case report A Case Report of Avulsion Fractures of the Bilateral Tibial Tuberosity in an Adolescent
Goh Teik Chiang*, AR Abdul Halim
Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Cheras, Malaysia
*Corresponding author: Goh Teik Chiang, Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Cheras, Malaysia. Email: teikchianggoh@hotmail.com
Received
Date: 25 November, 2018; Accepted Date: 13 December 2018, 2018; Published Date: 19 December, 2018
Citation: Chiang GT, Halim ARA (2018) A Case Report of Avulsion
Fractures of the Bilateral Tibial Tuberosity in an Adolescent. J
Orthop Muscular Syst Res: JOMSR-106. DOI: 10.29011/JOMSR-106.100006
Abstract
Bilateral tibial tuberosity avulsion
fractures are rare and occur mainly in adolescent males during vigorous
quadriceps contraction. So far, only ten simultaneous bilateral fractures have
been reported. We report the case of a 14-year-old male who avulsed both tibial
tuberosities when he landed on his knee after a fall while playing football.
Diagnostic imaging demonstrated Ogden Type IIA fractures. He underwent
bilateral open reduction and screw fixation the next day. While closed reduction
and percutaneous fixation has been proposed by some, the intraoperative findings
in our patient would have prevented correct adaptation of the fragments because
of a flap of periosteum impinged in both fracture gaps.
Keywords: Cannulated
Cancellous Screw; Open Reduction; Tibial Tuberosity Avulsion Fracture
Introduction
Tibial Tuberosity Avulsion Fractures (TTAF)
typically occur in adolescent males by avulsion of the bony insertion of the
patellar tendon, caused by sudden violent contraction of the quadriceps muscles
[1]. There seems to be an association with pre-existing Osgood-Schlatter
disease [2]. Tibial tuberosity fracture account for 0,4%-2.7% of all physeal
injuries [3]. Simultaneous bilateral TTAF is extremely rare, with only 10 such
cases reported in the literature so far [4]. The prognosis is usually excellent
if proper treatment is given. In 1980, Ogden proposed the classification of
these fractures that is commonly used today [2]. Accordingly, type I is a
fracture of the distal tibial tubercle without involvement of the growth plate.
Type II fractures extend along the growth plate proximally, whereas type III
fractures include the proximal tibial ossification centre extending into the
knee joint. There are three subgroups of A or B, with a possible of
intraarticular involvement as well as comminution of fragments [2]. We report
the case of a 14-year-old male patient with bilateral closed fracture of type
IIA TTAF who required open reduction and fixation.
Case Report
A 14-year-old boy presented to our emergency department with bilateral severe knee pain with swelling after fall during a football match in school. He weighed 90 kg with an athletic body habitus. A loss of knee extension capacity was noticed during the initial physical examination. Anteroposterior (AP) and lateral radiographs of both knees revealed an avulsion fracture in the anterior aspect of the tibial plateau without involvement of the articular surface, the distal tip of the fragments being hinged upward, respectively (Figure 1).
Preoperatively, we decided to perform primary open reduction and internal fixation if an initial attempt of closed reduction was unsuccessful. In effect, the severely dislocated fragment on the right side could not be reduced in anatomic position under image intensifier guidance, therefore the skin was incised using an anterolateral parapatellar incision. Intraoperatively on right side, a large flap of periosteum was found interposed into the fracture gap (Figure 2). The periosteal flaps were elevated, the fragments were easily reduced and osteosynthesis was performed using two cannulated cancellous screws 4.0mm on right side and only single cannulated cancellous screw 4.0mm on left side due to small fragment (Figure 3). The patient tolerated well post operation and was immobilized in a cylinder cast for 6 weeks. He was progressively mobilized with non-weight bearing crutches for 8 weeks and allowed weight bearing as tolerable. He was asymptomatic and without postoperative complication at his recent check-up at 6 months after surgery in our clinic.
Discussion
The avulsion fracture of the tibial
tuberosity is an uncommon injury of the knee, which predominantly occurs in
adolescence, mainly in boys. The age range corresponds to the time of growth
plate closure and maturation of the fibrocartilagionous attachment of the
tuberosity. The injury usually happens during sports activities, especially
during contact sports such as football and basketball [1,4]. The mechanism of
this avulsion fracture is described as passive flexion of the knee against
contracted quadriceps muscles or violent active extension [1]. When the tensile
forces of the quadriceps complex against the patellar tendon insertion overcome
the cohesive forces within the apophyseal cartilage an avulsion fracture of the
tibial tubercle may occur [5]. The tibial tubercle physis progressively fuses
from posterior to anterior, making it vulnerable to injury during the
transitional phase of closure. Fusion of this physis is completed at the age of
13-15 years in females, and 15-19 years in males [3]. Complications of TTAF
include compartment syndrome, most likely as a result of bleeding from the
anterior tibial recurrent artery, as well as knee stiffness, patella alta, and
genu recurvatum with leg length discrepancy but adverse results are infrequent.
In particular, growth disturbance is rare, as these fractures usually occur near
the end of physeal closure.
The treatment is based on the amount of
displacement and associated injuries [6]. Non-displaced fractures can be
treated non-operatively with cast immobilization. For Ogden type IA and IIA
fractures, an attempt at closed reduction can be made. In type IB, IIB, and III
fractures, open reduction and internal fixation are generally, but not
universally recommended [7]. In non-comminuted, slightly displaced type II and
III fractures, the surgeon may be tempted to perform closed reduction with
percutaneous screw fixation, as recently proposed by Ozkayin and Aktuglu.
However, as demonstrated in our patient, the interposition of a large
periosteal flap may compromise optimal anatomic reduction. This complication was
first described by Hand in 1971 [8]. Since then, others have noted similar
findings [3]. Complications may include bursitis over prominent screw heads,
prompting premature screw removal.
Conclusion
In this case, we emphasize the point that
with most of these fractures, primary open reduction should be performed if an
initial attempt at closed reduction does not lead to correct adaptation of the
fragments. Most authors suggest osteosynthesis by placement of cancellous
screws. As demonstrated in our patient, this is also our preferred method. This
method lessens the time needed for plaster immobilization of the knee, allows
for an earlier return to sports activities, and has consistently resulted in an
excellent prognosis.
Consent
As per international standard or university
standard, patient’s written consent has been collected and preserved by the
authors.
Ethical Approval
It is not applicable.
Competing Interests
Authors have declared that no competing
interests exist.
Figure 1: Radiographs of bilateral knee at presentation in AP and
lateral view.
Figure 2: Arrows showed
periosteal flap were elevated and fragments were easily reduced and two
cannulated screws inserted over the right tibial tuberosity.
Figure 3: Postoperative radiographs after open reduction and
fixation with two cannulated screws on the right and single cannulated screw
left.