The patient had full active range of motion (full extension to 135 degrees) andstrength(5/5) equivalent to the uninjured knee, with no residual pain, hardware irritation, or bursitis. Potential mechanisms: There are multiple classification systems with multiple modifiers. The mechanism of injury is described as passive flexion of the knee while the quadriceps is actively contracting. This site needs JavaScript to work properly. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. What causes this injury? 2012;35(8):692696. The unique construct, a slotted-plate over transosseous sutures, provided excellent results and likely has further applications. the display of certain parts of an article in other eReaders. Journal of Children's . The patellar height ratio (0.8) was within normal limits using both Caton-Deschamps (normal 0.8-1.2) and Insall-Salvetti (0.75-0.99)methods [10-12]. The functionality is limited to basic scrolling. Orthop. One case of fracture of the tibial tuberosity in the adult. The growth plate is an area of relative weakness, and fracture of it is usually due to sudden, vigorous activity of the patellar tendon pulling the bone away from the cartilage. Would you like email updates of new search results? Alternatively, the patellar tendon may avulse from an intact tubercle; this injury is similarly infrequent in healthy adults [2,3]. Stress avulsion of the tibial tuberosity after tension band wiring of a patellar fracture: a case report. The distal aspect of the patellar tendon could not be fully visualized by ultrasound due to overlying hematoma, but proximal retraction was noted (Figure (Figure22). Avulsion fracture the tibial tuberosity occurs in a young animal, usually between 4-8 months of age. Whereas older adults would sustain a patellar tendon tear, growing athletes sustain this uncommon injury. The third method involves anchor suture. The tibial tubercle is the part of the top of the shin bone where the patellar tendon attaches. They are written by UK doctors and based on research evidence, UK and . and transmitted securely. This link will take you to a third party website that is not affiliated with Cureus, Inc. Bethesda, MD 20894, Web Policies Compartment syndrome complicating tibial tubercle avulsion. Chloros GD, Razavi A, Cheatham SA. The clinical features and management of Osgood-Schlatter disease will be discussed here. We describe a case in an adult who suffered a left knee injury due to a fall from height. Tibial tuberosity avulsion fractures are extremely rare fracture patterns, with reported incidence rates of 0.4% to 2.7% of all epiphyseal injuries, <1% of all physeal injuries, and about 3% of all proximal tibial injuries 1,2,3. ADVERTISEMENT: Supporters see fewer/no ads. Such lesions are typically seen in adolescent males with well-developed quadriceps musculature and are usually incurred during jumping sports activities, such as basketball [3]. Insall J, Salvati E. Patella infera. (A) A slotted plate was positioned after transosseous suture placement through tibia, tubercle fragment, and patellar tendon. 24 (2): 181-4. The most commonly used is the modified Ogden classification. Cureus 12(5): e7929. Tibial tuberosity avulsion fracture combined with meniscal tear. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. [Lateral tibial head fracture and avulsion fracture of the tibial tuberosity: a rare combination of injuries]. (A) Free tubercle fragment (in forceps) and tibia donor site (lower arrow) with proximal migration of the patella (upper arrow). The lesion was treated with surgical reduction and internal fixation. However, screws may have limited purchase in small fragments or osteoporotic bone and may even cause fragment splitting [13]. McKoy B.E., Stanitski C.L. Right knee AP radiograph showing avulsion fracture of the tibial tuberosity. Copyright 2020Woolnough et al. Avulsion fractures of the tibial tuberosity represent 3% of all epiphyseal plate injuries in adolescents. Why Mechanism Matters: A Literature Review of Simultaneous Ipsilateral Tibial Tuberosity Avulsion and Patella Fracture With Case Report. They are often associated with patients who have underlying bone disease and other medical co-morbidities. Fukuoka Igaku Zasshi. High ratings should be reserved for work that is truly groundbreaking in its respective field. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. The normal ossification of the tibial tuberosity occurs from two centers, one distal and one proximal. 