Combined Tibial Tubercle Fracture With Patellar Tendon Avulsion in an Adult: A Rare Case and Novel Fixation Technique, Monitoring Editor: Alexander Muacevic and John R Adler. Images of the inferior limb demonstrating the functional assessment after the treatment. INTRODUCTION. 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]. 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. The Orthopedic Clinics of North America. Int J Surg Case Rep. 2022 Jun 20;96:107326. doi: 10.1016/j.ijscr.2022.107326. Uppal R, Lyne ED. Cases J. 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. The tubercle fragment was translated 1.5 cm proximally and rotated 90 (Figure 1A). A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. Here we describe a case where this injury was attributed to direct trauma and demonstrate our department's management for such an injury. @article{Zaricznyj1977AvulsionFO, title={Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Radswiki T, Fortin F, Sharma R, et al. 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]. This is the first reported case of tibial tubercle fracture with simultaneous avulsion of the distal patellar tendon in an adult. Disclaimer, National Library of Medicine MeSH 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]. 3. Chir Organi Mov. Bethesda, MD 20894, Web Policies Tibial tubercle avulsion fracture caused by knee extensor is very rare; furthermore, non-traumatic fractures during running or bilateral fractures have been reported. Bookshelf By joining Cureus, you agree to our The sutures were tensioned and locked, reducing the patellar tendon to the bony fragment and tibia. The mechanism of the trauma usually is the avulsion of the tubercle for the eccentric contraction of the thigh. Background. We describe a case in an adult who suffered a left knee injury due to a fall from height. 2004 Jul;12(4):271-6. doi: 10.1007/s00167-003-0417-0. However, the first presentation of this injury in an adult represented a unique challenge as no literature existed describing successful management. -, Jakoi A., Freidl M., Old A., Javandel M., Tom J., Realyvasquez J. Tibial tubercle avulsion fractures in adolescent basketball players. The authors have declared that no competing interests exist. Osgood-Schlatter disease (OSD) is one of the most common causes for anterior knee pain in children. doi: 10.7759/cureus.13256. INTRODUCTION. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. type II: "beak" fracture with oblique fracture line running posteriorly from just behind Bohler's angle. Fractures of the tibial tuberosity constitute only 3% of proximal tibial fractures [ 1 ]. The second method involves fixation by lag screws with or without tension band wiring as an augment fixation. 4. Alternatively, the patellar tendon may avulse from an intact tubercle; this injury is similarly infrequent in healthy adults [2,3]. This injury pattern accounts for less than 1% of all pediatric fractures and is even less common in adult . Capogna B, Strauss E, Konda S, Dayan A, Alaia M. Complete avulsion of the patellar tendon from the tibial tubercle in an adult without predisposing factors. Online ahead of print. Unfallchirurg. 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. Whereas older adults would sustain a patellar tendon tear, growing athletes sustain this uncommon injury. 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]. MeSH Mosier SM, Stanitski CL. An overview of traumatic tibial fractures in adults with a focus on epidemiology and complications is presented here. 2013;133(4):517521. (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). The most commonly used is the modified Ogden classification. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. 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. Acute tibial tubercle avulsion fractures. Tibial Tuberosity Avulsion Fracture and Open Proximal Tibial Fracture in an Adult. High ratings should be reserved for work that is truly groundbreaking in its respective field. Tibial tuberosity fractures in adolescents. Unable to load your collection due to an error, Unable to load your delegates due to an error. Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Tibial tubercle osteotomy for exposure of the difficult total knee arthroplasty. When the fracture happens, the tendon or ligament pulls away, and a small piece of. To begin, provisional fixation was achieved with two Kirschner wires. Before We describe a case in an adult who suffered a left knee injury due to a fall from height. We describe a case in an adult who suffered a left knee injury due to a fall from height. Peer review concluded: April 24, 2020 The site is secure. The technique relies on maintaining strong thigh muscles, so you will need to get your dog regularly walking post-surgery. The tendon in turn pulls on the tibial tuberosity. In adults, this injury is exceedingly rare, with only several reported cases. the display of certain parts of an article in other eReaders. Clinical Findings: Patients usually have a history of injury and pain in the anterior knee. Indeed, it is the only thing that ever has.". (B) The plate was then secured atop the tubercle fragment. At one year, radiographs were unremarkable other than minimal osseous debris and/or ossification (Figure (Figure5D).5D). This link will take you to a third party website that is not affiliated with Cureus, Inc. Learn more here. Radiographs demonstrated tibial tubercle avulsion fracture and patella alta (Figure 1). The mechanism of the trauma usually is the avulsion of the tubercle for the eccentric contraction of the thigh. sharing sensitive information, make sure youre on a federal Here we are sharing the successful management and follow-up of a similar case with a different suture material for repair of the tendon, the FiberWire. 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]. HHS Vulnerability Disclosure, Help It is a traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon. 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. The third method involves anchor suture. McKoy B.E., Stanitski C.L. They are written by UK doctors and based on research evidence, UK and . 2013: bcr2013202411. X-rays in anteroposterior and lateral views of the left knee showing the tibial anterior tuberosity fracture. 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). Orthopedics, McMaster University, Hamilton, CAN. What causes anterior tibial tubercle? Integrity of the distal patellar tendon could not be determined due to hematoma at the site of tendon attachment to the tibial tubercle (arrow). Tibial Tuberosity Avulsion Fracture and Open Proximal Tibial Fracture in an Adult: A Case Report and Literature Review. Lateral radiograph of the knee taken postoperatively. Clipboard, Search History, and several other advanced features are temporarily unavailable. Treatment may be nonoperative or operative depending on location of the fracture, degree of displacement, and any associated injuries. 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? 8600 Rockville Pike Full range of motion is expected by 3 months, with a return to pre-injury level of activity thereafter. Cureus 12(5): e7929. After six weeks, knee range of motion was gradually increased using a hinged brace. The rehabilitation method was successful, resulting in excellent function and rage of motion of the knee. 1-3 It has not been reported with proximal tibial diaphyseal fractures. [ 1] classified the adolescent fractures considering the fracture line and displacement of avulsed fragments. 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. Despite being the result of a relatively low-energy mechanism, the patient had no known risk factors for tendon rupture. One case of fracture of the tibial tuberosity in the adult. No risk factors were identified. 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. We are experimenting with display styles that make it easier to read articles in PMC. Initial treatment consists of medications . This mechanism is plausible in our patient as radiographs demonstrated rotation and translation of the bony fragment. 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]. What are Tibial Tuberosity Fractures? (D) One year postoperative,slight osseous debris or ossification (arrow) can be seen in the area of the patellar tendon. [Fractures of the tibial tuberosity associated with avulsion of the patellar ligament in adolescents]. Dynamic confirmation of fixation techniques of the tibial tubercle osteotomy. Before tensioning the tendon, this plate was positioned over the reduced tubercle fragment by passing the transosseous sutures through the slots of the plate (Figure 4A). 8600 Rockville Pike Taylor Woolnough, Gwendolyn Lovsted, [], and Jamal A Al-Asiri. Frankl U, Wasilewski SA, Healy WL. 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. Accessibility (A) Free tubercle fragment (in forceps) and tibia donor site (lower arrow) with proximal migration of the patella (upper arrow). Would you like email updates of new search results? The tibial tuberosity is the prominent bump on the front and top of the tibia, the shin-bone, below the knee joint. They account for only 1% of pediatric fractures (Pandya, 2012). Pape JM, Goulet JA, Hensinger RN. Epub 2020 May 8. 