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.     

Classification of proximal tibial fractures in children

Purpose  To develop a classification system for all proximal tibial fractures in children that accounts for force of injury and fracture patterns. Methods  At our institution, 135 pediatric proximal tibia fractures were treated from 1997 to 2005. Fractures were classified into four groups according to the direction of force of injury: valgus, varus, extension, and flexion–avulsion. Each group was subdivided into metaphyseal and physeal type by fracture location and Salter–Harris classification. Also included were tibial tuberosity and tibial spine fractures. Results  Of the 135 fractures, 30 (22.2%) were classified as flexion group, 60 (44.4%) extension group, 28 (20.8%) valgus group, and 17 (12.6%) varus group. The most common type was extension-epiphyseal-intra-articular-tibial spine in 52 fractures (38.5%). This study shows that proximal tibial fractures are age-dependent in relation to: mechanism, location, and Salter–Harris type. In prepubescent children (ages 4–9 years), varus and valgus forces were the predominate mechanism of fracture creation. During the years nearing adolescence (around ages 10–12 years), a fracture mechanism involving extension forces predominated. With pubescence (after age 13 years), the flexion–avulsion pattern is most commonly seen. Furthermore, metaphyseal fractures predominated in the youngest population (ages 3–6 years), with tibial spine fractures occurring at age 10, Salter–Harris type I and II fractures at age 12, and Salter–Harris type III and IV physeal injuries occurring around age 14 years. Conclusion  We propose a new classification scheme that reflects both the direction of force and fracture pattern that appears to be age-dependent. A better understanding of injury patterns based on the age of the child, in conjunction with appropriate pre-operative imaging studies, such as computer-aided tomography, will facilitate the operative treatment of these often complex fractures.     

The effect of proximal tibial fractures on the limb axis in children

Between 1985 and 2002 we treated 38 children with 39 fractures of the proximal tibia. Fractures affecting the proximal tibial physis were excluded from this study. Mean age at the time of injury was 7.1 years (range: 2.5 to 14). Conservative treatment was followed in 34 cases and four patients underwent surgery. We examined 31 children with 32 fractures followed up for an average of 4.8 years (range: 16 months to 15 years). Twenty eight (90.3%) patients developed post-traumatic tibia valga. Deformities were observed at an average 5.3 months after injury. All the cases with fractures of the medial cortex developed valgus angulation. The mean valgus angular deformity was 5.5 degrees. There was also an average of 5.31 mm limb lengthening in 27 patients. Eleven patients with an angulation >5 degrees were reevaluated at an average of 7.4 years from the initial injury. Partial remodelling was observed in 6 patients (54.5%) and total remodelling in 3 (25%). We recommend that children with proximal metaphyseal tibial fractures should be initially treated conservatively and followed up during skeletal development, because valgus deformity tends to remodel with age.     

Case report. Post-traumatic tibial recurvatum: resolution with growth

The outcome of proximal tibial fractures in children is often complicated by the development of malalignment. Progressive valgus deformity is frequently seen, but is known to correct spontaneously in a high proportion of cases; however, recurvatum of the tibia usually requires surgical intervention. We present a child with a proximal tibial metaphyseal fracture who developed increasing tibial recurvatum which corrected spontaneously.     

Operative treatment of fractures about the knee

It should be emphasized that most fractures about the knee in children and adolescents can be treated by closed methods. It follows that open reduction and fixation is employed when closed reduction fails. An interposed flap of torn periosteum may prevent closed reduction. Internal fixation is often required in avulsion fractures of the tibial tubercle, reduced displaced fracture-separations of the proximal tibial epiphysis, fracture-separations of the distal femoral epiphysis displaced in the sagittal plane, and displaced Salter-Harris type III and IV fracture-separations. A displaced avulsion of the anterior intercondylar eminence of the tibia can sometimes be reduced using closed means but more often requires reduction by arthrotomy or with arthroscopy. Late reconstruction for ensuing leg length discrepancy, angular deformity, or instability may be indicated.     