2 (6): 469-74. Compartment syndrome complicating tibial tubercle avulsion. Anterior avulsion fracture of the tibial tuberosity in adolescents - Two case reports. Unfallchirurg. Regarding combined lesions, in adolescents it has been proposed that tubercle avulsion is followed by rotation, which tensions soft tissues around the tubercle, arresting fragment translation; continued quadriceps contraction then causes tendon avulsion [5,6]. Incidence. 2004. The typical patient is an adolescent male approaching skeletal maturity with well-developed quadriceps. PMC At 3 months follow up, the patient had good knee range of motion from 0 to 100 degrees and by 6 months he had returned to his usual activities. Commonly described mechanisms of tibial tubercle avulsion fracture and patellar tendon avulsion include significant quadriceps contraction with a fixed foot or quadriceps contraction in the presence of an external force acting to produce knee flexion [1-3]. (A) Free tubercle fragment (in forceps) and tibia donor site (lower arrow) with proximal migration of the patella (upper arrow). Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-15612, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":15612,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/tibial-tuberosity-avulsion-fracture/questions/1174?lang=us"}, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, patella tendon or quadriceps tendon rupture, compartment syndrome due to the recurrent branch of the anterior tibial artery injury, violent knee flexion against a tight contraction quadriceps, e.g. Tibial tubercle avulsion fracture with simultaneous patellar tendon avulsion is a rare injury that has only ever been reported in adolescents; the diagnosis and management of this combined lesion has not been described in the adult population. A novelslotted-plate construct was used to fix the tubercle fragment prior to tightening the sutures. Pape JM, Goulet JA, Hensinger RN. 3. INTRODUCTION. The site is secure. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Diagnosis can be confirmed with plain radiographs of the knee. Two transosseous #5 polyester sutures (one medial and one lateral) were placed from intact cortical bone into cancellous bone of the donor site through pilot holes; these sutures were then pushed through the tubercle fragment and were secured through the patellar tendon using a Krackow technique (Figure 3C). Radiographs demonstrated a displaced fracture of the tibial tubercle; patellar tendon integrity could not be verified by ultrasonography. Rana R, Ganesh A, Behera S 2nd, Behera H. Cureus. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. After excising hemorrhagic prepatellar bursa, evacuating overlying traumatic hematoma, and exposing the fracture donor site (Figure (Figure3A),3A), it was apparent that in addition to the tibial tubercle fracture, the patellar tendon was completely avulsed from the tubercle fragment (Figure (Figure3B).3B). 2021 Dec 7;13(12):e20232. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. report of two cases. jumping, widening of open apophysis typically demonstrating a displacement of proximal apophysis, hemarthrosis if there is intra-articular extension, type I:usually non-operative immobilization in a long leg cast 4-6 weeks, type II-V:usually surgical -closed reduction via percutaneous clamping and lag screw fixation or open reduction. Fractures of the tibia may result from significant trauma or be the consequence of repeated overuse. At six weeks, the operative knee could be passively flexed with no pain to 20 so the patient began gradually increasing range of motion in a hinged knee brace, initially locked at full extension. Fractures of the tibial tuberosity constitute only 3% of proximal tibial fractures [ 1 ]. The sutures were tensioned and locked, reducing the patellar tendon to the bony fragment and tibia. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Compound or Open Fracture : A break where the bone has penetrated the skin to the exterior, or the wound that broke the bone has exposed the broken ends. Avulsion fractures of the tibial tuberosity in the adult are extremely rare with only 3 reported cases. Muscat J, Baskaradas A, Dhillon G, Motkur V, Thakrar R. Cureus. This injury pattern accounts for less than 1% of all pediatric fractures and is even less common in adult . Before A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. (C) Primary sutures were tensioned and a third, defunctioning suture (red) was placed through a distal pilot hole and secured to the patellar tendon with a running-locking technique. One year following surgery, the patient had full knee range of motion (full extension to 135 degrees of flexion) and full flexion and extension power (5/5) with no residual pain or other