Combined physeal/apophyseal fracture of the proximal tibia with anterior angulation from an indirect force: report of 2 cases

Physeal fracture of the proximal tibia is a rare injury, comprising less than 2% of all physeal injuries. The literature distinguishes between tibial tubercle avulsions (apophyseal injuries) classified by Ogden, Tross, and Murphy as type I, II, and III and Salter-Harris II fractures. An extensive review of the literature located only 5 cases in which patients sustained a combined fracture of the proximal tibial physis and tibial tubercle. We report 2 such cases, which are not amenable to classification by current systems, and agree with Ryu and Debenham's suggestion to add a fourth type, avulsion hinge fracture of the proximal tibial epiphysis, to the Watson-Jones/Ogden classification.     

Type III fractures of the tibial tubercle in adolescents.

Fifteen patients with Type III avulsion fractures of the tibial tubercle treated surgically were reviewed at an average of 9.6 years after injury. Six patients had a history of Osgood-Schlatter disease, and two patients had Type I osteogenesis imperfecta. Associated injuries to the meniscus were found and repaired in three patients. Two of these patients had also avulsed the origin of the tibialis anterior muscle, leading to a compartment syndrome in one. All but one fracture healed. There was one refracture. Five patients developed bursitis over prominent screw heads, which required screw removal. All but two patients were asymptomatic and participated in sports. A full range of knee motion without instability was present in all patients. Thigh and calf circumferences were equal to the opposite side. Radiographs showed normal knee joints in all but one asymptomatic patient, who showed signs of an early arthrosis. No patient developed angular or recurvatum deformities. However, a leg-length discrepancy of 1.0-1.8 cm was noted in four patients (two overgrowth, two undergrowth).     

Comminuted simultaneous bilateral tibial tubercle avulsion fractures: a case report

A 16-year-old male had simultaneous bilateral tibial tubercle avulsion fractures after making a sudden stop while running at full speed. The left knee injury (type V) was minimally displaced, was treated conservatively with closed reduction, and the patient recovered uneventfully. The right tibial tubercle injury was unusual. The tuberosity and anterior aspect of the proximal epiphysis remained as one, but there was severe intra-articular comminution posterior to the displaced tubercle fragment. The right knee injury (type III) required open reduction and internal fixation to reduce the apophyseal fragment and 2 intra-articular displaced fragments. The patient's recovery was complicated by a severe, persistent flexion deformity on the right side. Eventually, the patient required manipulation under anaesthesia, extensive continuous passive mobilisation and a turnbuckle extension splint. A residual 5-degree flexion deformity remained at 16 months post-injury. This case highlights the importance of identifying any intra-articular fragments, their careful anatomical reduction, and aggressive mobilisation when treating tibial tubercle avulsion fractures.     

Type III tibial avulsion fracture with associated anterior cruciate ligament injury: Report of two cases in adults

Tibial spine avulsion fractures are more common in children than adults. Many reports have provided classification and treatment options, including fixation for displaced type III fractures. However, long-term follow-up on injury to the anterior cruciate ligament and knee joint stability in adults is not well documented. We present 2 cases of type III tibial avulsion fractures in adults with associated interstitial injury to the anterior cruciate ligament. Primary anterior cruciate ligament reconstruction was performed in both patients.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: E20     

The tibialis anterior used as a local muscle flap over the tibia after soft tissue loss

BACKGROUND: A series of 12 extremities among 11 patients with open wounds exposing the tibia were treated using a local tibialis anterior muscle flap. There was an associated tibial shaft fracture in 11 of the 12 extremities, which were managed by external fixation or intramedullary nailing. The wounds, ranging from 1 to 15 cm in length, were located anteriorly over the middle and distal thirds of the tibia. METHODS: A retrospective chart review included patients whose open anterior tibial wounds were managed with an anterior tibialis rotational flap. These patients had been treated at the Medical College of Ohio between 1995 and 1999. No patients were excluded, and all the patients had at least 1 year of follow-up evaluation. RESULTS: Complete coverage was obtained in all cases. All the wounds healed without complication. All the associated tibial shaft fractures had a delayed union or nonunion, with 10 of the 11 requiring bone graft or an exchange intramedullary nail. CONCLUSION: The anterior tibialis is a relatively easy flap to use for covering anterior tibial open wounds. The high rate of nonunion seems related more to the injury than to the coverage technique.     

Avulsion fracture of the anteromedial bundle of the anterior cruciate ligament

The avulsion fracture of the tibial attachment site of the anterior cruciate ligament is relatively rare among adults. Although partial avulsion fracture of this site is very rare, complex forces exerted on the knee joint could produce this type of fracture. We report on an adult patient with an avulsion fracture of the attachment site of anteromedial bundle of the anterior cruciate ligament associated with injuries of lateral and medial collateral ligament and fibular fracture. We speculate varus stress in a flexed knee coupled with rotation between the femur and tibia caused this type of injury.     

