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Tibial Tubercle Avulsion Fracture

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Other Names

  • Tibial Tubercle Fracture
  • Avulsion of the Tibial Tubercle
  • Tibial tubercle avulsion fractures (TTAFs)

Background

History
Epidemiology

  • Account for 1% of all physeal injuries, 3% of all proximal tibial fractures[1]
  • Incidence of 0.25 - 2.7 cases per year[2]
  • Males > Females[3]
  • Typical age is 12-16 years[3]

Introduction

  • General
    • Typical patient is a adolescent male approaching skeletal maturity
    • Most commonly occurs in sports involving jumping
    • Equivalent to a Salter Harris Type III Fracture of the proximal tibial physis

Mechanism of Injury

  • Typically indirect injury
  • Transpire during jumping activities or sports
  • Eccentric quadriceps contraction with knee moving into flexion (landing from a jump)
  • Concentric quadriceps contraction with knee moving into extension (jumping)[4]

Associated Conditions

Anatomy of the Tibial Tubercle

  • Represents a secondary ossification site to the proximal tibial physis
  • Last part to fuse in the skeletally immature individual
  • Fuses under constant extension forces (unlike the majority of growth plates)

Risk Factors

  • Sports
    • Basketball[6]
    • Volleyball
    • Sprinting
    • High Jump
  • Male gender
    • In part because physis closure occurs at a later age in males
    • Also thought to be due to greater quadriceps strength than female athletes[7]
  • Osgood Schlatter Disease (OSD)
    • 25% of patients have pre-existing OSD symptoms, unclear if there is a causal relationship[8]

Differential Diagnosis

Differential Diagnosis Knee Pain


Clinical Features

  • History
    • Patient will report an acute injury and sudden onset of pain
    • Typically after jumping, sprinting
    • A pop may be heard, patient will fall to the ground
    • Inability to bear weight, move knee or ambulate
  • Physical Exam: Physical Exam Knee
    • Swelling, point tenderness over tibial tuberosity
    • Knee may be resting in 20-40° of flexion due to hamstring spasticity
    • There may be loss of knee extension
    • If extension is intact, extensor lag is often present
    • Palpable bone fragment can sometimes be felt
    • Joint effusion is present[9]
    • Be certain to evaluate the anterior compartment

Evaluation

Left Knee Tibial Tubercle Avulsion Fracture on POCUS


Knee CT with Tibial Tubercle Avulsion Fracture

Radiographs

  • Standard Radiographs Knee
    • Important to compare to contralateral knee if any uncertainty
  • Findings (best seen on lateral view)
    • Anterior swelling may be the only finding
    • Widening of open apophysis
    • Hemarthrosis/ effusion if intra-articular extension
    • Patella Alta

Ultrasound

  • Utility not well characterized in literature
  • Easily visualized, can be compared to contralateral limb

CT

  • Can be used to evaluate for extent of fracture, intra-articular involvement, posterior extension
  • Consider angiography if vascular injury is known or suspected

MRI

  • Indicated if other soft tissue injuries are suspected

Classification

Modified Ogden Classification courtesy of Franz et al[10]

Modified Ogden Classification

  • Type I: fracture of the secondary ossification center near the patella tendon insertion[11]
  • Type II: fracture between the primary and secondary ossification centers
  • Type III: fracture that traverses the primary and secondary ossification centers (most common type)
  • Type IV: fracture through the entire physis
  • Type V: avulsion of the periosteal sleeve
  • Modifiers: A (nondisplaced) and B (displaced)

Watson-Jones Classification

  • Type 1: avulsion of the apophysis without injury to the tibial epiphysis
    • Most common type
  • Type 2: epiphysis is lifted cephalad and incompletely fractured
  • Type 3: displacement of the proximal base of the epiphysis with the fracture line extending into the joint

Management

Nonoperative

  • Indications
    • Intact extensor mechanism
    • < 2-5 mm displacement depending on your source[11]
    • Ogden IA, IIA (with intact extension)
  • Immobilization in Cylinder Cast or Long Leg Cast
    • Typically for a minimum of 4 weeks, most often 6 weeks

Operative

  • Indications
    • Roughly 88% of TTAF are surgical[8]
    • Type II-V fractures (modified Ogden)
    • Loss of extensor mechanism
    • >5 mm displacement
  • Technique
    • Closed reduction with percutaneus clamping, lag screw fixation
    • Open reduction

Rehab and Return to Play

Rehabilitation

  • Postoperatively
    • Non weight bearing in long leg cast or brace in extension for 4-6 weeks
  • Physical therapy
    • Typically begins around 6 weeks
    • Progressive strengthening of extensor mechanism
    • Resistance training

