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Tibial Tubercle Avulsion Fracture
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Contents
Other Names
- Tibial Tubercle Fracture
- Avulsion of the Tibial Tubercle
- Tibial tubercle avulsion fractures (TTAFs)
Background
- This page refers to acute avulsion fractures of the proximal Tibial Tubercle
- This is a separate clinical entity from Osgood Schlatter Disease
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
- Quadriceps Tendon Rupture
- Patellar Tendon Rupture
- Osgood Schlatter Disease
- Connection is not well defined[5]
- Meniscus Injury
- Acute Compartment Syndrome
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
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
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
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
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)
- 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
- Knee Pain (Main)
- Knee Anatomy (Main)
- Physical Exam Knee
- Pediatric Fractures (Main)
- Apophyseal And Epiphyseal Injuries (Main)
External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Hand W, Hand C, Dunn A. Avulsion fractures of the tibial tubercle. J Bone Joint Surg Am 1971; 53:1579–1583.
- ↑ 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.
- ↑ 3.0 3.1 Little, Rhianna M., and Matthew D. Milewski. "Physeal fractures about the knee." Current reviews in musculoskeletal medicine 9 (2016): 478-486.
- ↑ 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.
- ↑ 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.
- ↑ Jakoi A, Freidl M, Javandel M, et al. Tibial tubercle avulsion fractures in adolescent basketball players. Orthopedics 2012; 35:692–696.
- ↑ McKoy B, Stanitski C. Acute tibial tubercle avulsion fractures. Orthop Clin North Am 2003; 34:397–403.
- ↑ 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.
- ↑ 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.
- ↑ Franz, Pia, Eva Luderowski, and María Tuca. "Tibial tubercle avulsion fractures in children." Current opinion in pediatrics 32.1 (2020): 86-92.
- ↑ 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.
- ↑ 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.
- ↑ 13.0 13.1 Frey S, Hosalkar H, Cameron D, et al. Tibial tuberosity fractures in adolescents. J Child Orthop 2008; 2:469–474.
- ↑ 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
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Last edited:
22 March 2023 14:39:27
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