Bilateral epiphyseal fractures of the proximal tibia within a six-month interval: a case report

An epiphyseal fracture commonly results from avulsion of the epiphysis by traction through the attached ligaments. A fracture of the proximal tibial epiphysis is, therefore, a rare injury because of the absence of collateral ligament attachments. Most proximal tibial epiphyseal injuries occur as avulsion fractures of the tibial tubercle; Salter-Harris Types I or II injuries involving pressure epiphyses are rare. In the current case of a thirteen-year-old boy, the proximal tibial epiphyseal injuries in both knees occurred during quadriceps contraction in the absence of violent trauma, and there was a six-month interval between the two injuries.     

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 to the upper tibial epiphysis. Apropos of 20 cases

The authors report 20 cases of injuries involving the proximal tibial epiphysis (16 avulsion fractures of the tibial tubercle, 4 epiphyseal fractures), occurring in adolescents engaged in athletics, in 3/4 of the cases. Sixteen displaced fractures needed open reduction and internal fixation with screw(s). Leg shortening (12 mm) occurred in a 14 year-old male with a displaced fracture of both the tibial tubercle and proximal epiphysis, in which premature ossification had taken place; fixation with Kirschner wires would have been the treatment of choice before closure of the tibial epiphysis. At follow-up, function was acceptable in all cases; all the patients had returned to full daily activity and no further surgical procedures were needed. Long-term knee laxity became obvious in one patient, however, with repeated fracture of the tibial tubercle. Associated ligamentous and meniscal tears should therefore be sought on early clinical examination and confirmed by arthroscopy or arthrotomy after surgical fixation.     

Type IV tibial tubercle fracture revisited: a case report

Tibial tubercle avulsions and proximal tibial physeal fractures are uncommon. An even more rare case was seen when an adolescent athlete presented with a combined Type III tibial tubercle avulsion and a Salter-Harris Type IV proximal tibial physeal fracture. There was no previous report in the literature of the combination of these two uncommon fracture patterns, both of which are associated with serious potential complications and long-term sequelae. The two fracture patterns must be recognized individually, with treatment directed appropriately.     

Frakturen der proximalen Tibia

Only 1-4% of all long bone fractures in children involve the proximal tibia. To evaluate these fractures appropriately, it is mandatory to differentiate between articular fractures and metaphyseal fractures. Articular fractures of the proximal physis are rare and include Salter Harris type III and IV injuries. The reconstruction of the articular surface is the fundamental goal of therapy. Injuries of the anterior crucial ligament which typically appear as an avulsion of the tibial spine and the avulsion fracture of the tibial tubercle apophysis can involve the articular surface. Dislocated fractures should be reduced and stabilized. Extraarticular fractures include Salter Harris type I and II fractures. Other types of metaphyseal fractures are the complete fracture, the compression fracture and the bending fracture of the proximal tibia. Care should be taken while treating bending fractures, especially a valgus deformity must be excluded. Due to unequal growth stimulation during remodelling, a progressive valgus deformity frequently develops. Small deformities in the sagittal plane can be compensated by spontaneous remodelling during further growth. Dislocated fractures should be reduced and stabilized by K-wires. The retention of bending fractures by a compression plate or external fixator for medial compression might be more beneficial.     

Fractures of the proximal tibial epiphysis

Fractures of the upper tibial epiphysis are rare. We report on three cases classified according to the Salter and Harris method. Case one, a Type III injury, was associated with a neurovascular lesion. Case two, a Type II injury, was associated with rupture of the medial collateral ligament of the knee, which was treated by internal fixation of the fracture and repair of the ligament. Case three was an unusual fracture, which has not previously been reported in the literature, a Type II injury with an accompanying fracture of the tibial tubercle.     

Avulsion fractures of the tibial tubercle in adolescents. A report of bilateral fractures and a review of the literature

Avulsion fractures of the tibial tubercle prior to epiphyseal closure are being treated with greater frequency. Watson-Jones Types I and III fractures are the most common; both require open reduction and internal fixation. Type II fractures respond to closed reduction and plaster immobilization. The authors have found only 76 fractures reported in the literature since 1935. Four cases were bilateral. Fifty-nine patients were boys, and two were girls; the sex was not reported for 11 patients. Type III fractures occurred most often in older adolescents. Types I and II fractures occurred in younger patients. No reports of growth disturbance of the proximal tibial epiphysis occurring after a Type III fracture were found.     