Pure Varus Injury to the Knee Joint

A 30-year-old male was involved in a car accident. Radiographs revealed a depressed marginal fracture of the medial tibial plateau and an avulsion fracture of the fibular head. Magnetic resonance imaging showed avulsion fracture of Gerdy''s tubercle, injury to the posterior cruciate ligament (PCL), posterior horn of the medial meniscus, and the attachments of the lateral collateral ligament and the biceps femoris tendon. The depressed fracture of the medial tibial plateau was elevated and stabilized using a cannulated screw and washer. The injured lateral and posterolateral corner (PLC) structures were repaired and augmented by PLC reconstruction. However, the avulsion fracture of Gerdy''s tubercle was not fixed because it was minimally displaced and the torn PCL was also not repaired or reconstructed. We present a unique case of pure varus injury to the knee joint. This case contributes to our understanding of the mechanism of knee injury and provides insight regarding appropriate treatment plans for this type of injury.     

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.     

Tibial tubercle fracture with avulsion of patellar ligament

Combined fractures of the tibial tubercle and the patellar ligament are rare. Here we report the case of an 18-year-old boy who fell to the ground while playing basketball and suddenly felt a pop in his left knee; thereafter he was unable to stand. In-hospital radiographic examination revealed a tibial tubercle fracture with a high-riding patella, and the diagnosis was a Salter-Harris type IV tibial fracture associated with a sleeve fracture. The patient underwent surgery using a wire loop, an Ethibond suture (Ethicon Inc., Somerville, NJ, USA), and a staple to repair the site of the injury. The knee was immobilized for 4 weeks and after 2 months of follow-up, the patient was pain free with normal motion and strength. In conclusion, combined tibial tubercle fracture and avulsion of the patellar ligament are rare. The authors assert that the repair technique that is described herein supports reduced pain, early rehabilitation, and successful outcomes.     

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.     

Avulsion fractures of the lateral tibial condyle in children

Avulsion fractures of the lateral tibial condyle are very rare in children and adolescents. Seven patients were treated between 1986 and 2000. They were all involved in sporting activities and an acute contraction of the fibres of the iliotibial band was considered to be their common pathogenetic factor. A subdivision in two types of avulsion fractures according to the anatomic location of the lesion was used. The Segond fracture, a small vertical avulsion fracture involving the midportion of the lateral tibial condyle distal to the plateau but proximal to the physis, was diagnosed in five patients. In two of them it was associated with a fracture of the anterior intercondylar eminence. The avulsion fracture of the Gerdy's tubercle was diagnosed in two other patients. 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. All patients were treated conservatively and were free of symptoms after a mean follow-up of 9 years.     

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.     

Medial and lateral segond fractures in a skeletally immature patient: a radiographic marker for the multiply injured knee

Marginal fractures of the medial tibial plateau have been reported in the literature as a secondary type of Segond fracture. Some reports described this entity in the setting of combined injuries such as root avulsions of the medial meniscus, complete disruption of the posterior cruciate ligament (PCL), partial tear of the anterior cruciate ligament (ACL), and tears of the medial meniscus and medial collateral ligament. It has been postulated that medial marginal fractures are secondary to compression of the medial aspect of the femoral condyle and tibial plateau with a corresponding posterolateral corner injury. However, this mechanism of injury may not always be as straightforward.This article presents a case of an alternate injury pattern in a skeletally immature patient. A 16-year-old boy sustained a varus force and twisting injury to his knee, resulting in radiographic evidence of multiple avulsion fractures of the knee, including a fibular epiphyseal avulsion fracture and medial and lateral Segond fractures. Usually, the avulsion fractures serve as markers for significant ligamentous injuries in adult patients, but our patient had minimal injury to the PCL, ACL, and posterolateral corner. Further physical examination and imaging studies revealed an anterior horn root avulsion, meniscocapsular separation, and anterior cortical rim fracture. A combination of imaging modalities helped us further characterize the injury pattern to devise the optimal surgical plan, especially the fixation of the anterior cortical fracture of the tibia.     

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.     

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.     

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.     

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.     

Management of a long segmental defect at the proximal meta-diaphyseal junction of the tibia using a cylindrical titanium mesh cage

This case report describes a Gustilo Anderson type IIIB tibia fracture associated with extensive segmental bone loss at the proximal meta-diaphyseal junction associated with a tibial plateau fracture and an avulsion of the tibial tubercle. After the tibial plateau fracture was stabilized using cannulated lag screws, the shaft fracture was stabilized using a statically locked intramedullary nail in combination with a cylindrical titanium mesh cage and cancellous bone graft. The soft tissue defect was covered with local flaps. Immediate full weight bearing was initiated, and early functional recovery was achieved. At the final follow-up, plain radiographs demonstrated excellent limb alignment, and bony healing with computed tomography examination revealed bony ingrowth through the cage. This technique may be a reasonable alternative in the treatment of segmental bone loss of long bones.     

Laceration of tibialis anterior tendon complicating a closed tibial fracture: A case report

Traumatic laceration of the tibialis anterior tendon complicating a closed tibial shaft fracture is a rare injury pattern. Only 3 such cases have been reported to date in the English literature and all were missed on initial examination. A case of a 17-year-old motorcyclist with an acute laceration of the tibialis anterior tendon resulting from a closed oblique tibial shaft fracture is presented. The tendon laceration was suspected preoperatively because of the patient's inability to actively dorsiflex his ankle joint and the existence of a palpable gap in the soft tissues over the anterolateral aspect of his tibia. Tibialis anterior tendon repair was performed simultaneously with fracture fixation. The role of careful physical examination is stressed so that this rare injury combination will not be missed.