Avulsion fractures of the tibial tuberosity in the adolescent athlete. Risk factors, mechanism of injury, and treatment

Based on a review of the literature and our study of six cases, we investigated avulsion fractures of the tibial tuberosity in the athletic adolescent. A study of the mechanism of this acute injury helps to explain the different types of avulsion fractures of the tibial tuberosity. An understanding of predisposing factors and the biomechanical conditions leading to this injury may help identify those young athletes at the highest risk and may help the surgeon determine the most effective treatment for such a fracture. No complications were experienced by the patients in our study. Displaced fractures underwent open reduction and fixation with screws. This method shortens the period during which athletic activities are restricted.     

Rehabilitation of avulsion fracture of the tibial tuberosity following Osgood-Schlatter disease

A sixteen-year-old boy suffered from sharp pain in the knee during a jump while playing basketball. He had a positive history of Osgood Schlatter disease. Radiographic evaluation demonstrated an avulsion fracture of the tibial tuberosity Type III according to the classification of Watson-Jones. Rehabilitation after avulsion fracture of the tibial tuberosity is an important consideration for this relatively uncommon adolescent injury. In such avulsion fractures, landing on the ground with the knee fully extended after a jump is the most likely cause. This case report reviews the rehabilitation program, and selected functional outcome measures after rehabilitation are reported. The patient returned to sporting activity after 12 months.     

Simultaneous bilateral tibial tubercle avulsion fracture in an adolescent: a case report and review of the literature

Avulsion fractures of the tibial tubercle are uncommon. Bilateral tibial tubercle avulsion fractures are extremely rare. In this article, we describe Watson-Jones type III simultaneous bilateral tibial tubercle avulsion fractures in a 17-year-old boy who fell on the ground while taking off in high jump in sport. An open anatomic reduction and internal fixation was performed. We report here on the successful surgical treatment of a simultaneous bilateral fracture of the tibial tuberosity in an adolescent. These types of fractures involve a growth plate, extend through the articular surface and appear to do well with open reduction and secure internal fixation despite their bilateral nature, with recovery and functional outcome comparable to results from unilateral tibial tubercle avulsion fractures.     

Avulsion fractures of the tibial tuberosity in adolescent athletes treated by internal fixation and tension band wiring

Avulsion of the tibial tuberosity is a rarely reported fracture. It is mainly considered as an athletic injury accounting for less than 3% of all epiphyseal lesions. In this study, we hypothesized that the use of tension band wiring as a supplement of the internal fixation for the avulsion fractures of the tibial tuberosity would lead the adolescent athletes to a more effective rehabilitation program and an earlier resumption of their previous activity level. Ten patients were treated in our department over a period of 11 years (1985–1995). Operative treatment was thought necessary for all our cases due to tibial tuberosity displacement. Open reduction and internal fixation in combination with tension band wiring was used. The result in all cases was that the reduction was maintained intact and the fracture united. The functional results were excellent, and all patients returned to their previous athletic activities. Our conclusion is that the combination of internal fixation and tension band wiring for avulsion fractures of the tibial tuberosity seems to be more effective and advantageous than conservative or other surgical methods. Avoiding the need of external support and allowing early joint motion, the method described prevents serious quadriceps atrophy, allowing the young athletes to return earlier to their previous sport activities.     

Transient lateral patellar dislocation: review of imaging findings, patellofemoral anatomy, and treatment options

Transient patellar dislocation is a common sports-related injury in young adults. Although patients often present to the emergency department with acute knee pain and hemarthrosis, spontaneous reduction frequently occurs, and half of cases are unsuspected clinically. Characteristic magnetic resonance imaging (MRI) findings often lead to the diagnosis. The purpose of this review is to illustrate the MRI findings of lateral patellar dislocation and concomitant injuries, such as kissing contusions of the medial patella and lateral femoral condyle; osteochondral and avulsion fractures; and injuries of the medial patellofemoral ligament/retinacular complex. This article will also briefly review patellofemoral anatomy and passive, active, and static stabilizers. Predisposing factors for patellar instability, including trochlear dysplasia, patella alta, and lateralization of the patella or tibial tuberosity and their relevant measurements will also be highlighted. Treatment options, including surgery, such as medial patellofemoral ligament reconstruction, tibial tuberosity transfer, and trochleoplasty, and their postoperative imaging appearances will also be discussed.     