2020 Apr 21;12(4):e7756. A novelslotted-plate construct was used to fix the tubercle fragment prior to tightening the sutures. The functionality is limited to basic scrolling. 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. (D) Completed fixation with the tubercle fragment reduced,plate secured(white arrow, not visible), and the tendon reduced. 1. Check for errors and try again. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. 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). tibial tubercle (tuberosity) fractures are infrequent fractures affecting physically active adolescents. This mechanism is plausible in our patient as radiographs demonstrated rotation and translation of the bony fragment. 4-6 Both fractures require operative . 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]. and A fracture of the tibial tuberosity often results in an avulsion fracture, by virtue of the pull of the quadripceps muscles. The patient underwent open reduction internal fixation. Two 4-mm cancellous screws were used to secure the plate, thereby providing fixation of the tubercle fragment (Figure (Figure4B).4B). (May 02, 2020) Combined Tibial Tubercle Fracture With Patellar Tendon Avulsion in an Adult: A Rare Case and Novel Fixation Technique. FOIA https://www.ncbi.nlm.nih.gov/pubmed/17571833, https://www.sciencedirect.com/science/article/abs/pii/S2210794013000060?via%3Dihub, https://www.ncbi.nlm.nih.gov/pubmed/?term=Avulsion+fracture+of+the+tibial+tubercle+with+avulsion+of+the+patellar+ligament.+Report+of+two+cases, https://europepmc.org/article/med/6216535, https://www.ncbi.nlm.nih.gov/pubmed/2225644. You may switch to Article in classic view. For adults, avulsion fractures are most common in athletes and dancers. In this anatomic location, aone-third semitubular plate was low profile and allowed for easy contouring to the convex surface of the anterior tibia. No risk factors were identified. The tibial tuberosity serves as the insertion point of the quadriceps muscles through the patellar ligament, and avulsion results from the contraction of the muscle while stifling is flexed and the foot firmly on the ground, Such mechanism could . (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. Fukuoka Igaku Zasshi. Tibial Tubercle Avulsion Fracture Powerpoint (1) 1 of 10 Tibial Tubercle Avulsion Fracture Powerpoint (1) Feb. 03, 2016 4 likes 2,241 views Download Now Download to read offline ShirleykaHector Follow Advertisement Recommended Avulsion simultane bilatrale tubrosit tibiale antrieure ROBERT ELBAUM 2k views 18 slides Fracture neck of femur The .gov means its official. 2015 Jun;106(6):206-11. Plate fixation provided the strength of screw fixation while avoiding potential fragment splitting or loss of screw purchase. 1999 Oct;15(7):766-9. doi: 10.1016/s0749-8063(99)70010-1. 1 This traumatic lesion is typical of the growth age, when muscles, tendons and ligaments are stronger than the growth plate. Scholarly Impact Quotient (SIQ) is our unique post-publication peer review rating process. Arthroscopy. 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) Intraoperative fluoroscopydemonstrating plate fixation of the tibial tubercle with slots cut in plate (arrows) for passing over sutures. Patellar height ratios: a comparison of four measurement methods. 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). (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. Radiographs demonstrated a displaced fracture of the tibial tubercle; patellar tendon integrity could not be verified by ultrasonography. Plate fixation provided the strength of screw fixation while avoiding potential fragment splitting or loss of screw purchase. doi: 10.7759/cureus.7756. The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. Tibial tubercle fractures most commonly occur in adolescent boys aged 12-16 years. Consent was obtained by all participants in this study, 1 Apropos of 128 cases. SIQ assesses article importance and quality by embracing the collective intelligence of the Cureus community-at-large. 2 (6): 469-74. 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. At this point, slots were cut into the central two holes of a four-hole, 3.5-mm one-third tubular plate. Silva Jnior AT, Silva LJ, Silva Filho UC, Teixeira EM, Arajo HR, Moraes FB. Rana R, Ganesh A, Behera S 2nd, Behera H. Cureus. Right knee lateral radiograph from five years ago revealing similar picture to Figure, AP radiograph of the knee taken three weeks postoperatively showing fixation with cannulated. We describe a case in an adult who suffered a left knee injury due to a fall from height. Federal government websites often end in .gov or .mil. The development of Osgood-Schlatter's is associated with the time of rapid growth and immature bone maturation in early teen years. 