complications. The https:// ensures that you are connecting to the Orthopedics, McMaster University, Hamilton, CAN. Examination of the left knee revealed a compromised extensor mechanism and a palpable defect at the inferior insertion of the patellar tendon, with diffuse pain and swelling but no neurovascular or skin compromise. Avulsion of the tibial tubercle (arrows) and patella alta can be seen; the bony tubercle fragment (arrows) is translated 1.5 cm proximally and is rotated 90 from its anatomic position. Scholarly Impact Quotient (SIQ) is our unique post-publication peer review rating process. Tubercle avulsion is considerably more common in adolescents than that in adults due to the weakness of an open physis although tubercle fracture may also occur in adults, typically as a result of direct impact [1,4]. The Orthopedic Clinics of North America. At one year, the patient had achieved excellent range of motion (full extension to 135 degrees of flexion) and strength (5/5 knee flexion and extension) without residual pain or complications. Medial and lateral retinacular defects were repaired. (D) Completed fixation with the tubercle fragment reduced,plate secured(white arrow, not visible), and the tendon reduced. 1-3 It has not been reported with proximal tibial diaphyseal fractures. PMC (D) One year postoperative,slight osseous debris or ossification (arrow) can be seen in the area of the patellar tendon. Orthop Clin North Am. (C) Three months postoperative, patella height is appropriate and with visible pilot-hole lucency (arrow) from transosseous suture placement. DOI: 10.2106/00004623-197759080-00022 Corpus ID: 2637082; Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. A combined lesion - tubercle fracture with patellar tendon avulsion from the tubercle fragment - has only ever been reported in adolescents, typically those involved in sport, and can present challenges in both diagnosis and management [4-9]. Avulsion fractures of the tibial tubercle. Tibial Plateau Fracture with Avulsion Fracture of Tibial Tuberosity: A Case Report and Review of Literature. Fixation using transosseous sutures through a slotted plate required no specialized instrumentation and provided an excellent outcome. One year following surgery, the patient had full knee range of motion (full extension to 135 degrees of flexion) and full flexion and extension power (5/5) with no residual pain or other complications. Osgood-Schlatter disease, also known as osteochondritis of the tibial tubercle, was first described in 1903 [ 1,2 ]. doi: 10.1097/MD.0000000000001684. J Knee Surg. We describe a case of a patient with undiagnosed Paget's Disease of the bone, sustaining a pathological avulsion fracture of the tibial tuberosity. type II: "beak" fracture with oblique fracture line running posteriorly from just behind Bohler's angle. Tibial tuberosity avulsion fracture usually occurs in younger dogs due to the area of the tibia not being fully fused to the rest of the bone. Ossification begins distally between the ages of seven and nine years. Please enable it to take advantage of the complete set of features! After six weeks, knee range of motion was gradually increased using a hinged brace. Recovery and aftercare There is a low risk of fracture after MMP surgery , so strict cage rest and keeping your dog on their lead when not in the cage is a must for the first 4-6 weeks. No risk factors were identified. . type III: infrabursal avulsed fracture by superficial fibers from the middle third of the posterior tuberosity. All registered users are invited to contribute to the SIQ of any published article. The authors declare that they have no competing interests. An anterior midline approach was used. FOIA government site. What are Tibial Tuberosity Avulsion Fractures? While a peak in boys. Hirschmann MT, Wind B, Mauch C, Ickler G, Friederich NF. Tibial tubercle avulsion fracture with simultaneous patellar tendon avulsion is a rare injury that has only ever been reported in adolescents; the diagnosis and management of this combined lesion has not been described in the adult population. Plate fixation provided the strength of screw fixation while avoiding potential fragment splitting or loss of screw purchase. An avulsion fracture of the tibial tuberosity is an infrequent injury and has an extremely low occurrence in adults, with only a few cases reported in literature. Online ahead of print. The aim of this report is to describe the diagnosis, operative management, and postoperative rehabilitation of a combined tibial tubercle fracture with distal patellar tendon avulsion in an adult. Ultrasonography demonstrated an