Características radiológicas del desarrollo de la tuberosidad tibial anterior

ObjectiveFew studies have evaluated the radiologic characteristics of the development of the anterior tibial tuberosity. This study aimed to evaluate the radiologic characteristics of the anterior tibial tuberosity in a pediatric population broken down into age groups.Material and methodsWe assessed 210 plain-film X-rays of the knee from patients aged from 10 to 17 years, divided into groups according to age and sex, for the presence of ossification of the anterior tibial tuberosity, the distance between the anterior tibial tuberosity and the metaphysis, and fusion with the epiphysis.ResultsAt 10 years of age, the anterior tibial tuberosity was ossified in 50% of the girls but in only 25% of the boys. In all the girls, the anterior tibial tuberosity was ossified at 11 years, fusion of the anterior tibial tuberosity with the epiphysis had started at 12 years, and fusion was complete by 17 years. In boys, the process is delayed by one year compared to girls. A single center of ossification was found in all cases.ConclusionThe ossification of the anterior tibial tuberosity starts distally, then the proximal part fuses with the rest of the epiphysis, and finally the distal part fuses with the tibia. The results of this study help enable a better analysis of the anterior tibial tuberosity in cases of knee pain.     

Calf muscle wasting after tibial shaft fracture

Objectives

To study the long term effect of tibial shaft fractures treated by immobilisation in a long leg cast on the calf muscle bulk.

Methods

Computed tomography scans were performed at fixed points on the lower legs of 23 non‐professional athletes who sustained closed tibial fractures 16 years previously. Length of immobilisation was determined from the hospital records. All the fractures were treated non‐operatively. The cross sectional area of the various leg compartments was measured and compared with the non‐injured leg.

Results

There was a significant reduction in cross sectional area of the posterior compartment (p<0.001, Student''s t test). No such difference was seen in the anterolateral compartment.

Conclusion

Tibial fractures treated non‐operatively are associated with significant long term calf muscle wasting.     

Tibial shaft fractures in amateur footballers

BACKGROUND: Footballers constitute a unique group of patients with tibial shaft fractures. They tend to have excellent general health and well developed musculature in the leg, and their fractures are generally closed injuries caused by low velocity trauma. However, little has been reported on the outcome after tibial shaft fractures in this group. OBJECTIVE: To identify patterns of injury, response to treatment, and functional outcome in such a group. METHOD: Fifty consecutive tibial shaft fractures in adult footballers treated at Merlin Park Regional Hospital over a five year period were analysed. RESULTS: Most of the fractures were type A injuries (AO/ASIF classification). The incidence of complications was low. All patients reported good or excellent satisfaction with their outcome. However, only 54% of patients returned to playing competitive football. CONCLUSION: Tibial shaft fractures in amateur footballers are associated with good results when traditional outcome criteria are used, but many patients do not regain their previous level of function.     

Articular cartilage contact pressure after tibial tuberosity transfer. A cadaveric study

Medial transfer of the tibial tuberosity has been commonly used for treatment of recurrent dislocation of the patella and patellofemoral malalignment. In this study, six fresh human cadaveric knees were used. Static intrajoint loads were recorded using Fuji Prescale pressure-sensitive film for contact pressure and contact area determination in a closed kinetic chain knee testing protocol. Peak pressures, average contact pressures, and contact areas of the patellofemoral and tibiofemoral joints were calculated on native intact knee specimens and after tibial tuberosity transfer. All native intact knee specimens had a normal Q angle. Medialization of the tibial tuberosity significantly increased the patellofemoral contact pressure. Medial displacement of the tibial tuberosity also significantly increased the average contact pressure of the medial tibiofemoral compartment and changed the balance of tibiofemoral joint loading. The results of our study suggest that caution should be used when transferring a patellar tendon in the face of a preexisting normal Q angle as this will result in abnormally high peak pressure within the tibiofemoral joint. Overmedialization of the tibial tuberosity should be avoided in the varus knee, the knee after medial meniscectomy, and the knee with preexisting degenerative arthritis of the medial compartment.     

Stress fracture of the tibial tuberosity in a high jumper: case report

A 16-year-old male high jumper sustained a stress fracture of the tibial tuberosity. Continued activity resulted in a type III fracture of the tibial tuberosity necessitating treatment via open reduction and internal fixation.     