Besondere Epiphysenverletzungen

In daily practice, the well-proved Salter-Harris-Rang epiphyseal injuries classification is used worldwide and in Hungary as well. Occasionally there are to be seen epiphyseal injuries which cannot be typed by this classification. The Ogden classification of epiphyseal injuries which enlarges the Salter-Harris-Rang classification with 6 subdivisions and 3 more subdivisions is very useful for the classification of such rare epiphyseal injuries. The authors focus one’s attention on Ogden IIB type and Ogden VI type injuries on the basis of their own experience. Ogden IIB is often unstable and susceptible to shortening. In Ogden VI type ligamentous instability beside growing disturbance, caused by meta-epiphyseal bone bridge formation, can be seen. The comminuted growing plate injury caused by high energy direct trauma and healed without growing disturbance in their case, is missed in the Ogden classification. The proper classification is a necessary condition of adequate treatment. We recommend the Ogden classification of rare epiphyseal injuries.     

Proximal avulsion of five ligaments and revised diagonal principle in tibial plateau fractures

PurposeThe aim of the study was to analyze the incidence of proximal avulsion of the five main ligaments and to revise the diagonal tension/compression concept in tibial plateau fractures.MethodsComputed tomographic images of 1263 cases of tibial plateau fractures were retrospectively analyzed by the OTA/AO classification and four-column nine-segment classification. The correlation between proximal avulsion of five ligaments and the injury mechanism was analyzed.ResultsIn total, 1263 tibial plateau fractures in 1253 patients were included. A total of 92 cases (7.3%) associated with proximal avulsions were identified among the 1263 tibial plateau fracture cases obtained from our institution's database. The 92 avulsions occurred in 82 patients, among whom 10 patients had two different avulsions in a single knee. The incidence of proximal avulsion fracture of the medial and lateral collateral ligament was 3.6% (45/1263) and 2.1% (26/1263), respectively. The incidence of avulsion of the anterior cruciate ligament and avulsion of the posterior cruciate ligament was much lower at 0.2% (2/1263) and 0.1% (1/1263), respectively. Proximal avulsion of the patellar ligament occurred in 18 cases (incidence rate = 1.4%). Several combinations of injuries, composed of distal tibial plateau fractures and proximal avulsion of ligaments, were identified.ConclusionsAmong the patients with tibial plateau fracture, the incidence of proximal avulsion of the five ligaments was 7.3% (92/1263). The four-column and nine-segment classification is an exhaustive method for recording injuries in these ligaments. The revised diagonal injury concept is useful for understanding the injury mechanism and choosing the appropriate surgical strategy.     

Fracture of the tibial tubercle in the adolescent

We have reviewed 16 patients with avulsion fractures of the tibial tubercle, mostly boys who sustained left-sided injuries during sport. Two-thirds had type I or II injuries and were treated conservatively. Fractures involving the knee joint (type III) had internal fixation. The final results were good except for minor complications such as a prominent and uncomfortable tibial tubercle.     

Type III fracture of the tibial tubercle with avulsion of the tibialis anterior muscle in the adolescent male athlete

INTRODUCTION: Type III fracture of the tibial tubercle by Watson-Jones, or type IIIa injury according to John Ogden's classification has been well described and its management is now well codified in standard orthopaedic textbooks. MATERIALS AND METHODS: The authors present a case of type III fracture of the tibial tubercle associated with an avulsion of the tibialis anterior muscle. RESULTS: We demonstrated the effectiveness of bioabsorbable material for fixing the fracture preventing the need for removal of metalware, and that the anterior tibialis muscle had been stripped by the injury. CONCLUSION: A displaced type III fracture of the tibial tubercle may have an associated with avulsion of the tibialis anterior muscle, particularly in adolescent athletes. Prompt recognition and appropriate surgical treatment can give an excellent outcome.     

