomic reduction and stabilization with a partially threaded transepiphyseal cannulated screw and a metaphyseal screw followed by early mobilization ensured an excellent recovery by the patient.Our case highlights the importance of vigilance and a high index of suspicion for coexisting fractures or soft tissue injuries when treating avulsion fractures of tibial tuberosity. A CT scan is justified in such patients to recognize complex fracture configurations, and surgical treatment should be directed appropriately to both the fractures followed by early rehabilitation. Patients with such injuries warrant close monitoring for compartment syndrome during the perioperative period.

Injuries and conditions of the extensor mechanism of the pediatric knee

The extensor mechanism of the knee is essential to ambulation and is subject to a number of traumatic, congenital, and inflammatory processes. In the pediatric population, the spectrum of pathologic conditions affecting the extensor mechanism is specific to skeletally immature patients. In addition, certain congenital and developmental disorders may further predispose the knee extensor mechanism to injury. The pathologic processes can be subdivided into categories: conditions of the attachments and insertions of the quadriceps and patellar tendons, conditions of the patella, conditions of the quadriceps muscle group, and avulsions of the superior attachments of the quadriceps. Cases of conditions affecting the extensor mechanism of the pediatric knee were collected at two large trauma centers, and the clinical and radiologic features were reviewed. Initial evaluation of these conditions is performed with radiography, but magnetic resonance imaging has evolved into a useful adjunct for assessing the soft tissues for a more precise evaluation of the true extent of an injury, thereby affecting decisions about surgical intervention and prognosis.

Acute tibial tubercle avulsion fractures in the sporting adolescent

INTRODUCTION

The authors report 7 cases of acute tibial tubercle avulsion fractures. The fracture occurred in 6 out of the 7, after an abrupt tension of the patellar tendon in male sporting adolescents (age 13-17 years). Two patients presented symptoms of homolateral Osgood-Schlatter's disease before the lesion.

METHOD

According to Ogden's classification, the tibial tubercle avulsion fracture was not displaced in 3 cases (stage IA) and was treated conservatively by immobilization for 6 weeks. In 4 cases, the fracture was displaced and necessitated an internal fixation with plaster for about 6 weeks. A torn patellar tendon was noted in one adolescent having a stage IIIB avulsion fracture.

RESULT

The mean follow-up was of 4.5 years (1.5-7.5 years). The results were satisfactory: complete functional recovery, resumption of sport at the previous level and absence of recurvatum.

Tibial tuberosity fractures in adolescents

BACKGROUND

Tibial tuberosity fractures in adolescents are uncommon. We retrospectively reviewed all tibial tuberosity fractures in adolescents (10-19) who presented to our level 1 pediatric trauma center over a 7-year period to review fracture morphology, mechanism of injury, fracture management including return to play, as well as complications. Additionally, we present a review of the literature and treatment algorithm.

METHODS

We reviewed the clinical charts and radiographs of consecutive patients with tibial tuberosity fractures between 01 January 2000 and 01 January 2007. Data parameters included the following: patients age and gender, involved side, injury classification, co-morbidities, mechanism of injury, treatment, return to activity and complications. Data were extracted and reviewed, and a treatment algorithm is proposed with some additional insights into the epidemiology of the injury. Nineteen patients met the inclusion criteria.

RESULTS

There were 19 patients with 20 tibial tuberosity fractures. The mean age was 13.7 years. There were 18 males and 1 female patient. There were nine left-sided injuries and eleven right-sided including one patient with bilateral fractures. Mechanism of injuries included basketball injury (8), running injury (5), football injury (3), fall from a scooter (2), high jump (1) and fall (1). Co-morbidities included three patients with concurrent Osgood-Schlatter disease and one with osteogenesis imperfecta. All were treated with ORIF, including arthroscopic-assisted techniques in two cases. Complications included four patients with pre-operative presentation of compartment syndrome all requiring fasciotomy, one post-operative stiffness and one painful hardware requiring removal. Range of motion was started an average of 4.3 weeks post-operatively and return to play was an average of 3.9 months post-operatively.

CONCLUSION

Although uncommon, tibial tuberosity fractures in adolescents are clinically important injuries. Early recognition and treatment (closed or open as appropriate) gives good results. All the patients in our series had surgical fixation as per different indications that have been elaborated. It is important for clinicians to recognize that compartment syndrome remains a significant concern post-injury and in the perioperative period. Close monitoring and timely intervention is recommended. A simple treatment algorithm is presented for clinicians to help manage these injuries.

