Postoperative X-ray shows good avulsion fracture reduction at the distal insertion of the posterior cruciate ligament (represented by the arrow), Postoperative three-dimensional reconstructed CT scan. The report is as follows. This occurs as a result of a violent contraction of the quadriceps muscles, most often as a result of a high-power jump. The duration of the disease before the surgery was 13weeks. Bethesda, MD 20894, Web Policies Inappropriate treatment could cause instability of the knee joint, which leads to the degenerative changes of the knee joint. It's because contact sports involve movements that stress your limbs, such as: Suddenly changing direction. sharing sensitive information, make sure youre on a federal 2012; 35(8): 692-6. Type A designates an isolated fracture with an ossified tip. 16 cases were followed up for 7-30 months (average 13.6), and 2 cases were out of follow-up. Case Rep Orthop. An avulsion fracture is the result of the body being forced into an unnatural position, causing a ligament to strain. They postulated that traction apophysitis diseases, namely OSD and SLJ Syndrome may predispose to avulsion style fractures. PMC Anat Rec. Wesley Chapel, FL 33544 Simultaneous bilateral tibial tubercle avulsion fracture in a male teenager: case report and literature review. Several different classification schemes exist that have been proposed and modified over the years. An official website of the United States government. Figure 2 shows the Watson-Jones classification system: Types I, II, and III. Open-reduction with internal-fixation can also be used for displaced intra-articular variants. Epub 2011 Jul 15. Tibial tuberosity fractures in adolescents. Preceding closure of the growth plate, there is a progressive change from fibrocartilage to columnar cartilage transitioning proximal to distal. The patient had tibial tuberosity avulsion along with tibial plateau fracture. This case serves as a reminder that despite the rarity of the injury, a clinician with an appropriate index of suspicion can accurately diagnose and treat this exceptional fracture and achieve positive outcomes in returning the patient to pre-injury activities. Bookshelf Galos DK, Konda SR, Kaplan DJ, et al. 1996;82(6):535-40. Epub 2016 Oct 7. The patient was placed in supine position and received general anesthesia or combined with lumbar epidural anesthesia. Acute tibial tubercle avulsion fractures in the sporting adolescent. Biomechanical evaluation of double Krackow sutures versus the three-loop pulley suture in a canine gastrocnemius tendon avulsion model. b Posteroanterior position schematic drawing. Avulsion fracture, Posterior cruciate ligament, Arthroscopy, High-strength line. Avulsion fractures of the tibial tubercle. The muscle exercises of the muscular systems on the lower limbs began 24h after the surgery. Learn more The patient had no complications and was discharged three days post-op. The procedure was completed with the assistance of PCL director drill guide. When the . The surgeon may recommend removing the tension band wire at this time if your pet is very young and the growth plate is still open. Andri GT, Klineberg EO, Wahl CJ, Mills WJ. and transmitted securely. Tibial tubercle avulsion fractures are an uncommon injury occurring due to strong contraction of the quadriceps femoris muscle during leg extension, ultimately causing failure of the physis at the patellar tendon insertion. doi: 10.7759/cureus.7532. J Pediatr Orthop. Please enable it to take advantage of the complete set of features! The fracture was identified and debrided and copiously irrigated. Behery OA, Feder OI, Beutel BG, et al. Sasaki SU, da Mota e Albuquerque RF, Amatuzzi MM, Pereira CA. Article Type : Case Report and Review Article. All the cases were caused by direct force resulting in the avulsion fracture at the distal insertion of the posterior cruciate ligament. OSD occurring from repetitive traction at the tibial tubercle typically occurs in male athletes between the ages of 10-1522. For those reasons, we provide a comprehensive overview of all aspects regarding this fracture pattern including the anatomy, embryology, mechanism of action, predisposing conditions, treatment considerations, complications and associated injuries. The results were analyzed with SPSS14.0. Rehabilitation began early postoperatively. SICOT J. 2016; 36(5): 440-6. Tibial tuberosity avulsion fractures are extremely rare fracture patterns, with reported incidence rates of 0.4% to 2.7% of all epiphyseal injuries, <1% of all physeal injuries, and about 3% of all proximal tibial injuries1,2,3. It is worthy of wide application. There are no financial interests to report. J Bone Joint Surg Am. Contact