Avulsion fractures of the tibial tubercle

Ambulatory surgical management of most displaced tibial tubercle fractures in children is safe and efficient

Purpose

The purpose of this study is to compare the outcome of patients with displaced tibial tubercle fractures treated surgically who spent one or more nights in the hospital after surgery with that of patients treated in an ambulatory setting with no perioperative hospitalization. We hypothesized that tibial tubercle fractures have a low rate of complications and that most patients do well without an overnight hospital stay for observation.

Methods

We retrospectively reviewed all pediatric tibial tubercle fractures treated operatively by a single surgeon over a 13.5-year period. Fractures treated in an inpatient setting, defined as at least one night of overnight hospitalization postoperatively, were compared with fractures treated in an ambulatory setting with no perioperative hospitalization.

Results

Seventy-one fractures in 70 patients were analyzed. All fractures were treated with open reduction and internal fixation with unicortical screws. Thirty-five fractures (49.3%) were fixed in an ambulatory setting, while 36 (50.7%) were inpatient. There were no significant differences between inpatient demographics (age, gender, body mass index, fracture type). Average operative time was significantly longer in the inpatient group compared with the ambulatory group (97.8 min versus 58.8 min, p < 0.001). There was no significant difference in the incidence of complications between inpatient and ambulatory groups (25.0% versus 11.4%, p = 0.22). No cases of compartment syndrome were noted.

Conclusion

Ambulatory surgical treatment of select tibial tubercle fractures with same-day discharge is safe and efficient. Not all patients with surgically treated tibial tubercle fractures need to stay overnight in the hospital.

Tibial tubercle fractures are sports injuries in male adolescents with a considerable risk of complications and reoperations: a systematic review

PURPOSE

There is growing interest in tibial tubercle fractures in pediatric and adolescent population within the last decade. However, there is limited evidence in the existing literature. Therefore, the purpose of this systematic review was to analyze and provide up-to-date data that may prove valuable in decision making and management of these injuries in the general as well as the athletic population.

METHODS

A systematic review of the literature in PubMed, Cochrane library and Virtual Health Library was conducted using the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis" (PRISMA) guidelines. Articles published in English or Spanish, during the past 20 years, reporting outcomes of tibial tubercle fracture management in patients younger than 18 years old, with a mean follow-up of at least 6 months reporting outcomes, type of management and classification were included.

RESULTS

A total of 919 patients with 956 fractures in 25 retrospective cohort studies were included. The mean age was 14.4 ± 0.6 years while 766 [83%] were males and 740 [81%] of the injuries were sports-related. Associated injuries were reported in 91[10%] cases, most common being patellar tendon avulsion. Surgical management was chosen for 845[88%] of the cases, the vast majority being open reduction internal fixation (ORIF) with screws. Union was achieved in 954 [99.8%] cases. Complications and re-operations rate stood at 172[18%] and 161 [19% of the operations], respectively. Return to play (RTP) was reported in 11 [44%] of the studies standing at an average of 98.9% ± 3.6.

CONCLUSION

Essentially, this is an adolescent sports knee injury that needs careful planning before decision making because it may affect both RTP and joint preservation. Although union was achieved in almost all patients, there is a high risk of associated injuries, complications and reoperations. The surgeon should be confident to perform fracture fixation as well as addressing associated knee soft tissue injuries to achieve optimal outcomes.

LEVEL OF EVIDENCE

Level IV.

Tibial tubercle avulsion fractures in adolescents: impact on function and quality of life

The objective of the study was to assess functional outcomes and quality of life of patients treated for tibial tubercle avulsion fractures (TTAFs). Retrospective study of patients under 18 years of age treated from June 2011 to May 2018. Demographic data included age, gender, mechanism of injury, side, fracture classification, associated injuries, predisposing factors, and type of treatment. Clinical results included knee range of motion, pain, return to sports, overall satisfaction, functional outcomes, and complications. At final follow-up, Tegner Lysholm Knee Scoring Scale, and Kidscreen-10 were applied. Ten patients were included, all males, with a median age of 15 years. Mechanism of injury: football (three patients), basketball (two patients), running (two patients), handball (one patient), gymnastics (one patient), and fall (one patient). Nine were treated surgically with reduction and fixation with cannulated screws or Kirschner wires, plus treatment of associated injuries (three patellar tendon avulsions, one contralateral proximal tibia epiphyseal fracture, and two prophylactic fasciotomies). One patient developed mild recurvatum and two presented minor decreased knee flexion. Eight patients returned to their previous level of sports activity. Median Tegner Lysholm Knee Score was 100/100 and Kidscreen-10 was 50/50. With appropriate treatment, nearly 100% of TTAFs have good functional outcomes and low impact on quality of life.