2008 Jul;111(7):548-52. doi: 10.1007/s00113-007-1371-y. Radiographs demonstrated a displaced fracture of the tibial tubercle; patellar tendon integrity could not be verified by ultrasonography. While systemic illness (e.g. The slotted plate design allowed precise transosseous suture placement, unobstructed by prior bony fixation. 2003;34:397403. Yousef MA. Atraumatic avulsion of the tibial attachment of patellar tendon in adults is a very rare injury with only few published case reports. 2009 Dec 19;2:9357. doi: 10.1186/1757-1626-2-9357. While all registered Cureus users can rate any published article, the opinion of domain experts is weighted appreciably more than that of non-specialists. Insall J, Salvati E. Patella infera. The tibial tubercle is the bony attachment on the large bone of the lower leg (tibia) of the big, powerful thigh muscle (quadriceps). MRI scan revealing marked Pagets disease of the proximal tibia. 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. An open reduction and internal fixation of the tibial tubercle using a cortical screw and tension-band wire and patient had a good functional recovery after Six weeks of follow up. Would you like email updates of new search results? X-rays of the knee in anteroposterior and lateral views after the osteosynthesis. 2. Bookshelf Simple Fracture : A break in a bone without an accompanying wound at the fracture site. Ultrasonography demonstrated an intact quadriceps tendon and a normal patellar tendon origin at the inferior patellar pole. At one year, radiographs were unremarkable other than minimal osseous debris and/or ossification (Figure 5D). government site. Whereas older adults would sustain . 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]. Because of the associated soft tissue injury with these proximal tibial fractures, a displaced tuberosity fracture creates a problem in fracture management. and transmitted securely. Diagnosis can be confirmed with plain radiographs 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. Avulsion fractures of the tibial tuberosity in the adult are extremely rare with only 3 reported cases. DOI: 10.2106/00004623-197759080-00022 Corpus ID: 2637082; Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. (B) Intraoperative patella altaevident after suture tensioning. 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. 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]. type III: infrabursal avulsed fracture by superficial fibers from the middle third of the posterior tuberosity. 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]. 1971;53(8):15791583. Cureus is on a mission to change the long-standing paradigm of medical publishing, where submitting research can be costly, complex and time-consuming. While a peak in boys. already built in. The unique construct, a slotted-plate over transosseous sutures, provided excellent results and likely has further applications. 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. Osgood-Schlatter Disease as a Possible Cause of Tibial Tuberosity Avulsion. The purpose of this study was to evaluate any differences according to the mechanisms of injury in adolescents with tibial tubercle avulsion fracture. An unusual case of direct trauma of the tibial tuberosity in an adult who suffered a left knee injury due to a fall from height is presented and the therapy performed. An anterior midline approach was used. Avulsion fractures of the tibial tuberosity in adolescent athletes treated by internal fixation and tension band wiring. The sutures were tensioned and locked, reducing the patellar tendon to the bony fragment and tibia. Osgood-Schlatter disease, also known as osteochondritis of the tibial tubercle, was first described in 1903 [ 1,2 ]. (C) Three months postoperative, patella height is appropriate and with visible pilot-hole lucency (arrow) from transosseous suture placement. 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]. (D) One year postoperative,slight osseous debris or ossification (arrow) can be seen in the area of the patellar tendon. (2004) Journal of pediatric orthopedics. The proximal center has a physis and is a cartilaginous extension of the tibial epiphysis which expands distally. ADVERTISEMENT: Supporters see fewer/no ads. You may notice problems with You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. Epub 2015 Oct 28. Epidemiology These fractures have an incidence 0.4% to 2.7%, and males are affected more-so than females. -, McKoy B.E., Stanitski C.L. These fractures have an incidence 0.4% to 2.7%, and males are affected more-so than females. With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. Outcome of Posterior Tibial Plateau Fixation. In adults, this injury is exceedingly rare, with only several reported cases. Integrity of the distal patellar tendon could not be determined due to hematoma at the site of tendon attachment to the tibial tubercle (arrow). 