intact quadriceps tendon and a normal patellar tendon origin at the inferior patellar pole. To begin, provisional fixation was achieved with two Kirschner wires. The ePub format uses eBook readers, which have several "ease of reading" features Ultrasound demonstrating tibial tubercle (TT) fracture with proximal migration of the patellar tendon and tubercle fragment. INTRODUCTION. Two weeks following surgery, the patient began weight bearing in a fixed knee splint. doi: 10.7759/cureus.13256. The unique construct, a slotted-plate over transosseous sutures, provided excellent results and likely has further applications. Diagnosis can be confirmed with radiographs of the knee. Tibial tubercle fracture with avulsion of patellar ligament. Wu KC, Ding DC. Avulsion fractures of the tibial tuberosity in adolescent athletes treated by internal fixation and tension band wiring. At one year, radiographs were unremarkable other than minimal osseous debris and/or ossification (Figure 5D). (C) Transosseous sutures through the donor site (metal probe) and tubercle fragment (lower arrow), secured to the patellar tendon with a running-locking technique (upper arrow). Published: May 02, 2020. On univariate analysis, the PM fractures were associated with fibular spiral (p=-016) fractures and no fracture of the fibular (p=.003), lateral direction of the tibial fracture (p=.04), female gender (p=.002), AO classification 42B1 (p=.033) and an increasing angle of tibial fracture. Rana R, Ganesh A, Behera S 2nd, Behera H. Cureus. Treatment was guided in part by evidence on fixation after tibial tubercle osteotomy; in that context, screw fixation is likely superior to wire fixation [9]. At this point, slots were cut into the central two holes of a four-hole, 3.5-mm one-third tubular plate. Tibial Tuberosity Avulsion Fracture and Open Proximal Tibial Fracture in an Adult: A Case Report and Literature Review. Dynamic confirmation of fixation techniques of the tibial tubercle osteotomy. nowadays. Federal government websites often end in .gov or .mil. sharing sensitive information, make sure youre on a federal 4-6 Both fractures require operative . Unable to load your collection due to an error, Unable to load your delegates due to an error. A piece of bone attached to a ligament or tendon breaks away from the main part of the bone. The aim of this study was to present an unusual case of direct trauma of the tibial tuberosity in an adult and the therapy performed. In addition to our case report, we have performed a . When the fracture happens, the tendon or ligament pulls away, and a small piece of. Frey S, Hosalkar H, Cameron DB, Heath A, David Horn B, Ganley TJ. Int J Surg Case Rep. 2022 Jun 20;96:107326. doi: 10.1016/j.ijscr.2022.107326. The typical patient is an adolescent male approaching skeletal maturity with well-developed quadriceps. First, the tendon was secured to the tubercle fragment with transosseous sutures. Tibial tubercle avulsion fracture caused by knee extensor is very rare; furthermore, non-traumatic fractures during running or bilateral fractures have been reported. Received 2020 Mar 30; Accepted 2020 May 2. Acute tibial tubercle avulsion fracture is an uncommon injury, typically seen only in adolescents due to the vulnerability of an open physis [1]. Epub 2003 Oct 3. -. A novelslotted-plate construct was used to fix the tubercle fragment prior to tightening the sutures. You may notice problems with A 54-year-old male presented with right knee pain after his knee gave way whilst standing in the goal area during a game of football, twisting his right ankle and falling. Please enable it to take advantage of the complete set of features! At one year, the patient had achieved excellent range of motion (full extension to 135 degrees of flexion) and strength (5/5 knee flexion and extension) without residual pain or complications. Postoperatively, the patient was permitted to bear weight as tolerated with the operative kneeimmobilized in extension. In adolescents, combined lesions have been treated using a variety of methods, including staples, wires or suture tape, tension banding, lag screws, suture anchors, and/or transosseous sutures [6,8]. Acute tibial tubercle avulsion fracture is an uncommon injury, typically seen only in adolescents due to the vulnerability of an open physis [1]. Tibial tuberosity avulsion fractures are uncommon, constituting <3% of all epiphyseal injuries and 1% of all physeal injuries in skeletally immature population [1, 2]. Tibial tubercle fractures most commonly occur in adolescent boys aged 12-16 years. When the quadriceps muscle on the front of the thigh works, it