Bilateral Avulsion Fractures of the Tibial Tuberosity: A Double Case for Open Reduction and Fixation

Tibial tuberosity fractures are rare and occur mainly in adolescent males during vigorous quadriceps contraction. So far, only ten simultaneous bilateral fractures have been reported. We report the case of a 16-year-old male who avulsed both tibial tuberosities when he landed on his feet after a gymnastics routine. Diagnostic imaging demonstrated Ogden Type IIIA fractures. He underwent bilateral open reduction and screw fixation with a good functional result after 3 months. While closed reduction and percutaneous fixation has been proposed by some, the intraoperative findings in our patient would have prevented correct adaptation of the fragments because of a flap of periosteum impinged in both fracture gaps. This case emphasizes that minimally invasive techniques may sometimes be inappropriate in the management of these types of fractures.

An en bloc avulsion fracture of tibial tuberosity and Gerdy's tubercle in an adolescent basketball player: a case report

We report a case of en bloc avulsion fracture of tibial tuberosity and Gerdy's tubercle, which has never been reported. A 14-year-old boy suffered from an acute pain in his left knee during running just before a jump. Simple radiographs showed an avulsion of the tibial tuberosity. On CT scans, the fractured fragment was attached not only to patellar tendon but also to iliotibial band (ITB) via Gerdy's tubercle. MRI evaluation revealed no intra-articular associated pathology. Open reduction and internal fixation with three cannulated screws were performed under lateral parapatellar approach to expose both the tibial tuberosity with patellar tendon and Gerdy's tubercle with ITB. At postoperative 1 year, he could walk, run, squat, and complained of no difficulty in activities on daily living with full range-of-motion of the knee. Radiographs showed well-healed fracture in situ. Gradually, he returned to sports activity. We believe that the injury was caused by the dynamic pull of quadriceps muscle via patellar tendon onto tibial tuberosity and the mostly static pull of ITB onto Gerdy's tubercle, both of which took a part in the fracture of the anterolateral portion of the unfused epiphysis of proximal tibia. The pes anserinus attaching on the anteromedial metaphysis of proximal tibia might exert the opposing deforming force. Preoperative planning including the determination of the extent of fracture and recognition of concomitant injury is a prerequisite for appropriate treatment.

[Avulsion fracture of the tibial tubercle in adolescents: 22 cases and review of the literature]

PURPOSE OF THE STUDY

Fracture of the anterior tibial tubercle is exceptional in adolescents. The purpose of this work was to better understand the circumstances of such fractures, identify potential complications, and assess outcome of different therapeutic options.

MATERIAL AND METHOD

This was a retrospective analysis of a consecutive series of 22 children with avulsion fracture of the anterior tibial tubercle. The circumstances of the fracture were noted. The Ogden classification was used to establish the radiological type. Associated lesions were also noted as were any complications. Two types of treatment were given: orthopedic or surgical (several types). The functional outcome was assessed at last follow-up.

RESULTS

Mean age at fracture of the anterior tibial tubercle was 13 years (range 12-16) in 14 boys and 7 girls. It occurred after a jump or reception after a jump in 22 of the children. Five patients presented symptomatic homo- or contralateral anterior tibial apophysitis before the accident. The fracture was not displaced (type IA) in ten patients and was treated orthopedically. In twelve patients, the fracture was displaced (type IB, II, or III) and required osteosynthesis. Immobilization was maintained for four weeks on average (range 3-7). Associated lesions were observed in half of the twelve displaced fractures, with five cases of patellar ligament avulsion and three cases of meniscal injury. There were no complications with type IA fractures. For the twelve displaced fractures, complications were observed in seven children: hematoma (n = 2), infrapatellar hypoesthesia (n = 2), complete rupture of the patellar ligament 38 months after surgery (n = 1), recurvatum with leg length discrepancy (n = 1), and stiff knee (n = 1). Mean follow-up was two years (range 9 months-8 years). The functional outcome was excellent in all patients with a non-displaced fracture and in seven of the twelve patients who underwent surgical treatment.

DISCUSSION

Non-displaced fracture of the anterior tibial tubercle I children (type IA) should be considered as a separate entity responding very well to orthopedic treatment. The other cases of displaced fracture generally require surgery which enables an assessment of often associated lesions. The prognosis of displaced fractures of the anterior tibial tubercle is more sever due to the associated lesions and potential complications. We describe the second case of recurvatum and leg length discrepancy following fracture of the anterior tibial tubercle.

CONCLUSION

Displaced fracture of the anterior tibial tubercle in adolescents is often associated with soft tissue injury (patellar ligament, menisci). Surgery is indispensable and provides good functional results.