Le fratture articolari ed extra-articolari del ginocchio

Joint fractures of the knee include epiphyseal detachments of the distal femur and proximal tibia (types 3 and 4 according to Salter-Harris). Extra-articular fractures include: avulsion of the tibial spines, detachment of the anterior tuberosity and patellar fractures. Fractures involving the distal femoral and proximal tibial epiphysis are relatively infrequent but may lead to long-term complications owing to the formation of post-traumatic bone bridges. Unless the fracture is composed, surgical treatment is always indicated. Avulsion fractures of the tibial spines occur as a result of a chondro-epiphyseal detachment of the insertion of the cruciate ligaments (predominantly the anterior one). They are infrequent injuries (3 per 100,000 cases per year, 2% of all knee injuries). Accurate diagnosis and appropriate treatment prevent unfortunate outcomes. Adolescent tibial tubercle fractures are uncommon, high-energy injuries sometimes combined with patellar tendon rupture; they represent a frequently missed diagnosis. Open reduction/internal fixation is generally required. Patellar fractures are caused by direct trauma (primary osseous fractures) or by an eccentric load during extension of the knee (sleeve and avulsion fractures). Most fractures require open reduction/internal fixation. The complication rate is low but late reconstruction of missed injuries may result in an extensor deficit.

     

双钢板治疗胫骨平台严重粉碎性骨折的体会

目的探讨特殊类型的胫骨平台严重粉碎性骨折的治疗方法。方法对胫骨平台骨折中按Sehatzke分类的（V型、Ⅵ型）骨折行双钢板固定：我科在2000年1月至2007年12月：（1）先用克氏针或尖端复位钳临时将平台的各骨块固定;（2）将塌陷的平台复位,用松质骨将平台骨缺损处填充紧密;（3）用克氏针或尖端复位钳再将平台与骨干固定;（4）用两板钢板行胫骨平台内外侧固定。（5）胫骨结节撕脱的平台骨折复位后应固定或修补胫骨结节及髌韧带。结果本组18例骨折术后即开始功能活动,3例用石膏托固定4周后开始活动,随访0．5年-6年,未发生骨不连,其中2例术后切口感染,优良率达90．5％。结论应用双钢板内固定治疗特殊类型的胫骨平台粉碎骨折,固定可靠,且术后可早期进行功能活动,减轻了伤后关节功能受限的程度,同时早期功能活动能增加骨折面的应力,防止骨质疏松,促进骨愈合。     

关节镜下经套管钢丝固定治疗胫骨髁间前棘骨折的体会

目的分析关节镜下钢丝捆扎固定治疗胫骨髁间前棘骨折的临床疗效。 方法采用微创关节镜技术复位,克氏针钻孔后经套管法置入一道或两道钢丝捆扎固定治疗胫骨髁间前棘撕脱骨折20例,纳入标准为新鲜骨折,排除陈旧性骨折及复杂的胫骨平台骨折(SchatzkerⅡ型以上),男12例,女8例,年龄18～65岁,平均(38.1±2.6)岁,交通伤14例,运动伤4例,砸伤2例。依据Meyers & Mckeever和Zaricznyj分型标准,Ⅱ型6例,ⅢA型10例,ⅢB型2例,Ⅳ型2例。 结果20例病人全部得到随访,随访时间12～26月,平均(15.5±2.1)月,所有骨折均愈合,采用Lysholm评分标准进行评分,得分为82～96分,平均(91±7)分。 结论关节镜下用钢丝捆扎固定治疗胫骨髁间前棘骨折,操作简便,固定牢靠,免除了二次关节镜取手术,是一种满意的治疗方法。     

Ogden Type I to III tibial tubercle fractures in skeletally immature patients: is routine anterior compartment fasciotomy of the leg indicated?