pulls on the patellar tendon. The second method involves fixation by lag screws with or without tension band wiring as an augment fixation. An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. In this anatomic location, aone-third semitubular plate was low profile and allowed for easy contouring to the convex surface of the anterior tibia. Fractures of the knee include fractures of the patella, femoral condyles, tibial eminence, tibial tuberosity and tibial plateau. We describe a case in an adult who suffered a left knee injury due to a fall from height. A tibial tubercle avulsion fracture is a complete or incomplete break (fracture) of the growth plate of the leg just below the knee at the tibial tubercle, a prominence just below the kneecap. See this image and copyright information in PMC. Indeed, it is the only thing that ever has.". The development of Osgood-Schlatter's is associated with the time of rapid growth and immature bone maturation in early teen years. Fracture of tibial tuberosity in an adult. Two weeks following surgery, the patient began weight bearing in a fixed knee splint. X-rays in anteroposterior and lateral views of the left knee showing the tibial anterior tuberosity fracture. Peer review concluded: April 24, 2020 A fracture of the tibial tuberosity often results in an avulsion fracture, by virtue of the pull of the quadripceps muscles. We describe a case of a patient with undiagnosed Paget's Disease of the bone, sustaining a pathological avulsion fracture of the tibial tuberosity. Right knee lateral radiograph from five years ago revealing similar picture to Figure 1. (1993) Clinical orthopaedics and related research. The avulsion fracture of the tibial tuberosity is regarded as a substantial injury to the extensor mechanism as the patellar tendon is attached to the tibial tuberosity. 4. report of two cases, Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in pediatric population: case series and review of literature, Dynamic confirmation of fixation techniques of the tibial tubercle osteotomy, Patellar height ratios: a comparison of four measurement methods, Patella position in the normal knee joint, Tibial tubercle osteotomy for exposure of the difficult total knee arthroplasty. - Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. Int J Surg Case Rep. 2020;71:1-5. doi: 10.1016/j.ijscr.2020.04.029. Associations patella tendon or quadriceps tendon rupture A Tibial Eminence Fracture, also known as a tibial spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity. Rodrigo Pires e Albuquerque, Andr Siqueira Campos, Gabriel Costa Serro de Arajo, Vincius Schott Gameiro. @article{Zaricznyj1977AvulsionFO, title={Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. However, screws may have limited purchase in small fragments or osteoporotic bone and may even cause fragment splitting [13]. We are experimenting with display styles that make it easier to read articles in PMC. The authors have declared that no competing interests exist. The primary fixation was reinforced using a third #5 polyester suture, placed through an additional transosseous pilot hole distal to the fracture site and secured to the tendon again using a Krackow technique (Figures (Figures4C,4C, ,4D).4D). We describe a unique case of tibial tuberosity avulsion fracture in an adult with PDB. All patients require a variable period of immobilization averaging 4 weeks. An MRI confirmed a diagnosis of Paget's disease of the bone. Bifocal disruption of the knee extensor mechanism: a case report and literature review. However, the first presentation of this injury in an adult represented a unique challenge as no literature existed describing successful management. Comminuted Fracture : Bone is crushed or splintered. This occurs as a result of a violent contraction of the quadriceps muscles, most often as a result of a high-power jump. The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Professional Reference articles are designed for health professionals to use. Two 4-mm cancellous screws were used to secure the plate, thereby providing fixation of the tubercle fragment (Figure 4B). Plain radiographs of the knee revealed an avulsion fracture of the tibial tuberosity with abnormal modelling of the proximal half of the tibia. The patient was healthy and denied previous trauma, and corticosteroid or quinolone use. Regarding combined lesions, in adolescents it has been proposed that tubercle avulsion is followed by rotation, which tensions soft tissues around the tubercle, arresting fragment translation; continued quadriceps contraction then causes tendon avulsion [5,6]. A tibial tubercle