Tibia valga after fracture: Documentation of mechanism

Summary Tibia valga following fracture in the proximal metaphysis of the tibia in children was previously attributed to various mechanisms. This case report offers an additional explanation based on bone scintigraphy 10 months after injury. Decreased radionuclide uptake at the lateral proximal tibial physis without evidence of increased uptake on the medial side suggests that a Salter type V injury to the lateral growth plate can occur in conjunction with a medial metaphyseal fracture, resulting in the development of tibia valga.     

Bilateral proximal tibia stress fracture following bilateral distal femoral hemiepiphysiodesis - A rare complication

Correction of lower limb deformities by hemiepiphyseodesis with 8-plates is gaining popularity among deformity surgeons. Complications including metal failure, recurrence of deformity have been reported but stress fracture has not been reported. We have encountered bilateral proximal metaphyseal tibia stress fractures following correction of valgus deformity of both knees by hemiepiphyseodesis of distal femur following inadvertent overcorrection to a varus deformity following loss of follow up. The varus deformity has been reversed by guided growth of distal femoral physis resulting in fracture union and normal gait pattern.We herewith emphasize the importance of timely follow up with removal of 8 plates for hemiepiphysiodesis in deformity correction to prevent unexpected complication. We are reporting a rare complication of proximal tibial stress fractures following distal femur hemiepiphysiodesis done for valgus deformity with 8-plates.     

Partial sleeve fractures of the tibia in children: an unusual fracture pattern.

Sleeve avulsion fractures of the patella are a well-recognized fracture pattern in children. Less appreciated is a similar fracture pattern involving the anterior metaphyseal area of the tibia. These metaphyseal sleeve fractures represent a fracture pattern characterized by the avulsion of a large area of periosteal attachment of the patellar tendon associated with small subchondral fragments of bone, encountered in skeletally immature children secondary to contraction of the quadriceps associated with forced knee flexion. Although an avulsion fracture of the tibial tubercle is the usual result of this type of trauma, partial sleeve avulsion fractures of the tibial apophysis and adjacent metaphysis occasionally occur and have not been adequately described. It was the authors' purpose to describe their experience with this fracture pattern. Since 1998, three boys have presented to a major pediatric trauma center with a partial sleeve fracture of the tibia. The average age was 13 years 6 months (range 10 years 3 months to 15 years 3 months). Follow-up ranged from 1 year 5 months to 2 years 3 months, with an average of 1 year 9 months. All three boys were treated with open reduction and internal fixation with small cancellous screws and postoperative plaster immobilization. At the time of most recent follow-up, each child showed full range of knee motion and had returned to all sports activities.     

Distale Tibiafrakturen

Distal tibial fractures can be divided by mechanism into injuries caused by torsion trauma or by compression trauma. The latter ones are often associated with a complete destruction of the tibial joint surface, so-called tibial plafond fractures. Another group of fractures are the distal metaphyseal fractures of the tibia with only minimal involvement of the ankle as a result of low energy torsion trauma. Multiple factors can be held responsible for posttraumatic complications and poor outcome: malalignment, nonanatomic reduction of the joint surface or bone defects, and severe soft tissue injury. Therefore a sophisticated therapeutic regime of distal tibial fractures is necessary, which we present in detail in this article. In cases with only minor soft tissue injury a primary definitive open reduction internal fixation (ORIF) of the tibial fracture is possible. Fractures with severe soft tissue injury should be initially fixed with an external fixator. Definitive fixation and reconstruction should here be performed in subsequent operations. Early functional therapy can be attempted if fractures are reliably stabilized.     

Fractures of the phalanges of the hand in children.

Fractures of the phalanges of the hand were studied in 203 children. Fingertip fractures caused disability for three weeks but usually had good results. Comminuted fractures often took the form of longitudinal splitting. Epiphyseal fractures were mostly of the Salter type 2 and metaphyseal types and usually had good results: remodelling occurred in both planes at the base of the proximal phalanx but only in the sagittal plane at the base of the middle phalanx. Epiphyseal fractures at the base of the distal phalanx often had unsatisfactory results. Fractures of the neck of phalanx showed no remodelling at all and if deformity is not corrected it is probably permanent.     