Clinical and epidemiological features of tibial tubercle avulsion fracture in Chinese adolescents

Background

Tibial tubercle avulsion fracture is rare in children. Accumulated knowledge on clinical and epidemiological features of this fracture is of practical significance for clinical colleagues to deal effectively with such fractures.

Methods

Clinical and epidemiological parameters were reviewed retrospectively in 29 patients with tibial tubercle avulsion fracture that was treated in our hospital in the past 7 years.

Results

Totally, 29 children with 30 tibial tubercle fractures were enrolled. They were all boys; the average age was 13.8 (12–15) years, and the average Body Mass Index (BMI) was 26.4 (19.2–34.3). Statistically, 41.4% of injuries occurred during jumping activities, and 1 (3.4%), 12 (41.4%) and 16 (55.2%) patients were injured bilaterally, on the right and left sides, respectively. The patients were classified into type I (4), II (3), III (13) and IV (10) fractures. Two patients (three knees) with fractures of type IV received close reduction and cast immobilization for 6 weeks. One patient with fracture of type IV underwent close reduction and was fixed with two cannulated screws. The remaining 26 patients underwent open reduction and were fixed with two or three cannulated screws. The average follow-up time was 38 (14–98) months; no complication was noted. Twenty-seven patients had an excellent outcome.

Conclusion

In Chinese adolescents, the tibial tubercle avulsion fracture predisposes to boys with higher body weight; jumping is the most common cause of injury; treatments show satisfactory outcome regardless of fracture types.

Tension band suture in isolated tibial tubercle avulsion: A case report and review literatures

INTRODUCTION

Isolated tibial tubercle avulsion in adults are extremely rare, with only a few cases having been reported. The common treatment is screw fixation, followed by immobilization. We report a rare case of an isolated tibial tubercle avulsion in an adult and demonstrate the results of a tension band suture without post-operative immobilization for treatment.

CASE PRESENTATION

A 64 year-old woman presented with an isolated tibial tubercle avulsion, and loss of her extensor mechanism. Treatment with tension band suture could provide early motion, and her return to full ambulation in 2 months.

CONCLUSION

An isolated tibial tubercle avulsion, there are many surgical techniques to secure the fixation. The tension band suture is one technique that the patient can acheive a good fixation without post-operative immobilization and rapidly return to normal activity.

Fracture of the anterior tibial tuberosity in children

Fractures of the anterior tibial tuberosity during childhood are an infrequent pathology (around 3% of all proximal tibial fractures), but the incidence of this injury has risen over recent years, likely due to the increased involvement of this age group in sports activities.

This fracture is more commonly seen in children 12–14 years old.

It is vital to identify the anatomical structures associated with this type of fracture, along with the pathophysiological mechanisms involved.

Treatment includes non-operative and operative options, with the goal of achieving articular congruency, restoring the extensor mechanism function, and avoiding damage to the proximal tibial physis.

Understanding the management of this fracture, and the complications that might arise, is critical. The provision of an appropriate clinical management plan and the avoidance of complications are vital in the prevention of disability.

Cite this article: EFORT Open Rev 2020;5:260-267. DOI: 10.1302/2058-5241.5.190026

Growth pattern of lumbar bone mineral content and trunk muscles in adolescent male soccer players

INTRODUCTION

Previous studies have reported that the peak in lean body mass (LBM) precedes the peak in bone mineral content (BMC). However, it is unknown whether the trunk region growth is similar.

MATERIALS AND METHODS

We investigated the difference between pubertal peak age in the increase of LBM in the trunk (trunk LBM) and pubertal peak age in the increase of BMC in the lumbar spine (lumbar BMC) in a longitudinal study of 201 Japanese male adolescent soccer players. The age of peak height velocity (PHV) and the developmental age were calculated. The participants were followed over a 2-year period, with height and dual-energy X-ray absorptiometry scans taken every 6 months.