fracture is an uncommon knee injury in young athletes. Whereas older adults would sustain . FOIA The .gov means its official. The primary fixation was reinforced using a third #5 polyester suture, placed through an additional transosseous pilot hole distal to the fracture site and secured to the tendon again using a Krackow technique (Figures 4C, 4D). At six weeks, the operative knee could be passively flexed with no pain to 20 so the patient began gradually increasing range of motion in a hinged knee brace, initially locked at full extension. type I: simple extra-articular avulsion fracture. Pathological fractures occurring from trivial injuries are a well-known clinical presentation in patients with Paget's disease. Keywords: Bethesda, MD 20894, Web Policies A healthy 62-year-old male hospitality worker presented to the hospital with left knee pain and an inability to walk following a mechanical fall on ice. doi: 10.7759/cureus.20232. Tibial tuberosity avulsion fracture in an adult a rare case report. HHS Vulnerability Disclosure, Help Mosier SM, Stanitski CL. With stress, the incompletely ossified tibial eminence in the child avulses before the ligament ruptures. First, the tendon was secured to the tubercle fragment with transosseous sutures. In this anatomic location, aone-third semitubular plate was low profile and allowed for easy contouring to the convex surface of the anterior tibia. Careers. official website and that any information you provide is encrypted (2013) BMJ Case Reports. Treatment was guided in part by evidence on fixation after tibial tubercle osteotomy; in that context, screw fixation is likely superior to wire fixation [9]. Tuberosity is the term used to describe the prominence of a bone that attaches the ligament to the bone. government site. X-rays of the knee in anteroposterior and lateral views after the osteosynthesis. Review of final fluoroscopic images confirmed reduction of the tubercle and showed patella baja (Figures 5A, 5B). The site is secure. Imaging features of both acute and chronic avulsion injuries of the pelvis, knee, ankle and foot, shoulder, and elbow were evaluated to help distinguish these injuries from more serious disease processes such as neoplasm and infection. Avulsion of the tibial tuberosity is not an uncommon entity seen in adolescents. Arthroscopy. [ 1] classified the adolescent fractures considering the fracture line and displacement of avulsed fragments. While all registered Cureus users can rate any published article, the opinion of domain experts is weighted appreciably more than that of non-specialists. Tibial tubercle fracture with avulsion of the patellar ligament: a case report. After excising hemorrhagic prepatellar bursa, evacuating overlying traumatic hematoma, and exposing the fracture donor site (Figure 3A), it was apparent that in addition to the tibial tubercle fracture, the patellar tendon was completely avulsed from the tubercle fragment (Figure 3B). What causes anterior tibial tubercle? landing from a jump, violent quadriceps contraction against a fixed foot, e.g. 8600 Rockville Pike Please note that by doing so you agree to be added to our monthly email newsletter distribution list. and adolescents resulting from a traction apophysitis of the tibial tubercle. In adults, this injury is exceedingly rare, with only several reported cases. This article is for Medical Professionals. (A) A slotted plate was positioned after transosseous suture placement through tibia, tubercle fragment, and patellar tendon. Tibial Plateau Fracture with Avulsion Fracture of Tibial Tuberosity: A Case Report and Review of Literature. Tension band wiring of displaced tibial tuberosity fractures in . 2020 Apr 21;12(4):e7756. Tibial tuberosity fractures affect the patellar ligament near the kneecap. With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. Frankl U, Wasilewski SA, Healy WL. (C) Transosseous sutures through the donor site (metal probe) and tubercle fragment (lower arrow), secured to the patellar tendon with a running-locking technique (upper arrow). MeSH The proximal center has a physis and is a cartilaginous extension of the tibial epiphysis which expands distally. (C) Primary sutures were tensioned and a third, defunctioning suture (red) was placed through a distal pilot hole and secured to the patellar tendon with a running-locking technique. Full range of motion is expected by 3 months, with a return to pre-injury level of activity thereafter. CT is helpful to determine intra-articular or posterior extension. 