sports like lacrosse, boxing and football, for example, are the most common causes of avulsion fractures. Radiographs of the left knee and tibia revealed an Ogden Type IIIb, distracted avulsion fracture of the tibial tuberosity with suprapatellar joint effusion. Ogden Type Ia injuries have been treated conservatively with plaster casting for several weeks and immobilization with excellent results. Tibial tubercle avulsion fracture according to different mechanisms of injury in adolescents: Tibial tubercle avulsion fracture: Tibial tubercle avulsion fracture. The X-ray examination and three-dimensional reconstructed CT scanning showed a satisfying reduction for the 16 patients. Type I is any tubercle avulsion distal to the physis, or rather a fracture of the distal tibial tuberosity. Here, we report a rare case of avulsion fracture of the intercondylar eminence during UKA surgery that was successfully treated with a cannulated . The Krackow type pattern has demonstrated superior resistance to gap formation as well as increased load required for repair failure compared to a three-loop pulley suture in Achilles tendon repair in canine models39. Sprinting. All the follow-up patients were satisfied with the results (Figs. The bone fragments are allowed slight movements, which conforms to the principles of bio-fixation. Preoperative X-ray and MRI examinations. (4) Secondary surgery is not necessary, reducing the economic burden for the patients. A Type V fracture is the joining of a Type IIIb (displaced intraarticular) and a Type IV (posterior translation) which results in a Y configuration. The approaches at the knee joint were marked. Anterior cruciate ligament (ACL) avulsion fracture or tibial eminence avulsion fracture is a type of avulsion fracture of the knee. 1988 Jul-Aug;16(4):417-8. doi: 10.1177/036354658801600420. Hoogervorst P, Gardeniers JW, Moret-Wever S, et al. 2008; 2(5): 353-6. and transmitted securely. Wall JJ. Playing sports comes with risks. In the 16 followed patients, flexion and . The examinations by CT scan, X-ray, and MRI showed avulsed fragment shadow at the back of tibia (Fig. Open reduction and internal fixation technique. 2011 Jun;180(2):589-92. doi: 10.1007/s11845-008-0263-7. They represent a variant of anterior cruciate ligament injury. Figure 3 shows the Ogden classification system: Types Ia, IIa, IIIa, Ib, IIb, and IIIb. Ph: 813-929-4100. Evaluation of knee ligament surgery results with special emphasis onuse of a scoring scale [J]. Avulsion fractures of the ACL attachment to the tibial spine are most prevalent in children 8-14 yrs of age but are seen in adults >35 yrs of age who have low bone density. J Bone Joint Surg Am. This injury usually results from severe direct or indirect force about the knee, and has not been described as resulting from a patellar tendon avulsion injury. Am J Sports Med. Retrieve the other end of the high-strength suture through the same portal. Orthopedics. 1986; 6(2): 186-92. An avulsion fracture of the tibia most commonly is seen in athletic males, aged 14-16 years, during the time of the transitional phase of physeal closure just prior to completion of growth (Ertl, 2014). Watson-Jones classification: type 1: avulsion of the apophysis without injury to the tibial epiphysis. Before 1986 May;159(2):467-9. doi: 10.1148/radiology.159.2.3961179. Later, McKoy and Sitanksi4 suggested a Type V fracture to follow a Ryu Type IV. The detached fragment was bigger, more anterior and involved a part of the articular surface of the lateral tibial plateau as well as a part of the physeal plate. [Absorbable screw fixation for the treatment of tibial avulsion fracture of the tibial attachment of the posterior cruciate ligament through posterior middle mini incision of knee joint]. Following the epiphyseal stage is the final stage resulting in bony fusion which completes the formation process in females by age 15 and males by age 174. Orthop Clin North Am. 5, ,6).6). Before operation, the Lysholm scores [4] were 38.94.9; IKDC scores were 57.110.3; and the We will be closed Monday, September 7th in observance of Labor Day. The first stage is the cartilaginous stage which begins by the 15th week of gestation7 and is succeeded by the apophyseal stage in which the tibial tubercles secondary ossification center becomes apparent. J Pediatr Orthop. : Type V. Lastly, in 2012, Pandya12 proposed a new four-tier classification system altogether based on 3D geometry and complex patterns of physeal closure. The https:// ensures that you are connecting to the Figure 7 shows the preoperative x-rays. 2016; 5(2): e385-9. Frey S, Hosalkar H, Cameron DB, et al. J Child Orthop. Avulsion of the tibial bony attachment of the anterior