RESULTS

The trunk LBM (ρ = 0.732, p < 0.0001) and the lumbar BMC (ρ = 0.621, p < 0.0001) significantly correlated with the developmental age. The increase of trunk LBM and lumbar BMC was significantly different according to the developmental stages (Kruskal-Wallis test; p < 0.0001 and p < 0.001, respectively). We used a cubic spline to estimate the developmental age, when the increase reached its peak: the peak age of the increase in trunk LBM was estimated to be - 0.08 years (approximately - 1 month) prior to PHV age, whereas the peak age of the increase in lumbar BMC was estimated to be 0.42 years (approximately 5 months) after the PHV age.

CONCLUSIONS

The maximal increase in trunk LBM occurs just before PHV age and approximately 6 months before the maximal increase in lumbar BMC during the pubertal growth spurt in the Japanese adolescent male soccer players.

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 of surgical treatment of the tibial tuberosity fractures in skeletally immature patients: an update

Tibial tubercle fractures in adolescents are uncommon injuries which typically occur in 12-16 year-old males involved in athletic activities. We hereby present our experience in the surgical treatment of such lesion. By reviewing all the tibial tuberosity fractures treated surgically at our institution between January 2012 and January 2016, we were able to identify 12 patients (14 fractures), of which 11 males and 1 female, whose average age at the time of the trauma was of 14.05. According to the Ogden classification, we identified two Type IIA fractures, one Type IIB fracture, one Type IIIB fracture, four Type IIIC fractures, four Type IVA fractures, one Type IVB fracture and one Type IVC fracture. All patients underwent surgical treatment-9 fractures ORIF (64.3%), 5 CRIF (35.7%)-and postsurgical immobilization in plaster cast for 15 days, with a non-weight bearing period of approximately 4.7 weeks. They all had a complete ROM recovery and returned to preinjury activities within 4.1 months on average. The successful union of the fracture was observed in all patients, and no cases of meniscal lesions, compartment syndrome, infections, lower limb length discrepancy or axial deviations emerged at the minimum follow-up of 24 months. After an average period of 11 months and 2 weeks (range 6.1-16.3), all patients underwent surgical implant removal. Our experience matches the outcomes described in the literature, therefore confirming the safety and effectiveness of this treatment.

Tibial tubercle avulsion fractures in school sports injury: A case report

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Most injuries in school occur during sport. Avulsion fractures of the tibial tubercle are uncommon school sports injuries.

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X-ray is the key to diagnosis. Then CT scan is needed to evaluate the fracture extension to the articular joint.

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Many cases are misdiagnosed and progress to recurvatum deformity especially in open physis individuals after neglected tibial tuberosity fractures.

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These injuries cause significant disruption to school and sport, but fortunately, complications are rare and functional recovery is usually complete.

Introduction

Most injuries in adolescent occur during school sports like volleyball, football or basketball. Tibial tubercle avulsion fractures (TTAF) are an unusual condition, resulting from a forced extension of the knee opposed to fixed leg.

Presentation of the case

A 16 years old male was hurt during school basketball, X-rays displayed avulsion fracture of tibial tuberosity of left knee, the treatment was operative using two cancellous screws, results were good including complete knee mobility and early coming back to school sport at 6 months.

Discussion

TTAF remains rare accounting for <3% of all epiphyseal injuries, it is frequent in teenage boys with open physis during school sport. We review the pathophysiology, mechanism, classification, diagnosis, and management of this injury.

Conclusion

complications are occasional and functional recuperation is common after closed reduction and cast immobilization for slightly or no displaced fractures, otherwise open reduction and internal fixation for displaced fractures.

A Narrative Review on Avulsion Fractures of the Upper and Lower Limbs

Avulsion fractures compromise function and movement at the affected joint. If left untreated, it can lead to deformity, nonunion, malunion, pain, and disability. The purpose of this review was to identify and describe the epidemiology and available treatment options for common avulsion fractures of the upper and lower extremities. Current evidence suggests that optimal treatment is dependent on the severity of the fracture. Conservative efforts generally include casting or splinting with a period of immobilization. Surgery is typically indicated for more severe cases or if nonoperative treatments fail; patient demographics or preferences and surgeon experience may also play a role in decision making. Some avulsion fractures can be surgically managed with any one of various techniques, each with their own pros and cons, and often there is no clear consensus on choosing one technique over another; however, there is some research suggesting that screw fixation, when possible, may offer the best stability and compression at the fracture site and earlier mobilization and return to function. Physicians should be mindful of the potential complications associated with each intervention.