Return to Play

  • Return to play criteria
    • Full range of motion
    • Tolerate full quadriceps load
  • Return to play depends on injury type
    • 8 weeks: Typically for Ogden type I, II
    • 6-8 months: type III-V fractures

Prognosis and Complications

Prognosis

  • Goal: restore or maintain extensor mechanism
  • Nonoperative outcomes
    • Christie et al reported excellent outcomes in 7/8 patients with Ogden type I fractures treated with casting only (need citation)
    • Betegon et al reported a series of 5 athletes with Ogden type IV, typically managed surgically, who all returned to sports in less than 25 weeks with casting only[12]
  • Operative outcomes
    • One study reported on 20 TTAF treated surgically with physical therapy beginning at 4 weeks and a mean return to sports of 4 months[13]
    • In a large study of 325 patients, 88% were treated surgically, 98% returned to sport at 29 weeks and 97% regained complete function[8]

Complications

  • Reported to be as high as 28%
  • Increased risk of complication is seen with
    • Intra-articular involvement
    • Involvement of posterior metaphyseal component
  • Acute Compartment Syndrome (ACS)
    • Occurs due to injury to the recurrent branch of the anterior tibial recurrent artery injury
    • Arterial injury occurs in up to 20% of cases[13]
    • ACS occurs in around 5% to 10% of cases[14]
    • Some surgeons suggest prophylactic fasciotomy, although is not universally accepted practice
  • Post op complications
    • Anterior knee pain from implant
    • Growth arrest
  • Refracture rate as high as 6%
  • Genu Recurvatum is rare, seen in less than 2% of cases
    • Seen with leg length discrepancy

See Also

Internal

External


References

  1. Hand W, Hand C, Dunn A. Avulsion fractures of the tibial tubercle. J Bone Joint Surg Am 1971; 53:1579–1583.
  2. Hamilton S, Gibson P. Simultaneous bilateral avulsion fractures of the tibial tuberosity in adolescence: a case report and review of over 50 years of literature. Knee 2006; 13:404–407.
  3. 3.0 3.1 Little, Rhianna M., and Matthew D. Milewski. "Physeal fractures about the knee." Current reviews in musculoskeletal medicine 9 (2016): 478-486.
  4. Zrig M, Annabi H, Ammari T, et al. Acute tibial tubercle avulsion fractures in the sporting adolescent. Arch Orthop Trauma Surg 2008; 128:1437–1442.
  5. Pretell-Mazzini, Juan, et al. "Outcomes and complications of tibial tubercle fractures in pediatric patients: a systematic review of the literature." Journal of Pediatric Orthopaedics 36.5 (2016): 440-446.
  6. Jakoi A, Freidl M, Javandel M, et al. Tibial tubercle avulsion fractures in adolescent basketball players. Orthopedics 2012; 35:692–696.
  7. McKoy B, Stanitski C. Acute tibial tubercle avulsion fractures. Orthop Clin North Am 2003; 34:397–403.
  8. 8.0 8.1 8.2 Pretell-Mazzini J, Kelly D, Sawyer J, et al. Outcomes and complications of tibial tubercle fractures in pediatric patients: a systematic review of the literature. J Pediatr Orthop 2016; 36:440–446.
  9. Gans, Itai, Keith D. Baldwin, and Theodore J. Ganley. "Treatment and management outcomes of tibial eminence fractures in pediatric patients: a systematic review." The American Journal of Sports Medicine 42.7 (2014): 1743-1750.
  10. Franz, Pia, Eva Luderowski, and María Tuca. "Tibial tubercle avulsion fractures in children." Current opinion in pediatrics 32.1 (2020): 86-92.
  11. 11.0 11.1 Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am 1980; 62:205–215.
  12. Checa Betego´ n P, Arvinius C, Cabadas Gonza´ les E, et al. Management of pediatric tibial tubercle fractures: is surgical treatment really necessary? Eur J Orthop Surg Traumatol Orthop Traumatol 2019; 29:1073–1079.
  13. 13.0 13.1 Frey S, Hosalkar H, Cameron D, et al. Tibial tuberosity fractures in adolescents. J Child Orthop 2008; 2:469–474.
  14. Pandya N, Edmonds E, Roocroft J, Mubarak S. Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment. J Pediatr Orthop 2012; 32:749–759.
Created by:
John Kiel on 7 July 2019 05:26:38
Authors:
Last edited:
22 March 2023 14:39:27
Categories:
Knee | Lower Extremity | Trauma | Pediatrics | Fractures | Acute