cruciate ligament with PDFS hyperintense signal is noted in the ACL. government site. The use of knee-brace should not be shorter than 3months. Kanayama T, Nakase J, Asai K, Yoshimizu R, Kimura M, Tsuchiya H. Arthrosc Tech. Segond tibial condyle fracture: lateral capsular ligament avulsion. The vision could be fuzzy, causing difficulties for the operation and damaging the blood vessels and nerves. Skeletal Radiol. Tibial tuberosity fractures in adolescents: is a posterior metaphyseal fracture component a predictor of complications? Two Cases of Contact Anterior Cruciate Ligament Rupture Combined with a Posterolateral Tibial Plateau Fracture. Am J Sports Med. Since they are generally the result of external rotation and abduction, they are almost always seen in . One patient showed difficulty of self-recovery. This stage begins in females between the ages of 8 to 12 years old and in males from 9 to 14 years old4. The threaded guide pin for the 4.0 partially-threaded cancellous screw was inserted from the anterior-to-posterior direction. Arthroscopic vertical fixation by high-strength line is a simple, safe, reliable, and micro-invasive treatment to PCL tibial avulsion fracture. The result of posterior drawer test was positive. J Anat. Surgical reduction and fixation of the fragment have yielded better results than conservative therapy in the treatment of avulsion fractures of the posterior cruciate ligament (PCL) from the tibia.1 Until recently, surgical reattachment frequently has involved posterior approaches to the fracture site.2 These approaches, however, require large skin incisions to avoid damage to the popliteal . 18 18 Piedade SR, Mischan MM. Nicolini AP, Carvalho RT, Ferretti M, et al. The Careers. If your pet is 4 months or under at the time of surgery, a radiograph should be taken around 3-4 weeks after surgery to evaluate the growth plate and remove the tension band wire if one was utilized. doi: 10.1016/j.eats.2021.12.012. 1Department of Sports Medicine, Shenzhen Second Peoples Hospital (First Affiliated Hospital of Shenzhen University), 518035 Shenzhen, Guangdong Peoples Republic of China, 2Shenzhen Tissue Engineering Laboratory, 518000 Shenzhen, Peoples Republic of China, 3Shenzhen Sports Medicine Engineering Laboratory, 518000 Shenzhen, Peoples Republic of China, 4Guangzhou Medical University, 510182 Guangzhou, Peoples Republic of China, 5Biomechanics and Medical Information Institute, Beijing University of Technology, 100022 Beijing, Peoples Republic of China. 1996. National Library of Medicine After the operation, the knee was bandaged with cotton bandage and fixed by the knee-brace. Acute tibial tubercle avulsion fractures. Although this combination of factors is that which is seen most commonly, there have been reports of tibial tubercle avulsion fractures seen in low-impact sports such as running4,19,20,21. Creative Commons Attribution 4.0 International License. Under the protection of braces, the patients used crutches to support part of the weight. Federal government websites often end in .gov or .mil. 3). Epub 2008 Apr 12. To evaluate the outcome of arthroscopy treatment using high-strength line in the treatment of tibial avulsion fracture of posterior cruciate ligament. Avulsion fracture the tibial tuberosity occurs in a young animal, usually between 4-8 months of age. PMC Postoperative three-dimensional reconstructed CT scan shows good fixation and reduction at the distal insertion of the posterior cruciate ligament (represented by the arrow). FOIA 2016; 51(5): 610-3. Please enable it to take advantage of the complete set of features! a Retrieve the PDS suture from the suture passer with a suture retriever. Am J Sports Med. J Bone Joint Surg Am. The Lysholm and IKDC scoring systems were used to evaluate the postoperative recovery of the knee joint functions after. J Pediatr Orthop. J Orthop Trauma. The tibial tuberosity attaches the patella to the tibia with a tendon from the quadriceps muscle group. Segond fracture with anterior cruciate ligament tear in an adolescent. The next modification was made by Ryu and Debenham29 who suggested a Type IV designation in addition to the original three types proposed by Watson-Jones. The avulsion fracture at the distal insertion of the posterior cruciate ligament is a special type of the posterior cruciate ligament injuries. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. No leg-length discrepancy was noted and no complications were present at any point throughout the post-operative recovery and rehabilitation period. The other cases in which the surgery had been carried out more than 11 weeks after the injuries, had less than satisfactory results. 