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Updated: 6/13/2021
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Tibial Tubercle Fracture
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4.4 of 63 Ratings
Matthew J. Steffes MD
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Eric Shirley MD
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TOPIC
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Summary
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Tibial Tubercle Fractures are common fractures that occur in adolescent
boys near the end of skeletal growth during athletic activity.
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Diagnosis can be confirmed with plain radiographs of the knee.
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Treatment may be nonoperative or operative depending on location of the
fracture, degree of displacement, and any associated injuries.
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Epidemiology
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Incidence
less than 1% of pediatric fractures
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Demographics
males >> females
ages 12 - 15 (approaching skeletal maturity)
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Risk factors
most common in basketball, football, sprinting and high jump
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Pathophysiology
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Mechanisms of injury
a concentric contraction of the quadriceps during jumping
an eccentric contraction of the quadriceps during forced knee flexion
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Associated conditions
compartment syndrome (4%)
meniscal tears with Type III injuries
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Anatomy
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Osteology
proximal tibia has two ossification centers *
primary ossification center (proximal tibial physis)
secondary ossification center (tibial tubercle physis or
apophysis)
insertion of patellar tendon
physeal closure occurs from posterior to anterior and proximal
to distal, with the tibial tubercle the last to fuse
places distal secondary center at greater risk of injury in
older children
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Muscles
extensor mechanism exerts great force at secondary ossification
center
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Blood Supply
recurrent anterior tibial artery can be lacerated
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Classification
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Based on level of fracture and presence of fragment displacement
Type III most common
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Ogden Classification (modification of Watson-Jones)
Type I
Fracture of the secondary ossification center near
the insertion of the patellar tendon
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Type II
Fracture propagates proximal between primary and
secondary ossification centers
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Type III
Coronal fracture extending posteriorly to cross the
primary ossification center
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Type IV
Fracture through the entire proximal tibial physis
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Type V
Periosteal sleeve avulsion of the extensor
mechanism from the secondary ossification center
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Modifier: A (nondisplaced), B (displaced)
Presentation
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Symptoms
sudden onset of pain
generally occurs during the initiation of jumping or sprinting
inability to immediately ambulate
knee swelling/hemarthrosis with Type III injuries
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Physical exam
inspection & palpation
knee effusion
tenderness at the tibial tubercle
evaluate for anterior compartment firmness
ROM & instability
extensor lag or extensor deficiency in Type II or III injuries
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- - .
retinacular fibers may allow for active extension
neurovascular exam
monitor for increasing pain suggestive of compartment
syndrome - - .
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Imaging
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Radiographs
recommended views
AP
lateral
optional views
internal rotation view will bring the tibial tubercle into profile *
comparison views of contralateral knee in younger pediatric
patients
findings
widening or hinging open of the apophysis
fracture line may be seen extending proximally and variable
distance posteriorly
anterior swelling may be the only sign in the setting of a
periosteal sleeve avulsion (type V injury)
patella alta
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CT
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can be useful to evaluate for intra-articular or posterior extension
arteriogram if concern for popliteal arterty injury
should not delay intervention in setting of compartment
syndrome
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MRI *
generally not indicated
useful for determining fracture extension in a nondisplaced Type II
injury or type V injury
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Treatment
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Nonoperative
long leg cast in extension for 6 weeks
indications
Type I injuries or those with minimal displacement (< 2
mm)
acceptable displacement after closed reduction/cast
application
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Operative
open reduction internal fixation with arthrotomy +/- arthroscopy,
+/- soft tissue repair - - - . .
