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.


1.       Nanninga AJ, Josaputra HA (1987) Tibial tuberosity fracture in adolescents - report of a case and review of the literature. Neth J Surg 39: 144-146.

2.       Ogden JA, Tross RB, Murphy MJ (1980) Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg (Am) 62: 205-215.

3.       Nikifordis PA, Babis GC, Triantafillopoulos IK, Themistocleous GS, NikolopoulosK (2014) Avulsion fracture of the tibial tuberosity in adolescent athletes treated by internal fixation and tension band wiring. Knee Surg Sports Traumatol Arthrosc 12: 217-276.

4.       Ergun M, Taskiran E, Ozgurbuz C (2003) Simultaneous bilateral tibial tubercle avulsion fracture in a basketball player. Knee Surg Sports Traumatol Arthrosc 11: 163-166.

5.       Stevens MA, El-Khoury GY, Kathol MH, Brandser EA, Chow S (1999) Imaging features of avulsion injuries. Radiographics 19: 655-672.

6.       Steven Frey, Harish Hosalkar, Cameron DB, Heath A, Horn BD, et al. (2008) Tibial tuberosity fractures in adolescents. J Child Orthop 2: 469-474.

7.       Bolesta MJ, Fitch RD (1986) Tibial tubercle avulsions. J Pediatr Orthop 6: 186-192.

8.       Hand WL, Hand CR, Dunn AW (1971) Avulsion fractures of the tibial tubercle. J Bone Joint Surg (Am) 53: 1579-1583.


© by the Authors & Gavin Publishers. This is an Open Access Journal Article Published Under Attribution-Share Alike CC BY-SA: Creative Commons Attribution-Share Alike 4.0 International License. With this license, readers can share, distribute, download, even commercially, as long as the original source is properly cited. Read More.

Journal of Orthopedics & Muscular System Research