Tibial plateau fractures (AO type B3) combined with tibial tubercle fracture: Case report and review of the literature

RATIONALE

Tibial tuberosity fractures most often occur in the adolescents. Fracture of tibial tuberosity in adults is extremely rare with only 5 reported cases till date. Tibial plateau fractures combined with tibial tubercle fractures are not common.

PATIENT CONCERNS

We report here a type B3 tibial plateau fracture (AO classification) with a concomitant fracture of tibial tuberosity.

DIAGNOSES

Anteroposterior and lateral knee view radiographs revealed a complex comminuted fracture of the right tibial plateau (AO Type B3; Schatzker Type IV) with tibial tubercle fracture. Three-dimensional computed tomography (CT) showed that the tibial media plateau was split into 2 pieces in the sagittal plane, along with the isolated tibial tubercle.

INTERVENTIONS

The open procedure was performed first and a standard posteromedial approach for medial and posteromedial tibial plateau fracture was used with double locking plate fixation. The tibial tuberosity was fixed with a cortical screw.

OUTCOMES

The patient showed full range of motion in right knee after 8 weeks. The patient was allowed full weight bearing at 4 months. Eight months after operation, he was asymptomatic, showed a full range of motion and good strength. He had returned to work with no limitations.

LESSONS

Fractures of the partial tibial plateau combined with tibial tubercle are present and should not be ignored. Accurate diagnosis and proper treatment will help achieve favorable outcomes in these patients.

Simultaneous bilateral tibial tubercle avulsion fracture in a male teenager: case report and literature review

Tibial tuberosity avulsion fractures are injuries accounting for less than 3% of all epiphyseal and 1% of all physeal injuries in adolescents. Bilateral injuries are very rare, with only 19 cases described in the literature. These types of fractures occur commonly in male teenagers during sport activities and are often associated with other orthopaedic disorders. We report the case of a male teenager with simultaneous bilateral tibial tubercle fractures, describe the evolution and treatment of this injury and review the literature on this subject.

LEVEL OF EVIDENCE

Case report.

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.

Surgical Fixation of Bilateral Simultaneous Avulsion Fractures of the Proximal Tibia in a 12-Year-Old with History of Conservatively Managed Unilateral Tibial Avulsion Fracture

Fractures of the proximal tibial epiphysis are rare, representing less than 3% of all epiphyseal and 1% of all physeal injuries in adolescents. Bilateral injuries are extremely rare. The specific anatomical and histological features of the proximal tibial epiphysis make it vulnerable to a specific fracture pattern that occurs when the tensile force of the quadriceps is greater than the fibrocartilaginous tissue underlying the tibial tuberosity. We report the first case to our knowledge of a 12-year-old boy who sustained simultaneous bilateral tibial avulsion fractures on the background of a previous conservatively managed unilateral tibial tuberosity avulsion fracture. We report this case for its uniqueness and as an educational review of the anatomy, the mechanism of injury, and the development of classifying these fractures and discussion of the stages of the growing physis that determine the treatment approach.

Physeal fractures about the knee

While some fractures may be managed similarly in adults and children, physeal fractures are uniquely limited to the pediatric population and require special consideration. Although physeal fractures about the knee are relatively rare, they are occurring more frequently due to increasing youth participation in sports and high-energy recreational activities. The evaluation and management of distal femoral and proximal tibial physeal fractures are similar to one another, but fractures of the tibial spine and tibial tubercle are approached somewhat differently. A thorough understanding of the pertinent developmental anatomy is critical for correlating the clinical findings with the imaging work-up, and for anticipating the most common and the most serious complications of each fracture. Diagnosis is usually made with appropriate plain radiographs with advanced imaging often used for preoperative planning. In general, fracture pattern and degree of displacement determine the need for surgical intervention and the overall outcome. While a variety of fixation techniques or constructs may be used, because of the importance of restoring physeal and articular anatomy for avoidance of growth disturbance and degenerative joint disease, respectively, achieving anatomic, rigid fixation is of greater importance than with many other fracture locations in the growing skeleton.