indications
Type II-IV fractures - need to visualize joint surface for
perfect reduction and evaluate for intra-articular
pathology
soft tissue repair for Type V (periosteal sleeve) fracture
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Techniques
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Open reduction and internal fixation
approach
midline incision to the fracture site
technique
evaluate and clean fracture site
remove any soft tissue (periosteum) interposition
anatomic reduction of fracture fragments
internal fixation with 4.0 cancellous, partially threaded screws
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larger screws can be used but may cause soft tissue irritation in
the long-term
smooth K wires for younger child (>3y from skeletal maturity)
postoperative care
immobilization
non-weightbearing in long leg cast or brace for 4-6 weeks
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
pros & cons
pros
anatomic reduction and stable fixation
excellent healing potential
may allow for earlier range of motion
cons
incision and associated complications
hardware irritation can necessitate implant removal
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Open reduction and internal fixation with arthrotomy or arthroscopy
approach
midline approach and parapatellar arthrotomy
joint surface must be visualized to assure anatomic reduction
alternatively, arthroscopy can be used to directly assess the
articular reduction
technique
same as above
evacuate intra-articular hematoma
visualize joint surface to achieve anatomic reduction
evaluate for meniscal tears and repair or debride as
appropriate if soft tissue repair indicated
postoperative care
immobilization
long leg cast for 4-6 weeks
non-weight bearing
rehabilitation
progressive extensor mechanism strengthening
return to sports at 3 months
pros & cons
pros
addresses intraarticular extension and soft tissue
injuries
cons
arthrotomy may require longer immobilization and/or
rehabilitation
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Soft tissue repair
similar to above
approach
midline incison to fracture site
technique
evaluate soft tissue injury
remove any soft tissue interposition (periosteum)
heavy suture repair of periosteum back to the secondary
ossification center
postoperative care
immobilization
long leg cast for 8-10 weeks
prolonged immobilization needed due to soft tissue (rather than
bone) healing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
pros & cons
prolonged healing time given to soft tissue healing
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Complications
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Recurvatum deformity
more common than leg length discrepancy
growth arrest anteriorly and posterior growth continues leading to
decrease in tibial slope
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Compartment syndrome *
related to injury of anterior tibial recurrent artery - -
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. . . . .
Stiffness
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Bursitis
most common complication following surgical repair
due to prominence of screws and hardware about the knee, resolved
upon hardware removal
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Vascular Injury
to popliteal artery as it passes posteriorly over distal metaphyseal
fragment
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Prognosis
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High rate of fracture union and return to sports with approriate treatment
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Low incidence of leg length discrepancy given age at which this injury
occurs
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FLASHCARDS (2)
Tibial Tubercle Fracture
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OBC
Complications
What specific arterial injury is associated with compartment
syndrome?
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by
Ben Sharareh
CARDS
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QUESTIONS (13)
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QUESTIONS
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(OBQ18.73) Which of the following is the likely mechanism of injury shown in
Figure A?
QID: 212969
A,
FIGURES:
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Select Answer to see Preferred Response
- EVIDENCE (17)
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Date
PMID: 23147615 J Pediatr Orthop. 2012 De…
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Tibial tubercle fractures: complications,
classification, and the need for intra-articular
assessment.
Pandya NK Edmonds EW Roocroft JH
Mubarak SJ
& Pediatrics - Tibial Tubercle Fracture
C - CORE
:$;
Pandya NK, JPO 2012
3 FREE PDF
...
336 views
12/1/2012
336 responses
2.7 "
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PMID: 19308478 J Child Orthop. 2009 Jun;3…
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Classification of proximal tibial fractures in
children.
Mubarak SJ
Kim JR
Edmonds EW Pring ME
Bastrom TP.
& Pediatrics - Tibial Tubercle Fracture
C - CORE
Mubarak SJ, JCO 2009
:$<
40 views
3 FREE PDF
6/1/2009
40 responses
2.7 "
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PMID: 8403649 Clin Orthop Relat Res. 199…
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Compartment syndrome complicating tibial
tubercle avulsion.
Pape JM
Goulet JA Hensinger RN.
& Pediatrics - Tibial Tubercle Fracture
D - TESTED
Pape JM, CORR 1993
:$<
...
92 views
3 FREE PDF
10/1/1993
92 responses
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VIDEOS & PODCASTS (2)
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Podcasts (1)
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Videos
5/15/2016
Tibial Tubercle Avulsions Indications and
Techniques - Drs Jazrawi
& Pediatrics - Tibial Tubercle Fracture
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1525 views
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Pediatrics | Tibial Tubercle Fracture
6
10/18/2019
& Pediatrics - Tibial Tubercle Fracture
6 Listen Now
19:15 min
500 plays
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CASES (3)
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8/5/2020
:
Pediatric Tibial Tubercle Fracture (C101553)
Jacob Triplet
& Pediatrics - Tibial Tubercle Fracture
>
598 8
7 2
1 9
3/3/2020
:
Bilateral Tibial Tubercle Fractures in 12F
(C101392)
Panagiotis Poulios
& Pediatrics - Tibial Tubercle Fracture
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128 8
12 2
0 9
10/27/2015
:
Tibial Tubercle Fracture in 11M (C2414)
Alceu Fornari Chueire
& Pediatrics - Tibial Tubercle Fracture
>
9474 8
5 2
17 9
9
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