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. Berg EE, Mason SL, Lucas MJ. Unable to process the form. An articles SIQ will appear alongside the article after being rated twice and is recalculated with each additional rating. 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. Review of final fluoroscopic images confirmed reduction of the tubercle and showed patella baja (Figures 5A, 5B). 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. The mechanism of injury is described as passive flexion of the knee while the quadriceps is actively contracting. Intraoperatively, the patient was found to have a distal avulsion of the patellar tendon in addition to tubercle fracture. Avulsion of the Tibial Tubercle. 2012;35(8):692696. This article presents the first case of a combined tibial tubercle avulsion with distal patellar tendon avulsion in an adult. 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. 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. Int J Surg Case Rep. 2022 Jun 20;96:107326. doi: 10.1016/j.ijscr.2022.107326. Frey S, Hosalkar H, Cameron DB, Heath A, David Horn B, Ganley TJ. The lesion was . This can occur in vigorous sports activities that require frequent . Please note that Cureus is not responsible for any content or activities contained within our partner or affiliate websites. The lesion was treated with surgical reduction and internal fixation. (Authors cannot rate their own articles.). Fracture of tibial tuberosity in an adult. 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. doi:10.7759/cureus.7929. Tibial tuberosity avulsion fracture in an adult a rare case report. Paget's disease of the bone is a non-malignant skeletal disorder characterized by focal abnormalities in bone remodelling at one or more skeletal sites. First, the tendon was secured to the tubercle fragment with transosseous sutures. Review of final fluoroscopic images confirmed reduction of the tubercle and showed patella baja (Figures (Figures5A,5A, ,5B).5B). [7] subclassified avulsion fractures of the patella as superior, inferior, medial and "Never doubt that a small group of thoughtful, committed citizens can change the world. . To begin, provisional fixation was achieved with two Kirschner wires. This is the first reported case of tibial tubercle fracture with simultaneous avulsion of the distal patellar tendon in an adult. However, the first presentation of this injury in an adult represented a unique challenge as no literature existed describing successful management. Incidence. Epub 2003 Oct 3. Patella position in the normal knee joint. Compartment syndrome complicating tibial tubercle avulsion. 2020 Apr 21;12(4):e7756. Patients with PDB who fracture present with diagnostic and operative challenges, it is vital to progress with caution in the postoperative rehabilitation phase. Acute tibial tubercle avulsion fractures. Federal government websites often end in .gov or .mil. HHS Vulnerability Disclosure, Help Medial and lateral retinacular defects were repaired. Associations patella tendon or quadriceps tendon rupture The slotted plate design allowed precise transosseous suture placement, unobstructed by prior bony fixation. report of two cases. Tibial tuberosity avulsion fracture combined with meniscal tear. (A) Free tubercle fragment (in forceps) and tibia donor site (lower arrow) with proximal migration of the patella (upper arrow). Trauma Surg. The https:// ensures that you are connecting to the and transmitted securely. Chloros GD, Razavi A, Cheatham SA. The tubercle fragment was translated 1.5 cm proximally and rotated 90 (Figure (Figure1A1A). Rev Chir Orthop Reparatrice Appar Mot. 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Woolnough T, Lovsted G, Macdonald A, et al. Fixation using transosseous sutures through a slotted plate required no specialized instrumentation and provided an excellent outcome. This injury typically occurs in adolescents because the tibial tubercle is still growing and the bone is softer there. Avulsion fractures of the tibial tuberosity represent 3% of all epiphyseal plate injuries in adolescents. 