开放性胫骨Pilon骨折的临床分析

目的：探讨开放性胫骨Pilon骨折的临床效果。方法：回顾性分析我院近年来收治的40例开放性胫骨Pilon骨折患者的临床资料。结果：40例开放性胫骨Pilon骨折患者,均获得随访,其中,36例患者I期愈合,4例患者延期愈合,6例患者切口感染,经换药及抗炎处理获得痊愈。骨折愈合时间：6～9个月,平均7.4个月,无踝内翻畸形发生。经Mazur（1979）踝关节评价,优24例,良10例,可5例,差1例,优良率为85.0%。结论：根据开放性胫骨Pilon骨折的骨折类型,选择合适的手术方式和手术时机,对于提高临床效果是十分重要的。     

Avulsion fractures of both anterior and posterior cruciate ligament tibial insertions

Ipsilateral femur fracture, patellar fracture, and tibial avulsion fractures of anterior and posterior cruciate ligament injuries are reported. We know of no other report of an injury such as this in the literature. We sutured the tibial avulsion fractures by transtibial suturing technique and internally fixated the femur by intramedullary interlocking nailing 2 weeks after the trauma. After 1 year the results were evaluated as very good. Early surgical repair is valuable in these injuries.     

Relationship between the skeletal maturation of the distal attachment of the patellar tendon and physical features in preadolescent male football players

Purpose

The aim of this study was to compare ultrasonography stages of the tibial tuberosity development and physical features.

Methods

This study examined 200 knees in 100 male football players aged 10–15 years. Tibial tuberosity development on ultrasonography was divided into 3 stages: Sonolucent stage (stage S), Individual stage (stage I), and Connective stage (stage C). Age, height, quadriceps and hamstring muscle tightness, and muscle strength in knee extension and flexion were determined. These findings were compared with the respective stages of development.

Results

The tibial tuberosity was stage S in 27 knees, stage I in 69 knees, and stage C in 104 knees, with right and left sides at the same stage in 95 %. Average age and height significantly increased with advancing tibial tuberosity development. Quadriceps tightness increased with tibial tuberosity development. Hamstring tightness decreased with development. The strength of both knee extension and flexion increased with advancing development, with a greater change seen in knee extension, hamstring/quadriceps ratio: stage C, 0.74; stage A, 0.64; stage E, 0.53.

Conclusions

Osgood–Schlatter pathogenesis reportedly involves increased quadriceps tightness with rapidly increasing femoral length during tibial tuberosity development. In this study, it was confirmed that quadriceps tightness increased, yet hamstring tightness decreased, suggesting that quadriceps tightness is not due to femoral length alone. Other factors, including muscle strength, may be involved. The study shows that thigh muscle tightness and thigh muscle performance change with the skeletal maturation of the distal attachment of the patellar tendon. These results add new information to the pathogenesis of Osgood–Schlatter disease.

Level of evidence

Cross-sectional study, Level III.     

Anatomic versus non-anatomic tibial fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft

We prospectively compared two series of 30 anterior cruciate ligament (ACL) reconstructions each where the bone-patellar tendon-bone graft was alternately fixed at the level of the tibial plateau (group A; anatomic fixation) or distal to the plateau level (group B; non-anatomic fixation). In group A, a 35-mm-long tibial tuberosity bone block was harvested. The distal 10–15 mm were resected and fixed proximally to the undersurface of the tendon to shorten it. After an average 18 months’ follow-up, there were no significant differences between the two groups concerning subjective evaluation, symptoms, range of motion and objective stability. Tibial tuberosity pain was more frequent in group A (53% vs 17%, P = 0.01). Radiographic evaluation showed that tibial tunnel enlargement was less frequent in group A (23% vs 43%, P = 0.02). There was no correlation between tunnel enlargement and objective stability. In conclusion, fixation of the graft at the tibial plateau level did not improve objective stability in this study. Because of the greater technical difficulty and occurrence of tibial tuberosity pain, this technique is not recommended.     

Roentgen diagnosis following knee surgery

After ventralization of the tibial tuberosity (Bandi-operation) the elevation can be shown. Chip and cortical fractures radiologically are demonstrated. After medialization of the patella ligament (Roux-Hauser operation) the site of excision is seen as a hyperlucent area and the site of apposition as a hyperdense area. After implantation of a sledge prosthesis risk factors indicating future complications can be identified by early postoperative radiography.     