PurposeDetermine the frequency of compartment syndrome of the leg after displaced, operatively treated modified Ogden I to III tibial tubercle fractures (TTFxs), evaluate the preoperative assessment and use of advanced imaging, and need for prophylactic fasciotomies.MethodsRetrospective analysis of operatively treated, displaced modified Ogden I to III TTFxs, at our level 1 paediatric trauma centre between 2007 and 2019. Modified Ogden Type IV and V fracture patterns were excluded. Fracture patterns were determined by plain radiographs.ResultsThere were 49 modified Ogden I to III TTFxs in 48 patients. None had signs nor symptoms of vascular compromise, compartment syndromes or impending compartment syndromes preoperatively. In all, 13 of the 49 fractures underwent anterior compartment fasciotomy at surgery; eight of the 13 had traumatic fascial disruptions, which were extended surgically. All incisions were primarily closed. There were no instances of postoperative compartment syndromes, growth arrest, leg-length discrepancy or recurvatum deformity postoperatively. All patients achieved radiographic union and achieved full range of movement.ConclusionThe potentially devastating complications of compartment syndrome or vascular compromise following TTFx did not occur in this consecutive series of patients over 12 years. The presence of an intact posterior proximal tibial physis and posterior metaphyseal cortex (Modified Ogden TTFx Type I to III) may mitigate the occurrence of vascular injury and compartment syndrome. Plain radiographs appear appropriate as the primary method of imaging TTFxs, with use of advanced imaging as the clinical scenario dictates. Routine, prophylactic fasciotomies do not appear necessary in Ogden I to III TTFxs, but should be performed for signs and symptoms of compartment syndrome.Level of evidenceLevel IV     

Classification to guide internal fixation for tibial fracture

Objective： To explore a classification method which can provide the clinical guidance for internal fixation of tibial fracture.
Methods： The different fractures were fixed according to their mechanical classification. Totally, 71 cases of tibial plateau fracture, tibial proximal fracture, tibial distal fracture and Pilon fracture were analyzed to test this selective principle. Results： All 71 patients were followed up for 6-32 months. The displacement was seldomly observed in cases treated acccording to the classification principle, while some cases against the principle had postoperative displacement.The difference was statistically significant （P〈0.05）. It was proved that there was remarkable correlation between tibial fracture classification, internal fixator and fixation methods.
Conclusion： Types Ⅲa3, Ⅲb 1 and Ⅲb2 fractures without eccentric moment should be fixed with double plates or angle-stable materials combined with locking structure, otherwise displacement may occur.     

The outcome of sequential repeated tibial tubercle osteotomy performed in 2-stage revision arthroplasty for infected total knee arthroplasty

Thirteen patients with infected total knee arthroplasty treated by 2-stage revision requiring tibial tubercle osteotomy in both stages for extensile exposure were retrospectively analyzed. The preoperative mean range of knee motion improved from 60° (range, 30°-90°) to 94° (range, 70°-120°) at latest follow-up. The Knee Society knee scores and function scores were 39 and 18 preoperatively and 78 and 67 at latest follow-up, respectively. Although proximal migration occurred in 3 cases and a partial proximal avulsion fracture of the osteotomy segment occurred in 1 case after the second-stage reimplantation, radiographic bony union was observed in all cases. Sequential repeated tibial tubercle osteotomy can be a useful extensile surgical approach in staged revision for infected total knee arthroplasty with satisfactory clinical and radiographic outcomes.     

Dislocation of the proximal tibiofibular joint in association with a tibial shaft fracture: two case reports and a literature review

Dislocation of the proximal tibiofibular joint (PTFJ) in association with a displaced tibial shaft fracture and an intact fibula is an exceedingly rare injury. We present 2 cases of tibia fractures associated with an intact fibula and a PTFJ dislocation. The first case involves a man who sustained a closed spiral fracture of the distal tibial shaft, with an intact fibula, an anterolaterally dislocated PTFJ, and a partial tear of the lateral collateral ligament. The tibia was percutaneously plated, and the PTFJ was reduced and then stabilized with temporary screw fixation. The second case involves a woman who sustained a closed fracture of the tibia in association with a PTFJ dislocation. The tibia was fixed with an intramedullary nail, and the PTFJ was similarly reduced and fixed with a temporary screw. We also provide a brief literature review focusing on classification of PTFJ dislocations, mechanism of injury, associated injuries, and treatment options.     

Dislocation of the proximal tibiofibular joint in association with a tibial shaft fracture: two case reports and a literature review.