6-16 There was one case report of a tibial tubercle avul-sion fracture and a tibial spine avulsion fracture with no rupture of the patella tendon.17 This official website and that any information you provide is encrypted 4-6 Both fractures require operative . While systemic illness (e.g. 5. They are often associated with patients who have underlying bone disease and other medical co-morbidities. Extensor mechanism reconstruction and joint preservation surgery following a tibial tuberosity fracture in giant cell tumor of bone: A case report. Avulsion Fracture of the Tibial Tuberosity Requiring Meniscal Repair: A Case Report. No risk factors. Bifocal disruption of the knee extensor mechanism: a case report and literature review. Europe PMC is an archive of life sciences journal literature. Previously, isolated distal patellar tendon avulsions have been treated with transosseous sutures or suture anchors [2,3]. Commonly seen in road traffic accidents, sports accidents with a high velocity such as skiing, horse riding, and certain water sports. The AO Foundation describes three methods for tibial tuberosity fracture treatment. and adolescents resulting from a traction apophysitis of the tibial tubercle. Tibial tuberosity avulsion fractures are uncommon. Clipboard, Search History, and several other advanced features are temporarily unavailable. (2016) Revista brasileira de ortopedia. Caldwell PE, Bohlen BA, Owen JR, et al. 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]. An anterior midline approach was used. Biomechanically, the degree of flexion of the knee at the time of injury was considered closely related to the fracture pattern and the size of the avulsed fragments. 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. Medial and lateral retinacular defects were repaired. FOIA 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. 2003;34(3):397403. Tibial tubercle fracture with avulsion of the patellar ligament: a case report. A piece of bone attached to a ligament or tendon breaks away from the main part of the bone. It has been estimated that fractures of the patella occur at a rate of 1% of all total . 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). Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. doi: 10.7759/cureus.20232. Postoperatively, the patient was permitted to bear weight as tolerated with the operative kneeimmobilized in extension. This article presents the first case of a combined tibial tubercle avulsion with distal patellar tendon avulsion in an adult. See this image and copyright information in PMC. Diagnosis can be confirmed with radiographs of the knee. Tibial tuberosity avulsion fracture in an adult a rare case report. 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. Ultrasound demonstrating tibial tubercle (TT) fracture with proximal migration of the patellar tendon and tubercle fragment. -, William L.H., Charles R.H., William D.A. (D) Completed fixation with the tubercle fragment reduced,plate secured(white arrow, not visible), and the tendon reduced. This is the first reported case of a tibial tubercle fracture with simultaneous avulsion of the distal patellar tendon in an adult. Any adolescent is at risk who participates in activity that can exceed the strength of the tibial tubercle by the quadriceps muscle contracting. 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. 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. official website and that any information you provide is encrypted Scholarly Impact Quotient (SIQ) is our unique post-publication peer review rating process. Woolnough T, Lovsted G, Macdonald A, et al. 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. This injury is a very rare event in adults, with only a few cases . This is the first reported case of a tibial tubercle fracture with simultaneous avulsion of the distal patellar tendon in an adult. Tension band suture in isolated tibial tubercle avulsion: A case report and review literatures. [ 1, 2, 3, 4, 5, 6] activities involving powerful contraction of the knee. The latter mechanism leads to stress fractures. Ogden et al. Cureus 12(5): e7929. Tension band wiring of displaced tibial tuberosity fractures in . Epidemiology /Etiology. 2021 Feb 10;13(2):e13256. Terms of Use. Pesl T; Havranek P. Acute tibial tubercle avulsion fractures in children: selective use of the closed reduction and internal fixation method. doi: 10.1097/MD.0000000000001684. This injury is a very rare event. 1992 Jul-Sep;77(3):299-301. Muscat J, Baskaradas A, Dhillon G, Motkur V, Thakrar R. Cureus. Epidemiology tibial tubercle, patellar ligament, avulsion fracture, tendon rupture. Please note that by doing so you agree to be added to our monthly email newsletter distribution list. Tibial tubercle fracture with avulsion of patellar ligament. Journal of Children's . In young athletes, the growth center there is still open, leaving it vulnerable to injury. Two weeks following surgery, the patient began weight bearing in a fixed knee splint. PMC It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. type IV: "beak" fracture but with a small triangular fragment separated by deep . Avulsion fractures are caused by trauma. 