Avulsion fracture of the tibial tuberosity with articular extension in an adult: a novel method of fixation

We report a rare avulsion fracture of the tibial tuberosity with a large sagittal plane anterior tibia fracture with articular extension in an adult. Avulsion fractures of the tibial tuberosity are uncommon fractures and are seen most frequently in adolescents with the disruption of the physeal plate. We report a variant of an Ogden type 3a fracture in an adult and describe a novel method of fixation.     

Surgical treatment and outcomes of extraarticular proximal tibial nonunions

INTRODUCTION: Although malunion of proximal tibial metaphyseal fractures are not infrequent, nonunion of the proximal tibia is rare. These nonunions can present particular challenges in management, such as malalignment, a short proximal segment, and soft tissue compromise. Few treatment guidelines and long-term outcomes are available. The purpose of this study was to determine the long-term functional outcomes of patients treated with open reduction and internal fixation. MATERIALS AND METHODS: Sixteen patients with a proximal tibial nonunion were treated between 1992 and 2005. Five fractures were originally open injuries, but all were aseptic at the time of definitive fixation. All nonunions were treated with a consistent approach of debridement, deformity correction, lateral plating, tensioning and compression, lag screws and bone grafting. Patients were reviewed radiographically and with a Knee Society questionnaire at a mean follow-up of 39 months (range 10-113 months). RESULTS: All nonunions healed at an average of 4 months, and alignment was within 5 degrees of anatomic in all cases. Knee Society function and knee scores improved significantly, to 87.4 and 89.4, respectively (P < 0.05 for both). Functional outcomes were excellent overall. Fourteen of the patients (88%) subjectively returned to their previous activities and were satisfied with their result. CONCLUSIONS: Using an algorithmic approach of débridement, deformity correction, lateral tension band plating with compression, and rigid stabilization, fracture healing and functional outcome can be reliably restored in these difficult fractures.     

Provisional plating of Type III open tibia fractures prior to intramedullary nailing

Intramedullary nailing of tibial shaft fractures is the preferred treatment of most displaced, unstable tibial shaft fractures. In open tibia fractures, direct exposure of the fracture segments for irrigation and debridement is required prior to fracture stabilization. We propose a method of provisional stabilization using commonly available implants placed through the associated traumatic open wound prior to intramedullary nailing. This technique, particularly helpful to surgeons operating with limited assistance, employs a temporarily applied 3.5-mm dynamic compression plate or limited contact dynamic compression plate implant secured with unicortical screws, allowing reaming and intramedullary nailing of a reduced, stabilized tibia fracture.     

Metatarsal fractures

Generally nondisplaced metatarsal fractures can be treated nonoperatively. Fracture angulation of more than 10 degrees or fracture displacement of more than 3-4 mm are a valid indication for open or closed reduction. Fractures of the metatarsal bases are often associated with Lisfranc injury. Special attention must be paid to proximal fractures of the fifth metatarsal (avulsion, Jones, proximal diaphyseal fracture). Dislocated midshaft fractures of the first and fifth metatarsals should be treated operatively to realign foot geometry. Subcapital fracture malalignment causes post-traumatic metatarsalgias. Stress and children's fractures are treated most times nonoperatively.     

Changes in bone-mass after tibial shaft fracture

We studied 20 patients who had suffered tibial shaft fractures 30 months previously. The bone-mineral content in diaphyseal and metaphyseal bone of the femur and tibia was determined by photon absorptiometry. There was a moderate, but significant, deficit of bone-mineral in metaphyseal bone at the knee and distal tibia. This loss was, however, far smaller than that previously reported. Persisting bone-mineral changes in diaphyseal bone were insignificant except in the fracture area where there was a 28 per cent increase. This may indicate that bone may, under some circumstances, locally increase in strength after remodelling of the fracture.     