2008 Jul;111(7):548-52. doi: 10.1007/s00113-007-1371-y. Epub 2015 Oct 28. Online ahead of print. Taylor Woolnough, Gwendolyn Lovsted, [], and Jamal A Al-Asiri. -, Kang S., Chung P.H., Kim Y.S., Lee H.M., Kim J.P. Bifocal disruption of the knee extensor mechanism: a case report and literature review. Accessibility An official website of the United States government. Conclusion: Uppal R, Lyne ED. Two 4-mm cancellous screws were used to secure the plate, thereby providing fixation of the tubercle fragment (Figure (Figure4B).4B). Whiteside LA, Ohl MD. (B) Freeedge of the avulsed patellar tendon with no remaining bony attachment (arrow). This injury typically occurs in adolescents because the tibial tubercle is still growing and the bone is softer there. The purpose of this study was to evaluate any differences according to the mechanisms of injury in adolescents with tibial tubercle avulsion fracture. Please note that Cureus is not responsible for any content or activities contained within our partner or affiliate websites. Here we describe a case where this injury was attributed to direct trauma and demonstrate our department's management for such an injury. Avulsion injuries are common among participants in organized sports, especially among adolescent participants. Bookshelf This can occur in vigorous sports activities that require frequent . Clipboard, Search History, and several other advanced features are temporarily unavailable. Learn more here. Arch. Tibial tubercle avulsion fracture with simultaneous patellar tendon avulsion is a rare injury that has only ever been reported in adolescents; the diagnosis and management of this combined lesion has not been described in the adult population. Epub 2020 May 8. X-rays in anteroposterior and lateral views of the left knee showing the tibial, Images of the knee during the surgery, showing the gap in the tibial. tibial tubercle (tuberosity) fractures are infrequent fractures affecting physically active adolescents. The first method involves non-operative treatment with casting or bracing in non-displaced and stable fracture. Orthopedics. The patellar height ratio (0.8) was within normal limits using both Caton-Deschamps (normal 0.8-1.2) and Insall-Salvetti (0.75-0.99)methods [10-12]. The tibial tuberosity is the prominent bump on the front and top of the tibia, the shin-bone, below the knee joint. Although Grogan et al. Radiographs demonstrated tibial tubercle avulsion fracture and patella alta (Figure 1). In young athletes, the growth center there is still open, leaving it vulnerable to injury. (2008) Journal of children's orthopaedics. Berg EE, Mason SL, Lucas MJ. How do you get tibial tuberosity? What are Tibial Tuberosity Fractures? Treatment may be nonoperative or operative depending on location of the fracture, degree of displacement, and any associated injuries. Do not disregard or avoid professional medical advice due to content published within Cureus. . A tibial tubercle fracture is a break or crack at this location, which usually occurs as a result of the patellar tendon pulling off a piece of the bone. The patient was healthy and denied previous trauma, and corticosteroid or quinolone use. Intraoperatively, the patient was found to have a distal avulsion of the patellar tendon in addition to tubercle fracture. The technique relies on maintaining strong thigh muscles, so you will need to get your dog regularly walking post-surgery. Anything above 5 should be considered above average. Unable to process the form. Fixation with a slotted-plate construct has promising applications outside of the present case, particularly in the setting of tibial tubercle osteotomies and knee arthroplasty where the screws of this construct may be angled to avoid the intramedullary canal, bypassing stemmed or keeled tibial implants. Accessibility Patella position in the normal knee joint. Epidemiology These fractures have an incidence 0.4% to 2.7%, and males are affected more-so than females. 1971;53(8):15791583. A tibial tuberosity avulsion fracture is an incomplete or complete separation of the tibial tuberosity from the tibia. J Bone Joint Surg Am The Journal Of Bone & Joint Surgery. the incidence of adult avulsion fractures may be underestimated.1 Ten case reports, including 17 patients, of ipsilateral simultaneous rupture of the pa-tella tendon and ACL have been reported. 