Avulsion fractures of the tibial tuberosity in adolescent athletes treated by internal fixation and tension band wiring

Avulsion of the tibial tuberosity is a rarely reported fracture. It is mainly considered as an athletic injury accounting for less than 3% of all epiphyseal lesions. In this study, we hypothesized that the use of tension band wiring as a supplement of the internal fixation for the avulsion fractures of the tibial tuberosity would lead the adolescent athletes to a more effective rehabilitation program and an earlier resumption of their previous activity level. Ten patients were treated in our department over a period of 11 years (1985-1995). Operative treatment was thought necessary for all our cases due to tibial tuberosity displacement. Open reduction and internal fixation in combination with tension band wiring was used. The result in all cases was that the reduction was maintained intact and the fracture united. The functional results were excellent, and all patients returned to their previous athletic activities. Our conclusion is that the combination of internal fixation and tension band wiring for avulsion fractures of the tibial tuberosity seems to be more effective and advantageous than conservative or other surgical methods. Avoiding the need of external support and allowing early joint motion, the method described prevents serious quadriceps atrophy, allowing the young athletes to return earlier to their previous sport activities.

Fractures around the knee in children

Traumatic forces applied to the immature knee result in fracture patterns different from those in adults. The relative abundance of cartilage in the knee of the growing child may make the diagnosis of certain injuries more challenging. If plain radiographs fail to reveal a fracture, a stress radiograph, computed tomography scan, or magnetic resonance imaging study may help to establish the diagnosis. Certain fractures, such as hyperextension injuries to the distal femoral or proximal tibial epiphysis, or displaced tibial tuberosity fractures, may be especially susceptible to neurovascular problems. Although the use of appropriate treatment techniques may minimize the occurrence of late complications such as malunion and physeal bridging, not all problems are preventable. A careful discussion of the injury with both patient and parents should stress the importance of follow-up so that any problems that do occur can be promptly addressed.

The immature athlete

The skeletally immature athlete poses unique problems in diagnosis and treatment of injuries to the extensor mechanism of the knee. An accurate and detailed history and physical examination of the knee are essential for making a specific diagnosis and formulating an appropriate treatment plan. This article presents an overview of acute and chronic injuries of the extensor mechanism of the knee that are unique to skeletally immature athletes. The subjects of femoral trochlear dysplasia and medial subluxation of the patella are briefly discussed. The etiopathology, clinical evaluation, and management (non-operative and operative) of sleeve fractures of the patella and avulsion fractures of the tibial tubercle in children and adolescents are discussed. The pathoanatomy, clinical features, and management of synovial plica syndrome, Hoffa's syndrome, Osgood-Schlatter disease, and Sinding-Larsen-Johansson disease are presented.

Pediatric sports injuries: when to refer or x-ray

When any athlete presents for evaluation of an injury, the history and physical examination is of paramount importance in establishing a differential diagnosis. A radiograph is often used to confirm a diagnosis or to reassess an injury following treatment failure. There are certain drawbacks involved with getting a radiograph including cost, inconvenience, radiation exposure, and misinterpretation. Therefore, the radiographic evaluation of the injured athlete should be used only as clinically necessary. The benefits of getting a radiograph, to allow assessment of the severity of the injury, and thereby allow a more appropriate and aggressive treatment and rehabilitation program. The skills of history taking and physical examination presented in this article should make it easier to decide when the child athlete needs a more comprehensive and aggressive evaluation including radiographic studies.

Physeal Fractures About the Knee

The knee is the most common site of injury in childhood sports, and with increased participation in organized sports, the potential for knee injuries has accordingly increased. The epiphyses and apophyses provide a site of injury unique to the immature patient. The distal femoral and proximal tibial physes and the tubercle apophysis respond differently to acute and repetitive load and often provide less resistance to traumatic forces than do surrounding ligament and bone. Treatment of displaced physeal fractures about the knee remains one of the more difficult problems in orthopaedics. Even with appropriate conservative or surgical treatment, a successful outcome is not ensured. The Salter-Harris classification system provides general guidelines regarding the risk of growth disturbance, but there are no clinical methods for quantifying the true extent of physeal damage in an acute injury. Ultimately, the value of a treatment method must be evaluated on the basis of not only the restoration of articular congruity and physeal anatomy but also the restoration of physeal function, as evidenced by the continuation of normal growth. The mechanism of injury, clinical evaluation, treatment, and outcomes for all epiphyseal injuries about the knee are discussed, as well as differences from adult injuries.