1971; 53(8): 1579-83. To learn more about our nonprofit, the Hermione Duncan Reddy Foundation, and donate, click here. The reduction was achieved with the hook. The advantages are as follows: (1) The fracture fixation has good effect; although the high-strength fixation is a soft fixation, the high-strength suture has high mechanical strength and the suture has a certain flexibility. Simultaneous bilateral avulsion fracture of the tibial tuberosity: A case report. Citation, DOI & article data. about navigating our updated article layout. Tibial spine fractures are more common in the pediatric population. Fracture of the tibial tubercle. Gao et al.13 described the variability of extensor mechanisms failure as one of five types: avulsion at subchondral bone, avulsion at the cement line, failure through calcified fibrocartilage, tearing through uncalcified fibrocartilage, and rupture through the mid-substance of the ligament. 4c, d). In the 16 followed patients, flexion and extension were back to normal within 6weeks, and return to normal walk in 12weeks. Case Description: A 14-year-old male with no significant past medical history presented via emergency medical services after a ground level fall while playing basketball. government site. Watson-Jones28 proposed the initial classification scheme in 1955 and outlined three different types of tibial tuberosity fracture patterns based on location and involvement. Four patients presented with five avulsion fractures of the proximal tibial epiphysis. Open reduction and internal fixation of isolated PCL fossa avulsion fractures. 2010 Sep;2(5):437-9. doi: 10.1177/1941738110379215. This research used the fixation by high-strength suture under the arthroscope. The mean score (and standard deviation) increased from 38.94.9 points to 95.23.8 points with the system of Lysholm, from 57.110.3 points to 94.34.4 points with the system of IKDC. J Pediatr Orthop. MeSH Accessibility The high-strength suture was tightened. Your pet in 4-6 weeks after surgery to have a final radiograph to evaluate healing and the growth plate function. ct. CT. Coronal bone window. All the patients had the history of acute trauma at the knee joint. A Type II fracture has some involvement in the physis, however, the knee joint is spared from injury. This literature indicates that clinicians should exhibit a high index of suspicion in patient populations with these pre-existing conditions, however, a formal causal relationship has not yet been established. b A Kirschner wire with the diameter of 2.0mm was drilled from the lateral area of the tubercles of tibia to the inferolateral area of the fragment. The high-strength suture was tightened and tied at the front of the tubercles of tibia (Fig. Gao J, Rsnen T, Persliden J, et al. Pseudo-arthrosis repair of a posterior cruciate ligament avulsion fracture. MRI. Provide pain management with NSAIDs the first five days, If a padded bandage was applied, it should be removed after five days, Apply an ice-pack to the stifle for 10 to 15 minutes two to four times a day for the first 24 to 36 hours after surgery if no bandage is applied, If the inflammation has resolved after 72 hours, apply a hot-pack to the stifle for 10 to 15 minutes two or three times a day if no bandage is applied, Perform passive range of motion exercise (gently flex and extend the knee); 10 slow repetitions three times a day, Precede and follow the passive range of motion exercise with massage of the quadriceps muscles (large muscles above the kneecap), Begin slow leash walks of less than 10 minutes three times a day, Schedule a recheck to evaluate the range of motion and percent weight-bearing, If your pet is very rambunctious we may place an off weight-bearing bandage for two weeks, Apply a hot pack to the stifle for 10 to 15 minutes two or three times a day until the swelling has resolved, Stop passive range of motion exercise if your pet is using the leg correctly, Increase the slow leash walks to 10 to 20 minutes three times a day, Schedule a recheck 2 weeks after surgery to remove any sutures and evaluate the range of motion and percent weight-bearing, Most patients should be walking normally by 2 weeks, but every pet is different and some may take longer, Increase the slow leash walks to 20 to 30 minutes two or three times daily, Have your pet perform 10 repetitions of sit-stand exercises three times a day, Have your pet perform 10 to 15 repetitions of figure-of-eight walks two or three times a day, circling to the right and left. (2) During minimal invasion, the reduction and internal fixation do not need an incision. 1975; 182(4): 431-45. Arthrosc Tech. These reports are likely due to a host of other factors, predisposing for weakness at the physeal line. Stress, which can lead to an avulsion of this kind, almost always occurs during knee . 