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Cureus 12(5): e7929. All content published within Cureus is intended only for educational, research and reference purposes. The tendon in turn pulls on the tibial tuberosity. Integrity of the distal patellar tendon could not be determined due to hematoma at the site of tendon attachment to the tibial tubercle (arrow). Check for errors and try again. These fractures have an incidence 0.4% to 2.7%, and males are affected more-so than females. (May 02, 2020) Combined Tibial Tubercle Fracture With Patellar Tendon Avulsion in an Adult: A Rare Case and Novel Fixation Technique. Optional views include an internal rotation view bringing the tibial tuberosity into profile or a contralateral knee radiograph for comparison. chronic renal failure, diabetes, chronic steroid use, quinolone treatment, systemic lupus erythematous) may increase risk of tendon rupture, this patient reported no known risk factors [3,4]. This article presents the first case of a combined tibial tubercle avulsion with distal patellar tendon avulsion in an adult. By joining Cureus, you agree to our Avulsion fractures are caused by trauma. Tibial plateau fractures are typically caused by a strong force on the lower leg with the leg in varus or valgus position, or simultaneous vertical stress and flexion of the knee. Tibial tubercle avulsion fractures are an uncommon injury occurring due to strong contraction of the quadriceps femoris muscle during leg extension, ultimately causing failure of the physis at the patellar tendon insertion. Tibial tuberosity avulsion fractures are uncommon. (2004) Journal of pediatric orthopedics. Caldwell PE, Bohlen BA, Owen JR, et al. Extensor mechanism reconstruction and joint preservation surgery following a tibial tuberosity fracture in giant cell tumor of bone: A case report. The https:// ensures that you are connecting to the In patients with radiographic evidence of tibial tubercle fracture, lateral flexion extension radiographs, ultrasonography, and/or magnetic resonance imaging are prudent to rule out concomitant patellar tendon avulsion [5,6]. (May 02, 2020) Combined Tibial Tubercle Fracture With Patellar Tendon Avulsion in an Adult: A Rare Case and Novel Fixation Technique. The distal aspect of the patellar tendon could not be fully visualized by ultrasound due to overlying hematoma, but proximal retraction was noted (Figure 2). Scholarly Impact Quotient (SIQ) is our unique post-publication peer review rating process. Bolesta MJ, Fitch RD. Right knee lateral radiograph showing avulsion fracture of the tibial tuberosity. We describe a case in an adult who suffered a left knee injury due to a fall from height. Osgood-Schlatter disease (OSD) is one of the most common causes for anterior knee pain in children. While systemic illness (e.g. An official website of the United States government. They account for only 1% of pediatric fractures (Pandya, 2012). The patient underwent open reduction internal fixation. HHS Vulnerability Disclosure, Help Postoperatively, the patient was permitted to bear weight as tolerated with the operative kneeimmobilized in extension. Exact cause is unknown but chronic repetitive trauma to the maturing proximal tibial growth plate by excessive force exerted on the secondary ossification center or apophysis by the patellar tendon leading to avulsion and tibial fragmentation with soft-tissue swelling of tubercle.. How do you treat Osgood-Schlatter in adults? Adult fracture; Bone fragility; Paget's disease of the bone; Tibial tuberosity fracture. The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. Incomplete fractures are usually treatable with the traditional RICE (rest, ice, compression, elevation . Tibial tubercle avulsions. You may switch to Article in classic view. Disclaimer, National Library of Medicine No risk factors were identified. It is a traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon. Fractures of the knee . The aim of this report is to describe the diagnosis, operative management, and postoperative rehabilitation of a combined tibial tubercle fracture with distal patellar tendon avulsion in an adult. They usually happen when a bone is moving one way, and a tendon or ligament is . Ultrasonography demonstrated an intact quadriceps tendon and a normal patellar tendon origin at the inferior patellar pole. (A) Intraoperative fluoroscopydemonstrating plate fixation of the tibial tubercle with slots cut in plate (arrows) for passing over sutures. (B) The plate was then secured atop the tubercle fragment. Capogna B, Strauss E, Konda S, Dayan A, Alaia M: Kang S, Chung PH, Kim YS, Lee HM, Kim JP: Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. An avulsion fracture of the tibial tuberosity is an infrequent injury and has an extremely low occurrence in adults, with only a few cases reported in literature. Tension band suture in isolated tibial tubercle avulsion: A case report and review literatures. 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