Changes in bone-mass after tibial shaft fracture

We studied 20 patients who had suffered tibial shaft fractures 30 months previously. The bone-mineral content in diaphyseal and metaphyseal bone of the femur and tibia was determined by photon absorptiometry. There was a moderate, but significant, deficit of bone-mineral in metaphyseal bone at the knee and distal tibia. This loss was, however, far smaller than that previously reported. Persisting bone-mineral changes in diaphyseal bone were insignificant except in the fracture area where there was a 28 per cent increase. This may indicate that bone may, under some circumstances, locally increase in strength after remodelling of the fracture.     

Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury

Eight patients with unstable fractures involving the articular surface and metaphyseal-diaphyseal bone of the proximal or distal tibia associated with severe soft-tissue injury or compounding wound were treated with irrigation, debridement, tetanus inoculation, antibiotic prophylaxis, and combined internal fixation with one-half frame external skeletal fixation for neutralization. All patients were followed to complete healing and functional restoration of the extremity. All fractures healed, but one superficial and one deep infection occurred. All patients achieved at least 110 degrees of knee motion. This method should be considered in unstable metaphyseal and articular tibia fractures not adequately stabilized with a lateral plate in which use of an additional medial plate is required for stability, but contraindicated because of the status of the soft tissues or extensive comminution of the bone.     

A Pilon Fracture With Fibular Head Dislocation Treated With the Use of 3D Preoperative Planning: A Case Report and Literature Review

Pilon fractures with intact fibula have been associated with low-energy trauma. However, the compression force onto the ankle joint can damage the tibiofibular linkage as in a Maisonneuve fracture. Herein, we describe a case of a patient who had a pilon fracture (AO type 43 C3.2) without a fibular fracture. Three-dimensional preoperative simulation by reduction with the surface registration technique was performed as the fibular length was intact and there was no reference for the tibial length. The preoperative simulation revealed superior fibular head dislocation and shortening of the distal tibia. After emergency external fixation on the day of arrival, a 2-staged surgery was performed. During the first operation, the fibular head was reduced and the tibial posterolateral fragment was fixed to restore the tibia length. During the second operation, medial and anterolateral fragments were fixed in order to reduce joint surface of the distal tibia. In general, proximal fibular head fractures are easily overlooked. In the case of pilon fractures with severe length shortening of the tibia without a fibular fracture, a proximal tibiofibular injury should be suspected.     

Metatarsale Frakturen

Generally nondisplaced metatarsal fractures can be treated nonoperatively. Fracture angulation of more than 10° or fracture displacement of more than 3–4 mm are a valid indication for open or closed reduction. Fractures of the metatarsal bases are often associated with Lisfranc injury. Special attention must be paid to proximal fractures of the fifth metatarsal (avulsion, Jones, proximal diaphyseal fracture). Dislocated midshaft fractures of the first and fifth metatarsals should be treated operatively to realign foot geometry. Subcapital fracture malalignment causes post-traumatic metatarsalgias. Stress and children’s fractures are treated most times nonoperatively.     

Acute PIP joint fractures

Recent PIP fractures are challenging trauma in terms of diagnosis as well as treatment. It must be remembered that the final outcome will have a considerable impact on the global finger and hand function. Immediate mobilization and rehabilitation are mandatory, and may justify a surgical approach and fixation in selected cases. A good understanding of the fracture type is essential and relies in good part on precise, focused and standardized radiographs. Non-displaced fractures are generally treated conservatively. In the proximal phalanx, the orientation of the fracture line dictates the stability of the fracture. Thus non-displaced fractures can occasionally be preventively stabilized, in order to allow early mobilization. Displaced fractures should always be anatomically reduced and surgically fixed. A temporary joint stabilization is optional. In the middle phalanx, one must consider palmar and dorsal fractures differently. Palmar fractures include a distal palmar plate avulsion. The degree of impaction will dictate the stability of the joint towards dorsal subluxation. Dorsal fractures include central slip avulsion of the extensor tendon. An antomical reduction and surgical fixation is mandatory to avoid a progressive boutonniere deformity. Prognosis of all the middle fractures is closely dependent on the degree of impaction. When direct osteosynthesis is not possible, distraction devices, bone graft or palmar plate reconstruction may be useful alternatives. In complex fractures, bone fixation and joint stabilization must be combined in order to prevent secondary displacement and joint instability.