Isolated greater tuberosity fractures of the proximal humerus: anatomy,injury patterns,multimodality imaging,and approach to management

The greater tuberosity is an important anatomic structure and its integrity is important for shoulder abduction and external rotation. Isolated fractures of the greater tuberosity are often subtle and may not be detected on initial radiographs. Clinically, these patients display symptoms which mimic a full thickness rotator cuff tear. It is important to differentiate these two entities, as their treatment is different (typically nonsurgical management for minimally displaced fractures versus rotator cuff repair for acute full thickness rotator cuff tears). When greater tuberosity fractures are significantly displaced and allowed to heal without anatomic reduction, they can lead to impingement. This article will review greater tuberosity anatomy and function, as well as the clinical presentation and multimodality imaging findings of greater tuberosity fractures. Imaging optimization, pitfalls, and clinical management of these fractures will also be discussed.     

Avulsion of the tibial tuberosity with a lateral plateau rim fracture: case report

An avulsion fracture of tibial tuberosity with an unusual articular involvement was treated with open reduction and internal fixation. Although the mechanism of tibial tuberosity fracture is described as passively flexing the knee while active quadriceps femoris contraction, the weight transmitted from the menisci on the lateral side of the knee joint may cause an epiphyseal disruption. We report a case of tibial tuberosity fracture with lateral plateau rim fracture in a young male adolescent, which has not been published previously in the literature.     

Radiology of postnatal skeletal development

The patella initially ossifies at between three and five years, commencing as multiple foci that rapidly coalesce. As the patellar ossification center enlarges the expanding margins may be irregular and associated with accessory ossification centers. These are most common superolaterally and may lead to the development of a bipartite patella. The bipartite patella has cartilaginous continuity despite the appearance of osseous discontinuity. The patella expands to all cartilaginous contours during late adolescence when the epiphyseal ossification centers around the knee are also in the final stages of maturation. The only cartilage not replaced is that occupying the superior twothirds of the articular surface (the lower one-third is covered by the fat pad). The subchondral plate does not assume the actual articular contours until the late stages of osseous maturation (after ten to twelve years). Accordingly, typical measurements such as medial and lateral angulation cannot be accurately done prior to the final stages of patellar ossification expansion and maturation.The tibial tuberosity begins ossification at between seven and nine years as a distal focus. This progressively enlarges proximally and anteriorly, while the main tibial ossification center concomitantly expands downward into the tuberosity. A section of epiphyseal cartilage usually remains between these two ossification centers until close to physeal maturity. The anterior chondro-osseous region at the site of patellar tendon attachment is a biomechanically susceptible region that may be acutely or chronically traumatized to create an Osgood-Schlatter lesion. The physis associated with the tibial tuberosity is histologically modified in a proximal to distal gradation of columnar adaptation to specific biomechanical demands in this region. Closure of the tuberosity physis occurs in a proximal to distal direction.     

复杂胫骨平台骨折的手术疗效观察

目的探讨锁定钢板、LISS钢板治疗复杂胫骨平台骨折方法及疗效。方法将34例复杂胫骨平台骨折手术患者行锁定钢板、LISS钢板固定,观察治疗效果。结果随访时间11～34个月,平均24个月,据HSS膝关节评分法评价疗效,优20例,良12例,中1例,差1例,总体优良率达97%。结论锁定钢板,特别是LISS钢板固定治疗复杂性胫骨骨折,创伤小、固定可靠、功能满意,是一种有效的内固定方法。     

关节镜辅助下手术治疗胫骨平台骨折56例

目的观察膝关节镜辅助下微创经皮螺钉内固定术治疗胫骨平台骨折的临床疗效。方法自2007年1月～2011年1月采用膝关节镜辅助下微创经皮螺钉内固定术治疗56例胫骨平台骨折。其中男性39例,女性17例;年龄16～67岁,平均35岁;闭合性骨折46例,开放性骨折10例;按Schazker分型:Ⅰ型13例,Ⅱ型24例,Ⅲ型19例。结果 56例患者随访6～54个月,平均34个月。术后膝关节功能评价参照Rasmussen评分标准,疗效优35例,良18例,中3例;总优良率94.6%。结论关节镜辅助下微创治疗胫骨平台骨折(SchazkerⅠ型、Ⅱ型、Ⅲ型),具有创伤小、复位准确、关节功能恢复良好、并发症少等优点,是一种治疗胫骨平台骨折较理想的方法。