Lessons learnt from managing an avulsion fracture of the tibial tubercle extending into the tibial physis

Acute avulsions of the tibial tubercle apophysis are uncommon, with reported incidence of 0.4-2.7% of all physeal injuries. In our case the extent of the injury was not realised at first presentation and initial internal fixation was attempted. At first outpatient follow-up, repeat radiographs indicated the fracture was not reduced and further CT imaging requested. The three-dimensional CT reconstructed images provide considerably more information on the fracture pattern and retrospectively these may have been helpful during the initial procedure. Therefore we would recommend obtaining a preoperative CT scan if extension of the fracture into the tibial physis is suspected. During the second procedure arthroscopy was tried to aid fracture reduction, but visualisation of the anterior articular surface under the anterior horns of the menisci was difficult through the anterior portals with a standard 30° arthroscope and we further recommend having a 70° scope available to ensure optimal visualisation.

Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment

BACKGROUND

Adolescent tibial tubercle fractures are uncommon, complex, high-energy injuries. The use of lateral radiographs in isolation to diagnose and treat these injuries is the standard of practice. However, with a single 2-dimensional (2D) view, there may be a risk that the degree of injury can be underestimated. This study was performed to report on the outcomes of tibial tubercle fractures operatively treated, determine the utility of a single lateral x-ray to accurately document injury severity and pattern, delineate the role of advanced imaging and intraoperative arthroscopy/arthrotomy in injury treatment, and propose a new classification system of tibial tubercle fractures that accounts for the complex 3D nature of proximal tibial physeal closure, and recognizes the importance of intra-articular extension, providing guidance for intervention.

METHODS

A retrospective review of operatively treated tibial tubercle fractures at our institution from 2003 to 2010 was performed. Child age, weight, mechanism of injury, Ogden classification (x-ray), advanced imaging results [computed tomography (CT)/magnetic resonance imaging (MRI)] including intra-articular fracture patterns, surgical techniques, intraoperative articular findings, and postoperative complications were collected. In addition, we classified all of our patients into a new classification system (type A--tubercle youth, type B--physeal, type C--intra-articular, type D--tubercle teen) based on a combination of plain radiograph (anteroposterior and lateral), advanced imaging (CT/MRI), and intraoperative arthrotomy/arthroscopy findings.

RESULTS

We found 41 tibial tubercle fractures in 40 children (all of whom were male) with a mean age of 15.0 ± 1.1 years, and mean weight of 80.3 ± 23.4 kg. Injuries mostly occurred during jumping activities. At initial presentation, compartment syndrome or vascular compromise was seen in nearly 10% of patients, all of whom had type B--physeal injuries under our new classification system. Fifty percent of injuries were underestimated and/or not appreciated by lateral x-ray alone. In patients with intra-articular involvement, consistent 3D fracture patterns were seen on CT including anterior fragments (sagittal plane), lateral fragments (coronal plane), and anterolateral fragments (axial plane). Our new 4 part classification system was able to classify all fractures: type A (2 patients, mean age, 12.7 ± 0.2 y), type B (13 patients, mean age, 14.8 ± 0.7 y), type C (22 patients, mean age, 15.3 ± 1.1 y), and type D (2 patients, mean age, 15.5 ± 0.1 y). All fractures achieved radiographic union with 2 patients (type A--tubercle youth and type B--physeal) requiring additional procedures due to premature physeal closure.

CONCLUSIONS

Tibial tubercle fractures represent high-energy injuries with potentially devastating complications such as compartment syndrome and/or vascular compromise. Intra-articular involvement is often missed with the use of plain x-ray and drastically underestimates injury severity. The use of preoperative CT scan or MRI should be utilized as adjunct to plain lateral radiograph. If intra-articular involvement is recognized preoperatively, arthroscopy or open arthrotomy should be utilized at the time of surgery. Our new classification system is rooted in the development of the proximal tibia, accounts for intra-articular involvement, and provides guidance for treatment.

LEVEL OF EVIDENCE

Level III--diagnostic study.

Tibial tubercle avulsion fractures in adolescent basketball players

Tibial tubercle avulsion fractures most commonly occur in adolescent boys and usually result from pushing off or landing while jumping. These fractures are relatively uncommon but can have a significant functional effect. The purpose of this study was to determine the long-term outcome with return to play in 8 adolescent basketball players with at least 4 years of postoperative reconditioning. Results with return to play at the preinjury level are favorable after treatment of acute tibial avulsion fractures in adolescent basketball players. Long-term outcome was excellent in all patients regardless of fracture type. Open reduction and internal fixation using 1 or 2 cancellous bone screws achieved union in all cases.