Dislocation of the proximal tibiofibular joint (PTFJ) in association with a displaced tibial shaft fracture and an intact fibula is an exceedingly rare injury. We present 2 cases of tibia fractures associated with an intact fibula and a PTFJ dislocation. The first case involves a man who sustained a closed spiral fracture of the distal tibial shaft, with an intact fibula, an anterolaterally dislocated PTFJ, and a partial tear of the lateral collateral ligament. The tibia was percutaneously plated, and the PTFJ was reduced and then stabilized with temporary screw fixation. The second case involves a woman who sustained a closed fracture of the tibia in association with a PTFJ dislocation. The tibia was fixed with an intramedullary nail, and the PTFJ was similarly reduced and fixed with a temporary screw. We also provide a brief literature review focusing on classification of PTFJ dislocations, mechanism of injury, associated injuries, and treatment options.     

Physeal fractures of the distal radius and ulna: long-term prognosis

OBJECTIVES: The long-term prognosis of injuries to the distal physis of forearm bones, including complications such as radioulnar length discrepancy and styloid nonunion, has not been extensively studied. Reliable radiographic prognostic criteria to predict physeal disturbance at trauma are also lacking. The aim of this study is to investigate both issues. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS/PARTICIPANTS: One hundred sixty-three lesions to the distal physis of the forearm bones in 157 patients were available for a long-term follow-up. Seventy-seven injuries of the distal radial physis were radiographically isolated, 54 were associated with a fracture of the ulnar styloid, and 26 with a fracture of the distal ulnar metaphysis. Of the six injuries of the distal ulnar physis, five were associated with a fracture of the distal radial metaphysis, and one was an isolated injury of the distal ulnar physis. INTERVENTION: Treatment consisted of wrist immobilization in a long-arm plaster cast for 6 weeks. Dorsal or volar displacement was reduced using general anesthesia. MAIN OUTCOME MEASUREMENTS: All patients had both clinical and radiographic evaluation, with an average follow-up of 25.5 years (range 14-46 years). The average age of the patients at injury was 11.6 years (range 5-17 years), whereas their average age at follow-up was 35.5 years (range 22-56 years). Both the Salter and Harris and the Ogden classifications were used to classify physeal injuries. RESULTS: According to Salter and Harris, of the 157 radial lesions, 18 were type 1 and 139 type 2. According to Ogden, 14 were type 1A, 4 type 1C, 84 type 2A, 13 type 2B, 17 type 2C, and 25 type 2D. Of the 6 ulnar lesions, 2 were Salter and Harris type 1 (Ogden type 1A), 3 type 2 (Ogden type 2A), and 1 type 4 (Ogden type 4A). Fifty-four radiographically evident fractures of the ulnar styloid associated with injuries of the distal radial physis were classified as Ogden type 7A. At follow-up, all of our patients were fully asymptomatic, except for those who had forearm bone growth failure of more than 1 cm. Shortening of the previously injured forearm bones ranging from 1 to 6.5 cm was observed in 2 open and subsequently infected lesions as well as in 5 uncomplicated lesions of the 157 distal radial physeal injuries (4.4%), and in 3 of the 6 distal ulnar physeal injuries (50%). Shortening of 1 cm or more was observed in the uncomplicated lesions of radial physeal injury with Ogden type 1C, 2B, and 2D lesions, and in ulnar physeal injuries Ogden type 1A, 2A, and 4A. Thirty-eight additional patients had radioulnar length discrepancy that ranged from 2 to 9 mm, and 53 patients had styloid nonunion, but all of them were asymptomatic. CONCLUSIONS: None of the patients reviewed at follow-up, including those with radioulnar length discrepancy of less than 1 cm and those with styloid nonunion, complained of any symptom related to their previous injury, not even those engaged in heavy manual labor. Of the 10 patients with either radial or ulnar shortening of more than 1 cm, only 2 with radial growth arrest and marked radioulnar length discrepancy had severe functional problems. Growth disturbances of more than 1 cm following distal radial physeal injury occurred only in Ogden type 1C, 2B, and 2D lesions, whereas in distal ulnar physeal injuries, growth disturbances occurred regardless of the Ogden classification type.