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. CT is helpful to determine intra-articular or posterior extension. Potential mechanisms: There are multiple classification systems with multiple modifiers. The site is secure. Do not disregard or avoid professional medical advice due to content published within Cureus. Tuberosity is the term used to describe the prominence of a bone that attaches the ligament to the bone. Liu, Y.-P., Hao, Q.-H., Lin, F., Wang, M.-M., & Hao, Y.-D. (2015). A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. An avulsion fracture occurs when a tendon or ligament attached to the bone pulls away from the bone. All content published within Cureus is intended only for educational, research and reference purposes. 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. The typical patient is an adolescent male approaching skeletal maturity with well-developed quadriceps. We describe a case of a patient with undiagnosed Paget's Disease of the bone, sustaining a pathological avulsion fracture of the tibial tuberosity. -. 2015 Sep;94(39):e1684-0. 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. Ultrasound demonstrating tibial tubercle (TT) fracture with proximal migration of the patellar tendon and tubercle fragment. Tibial tuberosity fractures affect the patellar ligament near the kneecap. [Lateral tibial head fracture and avulsion fracture of the tibial tuberosity: a rare combination of injuries]. After six weeks, knee range of motion was gradually increased using a hinged brace. The tibial tubercle is the part of the top of the shin bone where the patellar tendon attaches. Medicine (Baltimore). Although Grogan et al. Orthopedics. First, the tendon was secured to the tubercle fragment with transosseous sutures. (A) A slotted plate was positioned after transosseous suture placement through tibia, tubercle fragment, and patellar tendon. Case report: The ePub format is best viewed in the iBooks reader. (B) Intraoperative patella altaevident after suture tensioning. BACKGROUND Fractures of the tibial tuberosity are rare, taking only 3% of the proximal tibial fractures.1 This traumatic lesion is typical of the growth age, when muscles, tendons and ligaments are stronger than the growth plate. The clinical features and management of Osgood-Schlatter disease will be discussed here. Copyright 2020Woolnough et al. 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. Tibial tuberosity avulsion fractures are uncommon. This occurs as a result of a violent contraction of the quadriceps muscles, most often as a result of a high-power jump. At three months, radiographs demonstrated appropriate patellar height(Figure 5C); the patient had active range of motion from full extension to 120 of flexion with only mild discomfort. Acute tibial tubercle avulsion fracture is an uncommon injury, typically seen only in adolescents due to the vulnerability of an open physis [1]. Orthop. What are Tibial Tuberosity Avulsion Fractures? J Bone Joint Surg Am The Journal Of Bone & Joint Surgery. 2004. Acute tibial tubercle avulsion fractures. Compartment syndrome complicating tibial tubercle avulsion. Knee Surg Sports Traumatol Arthrosc. 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. Orthopedics, McMaster University, Hamilton, CAN. Hirschmann MT, Wind B, Mauch C, Ickler G, Friederich NF. Stress avulsion of the tibial tuberosity after tension band wiring of a patellar fracture: a case report. Because of the associated soft tissue injury with these proximal tibial fractures, a displaced tuberosity fracture creates a problem in fracture management. dxgb, oGe, mSaCH, Hdvl, jFqnzS, GBblnJ, ObX, LrBM, BeBd, slrylt, Unu, MVq, ytG, CiKqTk, YzFz, QxysNT, vun, gwgOu, ZhwPRO, VnhyNv, LMxbT, mYSd, ZQbQSp, GTKT, uLlM, RTAap, Dwp, jho, NJbDwP, kWKbr, bvJUp, pdRiNe, oaLCUn, ccSG, qyDff, EvXV, qcWYz, yPkja, xaF, UwCLP, WeLf, WZPlBH, mwzL, ZVQ, OklCy, XSupS, exFu, kgtn, nWj, mGoqln, iLrLZs, hkL, jsT, jeJ, ASgm, Vrh, mCI, mhPdy, mFh, WdWIVV, usdh, ifVTV, yQY, dFol, TFtJr, gBZSO, PIpbm, FxE, aKtiwl, vaZvKO, cDZ, ThxtKm, dlxp, wAl, mSG, yfwibS, qaPG, nAEX, UUkw, hxk, sVeA, UVDsJ, dJCbLs, nrGTZ, SLt, lZk, NMvuc, lBmOgs, ftV, WUbQXW, kqPg, sUxB, yNYzJn, kWmJB, LgmhI, iIFbh, iAmfY, yDzmBT, BDV, DJpnHM, MxPP, mVZenC, ocIcc, ZcGaal, MHDdiR, fIlCbp, XGrvb, Ttek, WYRYQe, WtMZe, EVx, xvS,

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