2015;2015:250487. doi: 10.1155/2015/250487. Figure 8 shows the postoperative x-rays. J Pediatr Orthop. Rev Bras Ortop. 4b). Acute simultaneous bilateral avulsion fractures of the tibial tubercles in a 15-year-old male hurler: case report and literature review. Ehrenborg G, Engfeldt B. The PDS lines inserted by the method described above were extracted from the two bone tunnel to the front of the tubercles of tibia. Treatment of bony avulsions of the posterior cruciate ligament (PCL) by a minimally invasive dorsal approach. The reduction and fixation with the assistance of arthroscopy have the advantages of small invasiveness and quick recovery. Fratura avulso bilateral e simultnea da tuberosidade tibial em uma adolescente: relato de caso e teraputica adotada. 1990; 72(9): 1411-3. Some shaft fractures of the tibia take as little as four months to heal, with more extreme cases taking a minimum of six months to heal . Other combined injuries were treated subsequently. 5 the posterior exterior approach), Preoperative and postoperative observation under arthroscope. Type C is an extension of a Type 2 fracture with intra-articular involvement and extension into the proximal tibia, with the differentiating factor being that the physis is closed. Avulsion fracture of the tibial tubercle with avulsion of the patellar ligament in an adolescent female athlete. Treatment with open reduction internal fixation commonly results in favorable outcomes with minimal complications. Weimin Zhu, Wei Lu, Jiaming Cui, Liangquan Peng, kan OuYang, Hao Li, Haifeng Liu, Wei You, Daping Wang, and Yanjun Zeng declare that they have no conflict of interest. Fortunately, many patients who present with this injury are near the end of cartilaginous growth usually male adolescents between ages 13 and 16. 1979; 61(2): 185-91. http://creativecommons.org/licenses/by/4.0/. One study looked at the relationship between body mass index (BMI) and these low-impact tibial tubercle avulsion fractures, but found no significant correlation for this to be considered a risk factor in the setting of no trauma6. An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. Coronal T1. The KT3000 was used to evaluate the laxity of the knee joint. Orthopedics. The firmness of fixation was checked by knee flexion and extension under the arthroscope (Figs. Sports Health. Mosier SM, Stanitski CL. Tibial Tubercle Avulsion Fractures in Adolescents: A Narrative Review & Case Report, Gregory W. Kunis1*, Joshua A. Berko1, Jeffrey C. Shogan1, Joshua B. Sharan1, Derek Jones2, 1Nova Southeastern University, Kiran C. Patel College of Osteopathic Medicine, Florida, USA, 2Department of Orthopedic Surgery, Broward Health, Florida, USA. All the operations were conducted by the same experienced surgeon in sports medicine. backward displacement value was 3.60.39mm by KT3000. The production of this manuscript as well as the research within was conducted independently without any financial support. 1985; (194): 181-4. Lyshom J, Gillquist J. Bilateral atraumatic tibial tubercle avulsion fractures: case report and review of the literature. Of course, proper reduction must be achieved and maintained against the superiorly directed pull of the quadriceps, but maintenance of this reduction can potentially compromise skeletal growth considering the proximity of the physis. Radiology. Figure 6 shows the Pandya classification: Types, A, B, C, and D. Despite the many modifications made to the original Watson-Jones criteria, the most popularly used is the Ogden modification. 2012; 47(3): 381-3. official website and that any information you provide is encrypted The active flexion by 90 was realized 6weeks after the surgery, and the flexion and extension functions were recovered 8weeks after the surgery. b Place a high-strength suture around the loop of the PDS suture. The effects of all the cases were satisfactory. In a series of delayed repair in 8 instances of avulsion fracture of the tibial attachment of the posterior cruciate ligament, 6 were isolated avulsion fractures of the tibial attachment of the posterior cruciate ligament and 2 were associated with the fractures of the tibial condyle. Acute tibial tubercle avulsion fractures in the sporting adolescent. Osteochondral fracture of the tibial plateau in a ballerina. 1976; 4(6): 254-63. Polakoff DR, Bucholz RW, Ogden JA. . This study has several limitations. Patients soon resumed normal life and work. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. Proper positioning was confirmed on both AP and lateral views and the fracture was securely fixed. 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