Intercondylar Eminence Fractures Treatment & Management

Most authors recommend aspiration of the hemarthrosis and casting for nondisplaced type I intercondylar eminence fractures. This is also the initial management used for displaced fractures. The position of immobilization is still controversial. It was thought initially that the immobilization should be in full extension so that the fracture fragment is reduced by condylar contact. However, because full extension is the tightest position for the ACL, this method may result in increased tension and displacement at the fracture site.

Although most authors agree that displaced intercondylar eminence fractures need repair, the choice of fixation is still debated. Meyers and McKeever used sutures to tack the fragment onto the anterior horn of the medial meniscus. Zaricznyj reported the use of multiple K-wires. Others have reported good results with cannulated screw fixation, which is usually the fixation chosen for adults. In skeletally immature patients, screw fixation is secure but may require hardware removal.

Whether via open, mini-open, or arthroscopic approach, suture fixation does provide secure fixation but may limit the speed of rehabilitation.^{[6, 7, 8, 9, 10, 11, 12, 13]} See arthroscopic images below.

The details of intercondylar eminence fracture reduction depend mainly on the approach used. However, the basic steps are the same. The fracture bed is cleared of any hematoma and debris. Because the attachments of the medial and lateral menisci also may inhibit reduction, these are retracted out of the way as the avulsed tibial eminence is reduced to its bed. The avulsed tibial eminence can be held by sutures to the medial meniscus or through a drill hole or held by K-wires or a cannulated screw (depending on the degree of comminution).

The traditional approach to postoperative care for intercondylar eminence fractures has been long leg casting in extension (or slight flexion) for 4 weeks, followed by a rehabilitation program. Recent studies have reported use of early ACL rehabilitation protocols, with excellent results achieved.

Patients with intercondylar eminence fractures should be monitored at least until bony union is seen radiographically. At that point, hardware may need to be removed. Continued follow-up is warranted as patients resume their preinjury levels of activity, because ACL laxity can become symptomatic.

The most devastating complication of open or arthroscopic fixation of a displaced intercondylar eminence fracture is infection. Sterile technique and implants, intraoperative antibiotics, and proper wound closure should keep this complication to a minimum.

Another concern with acute surgery is fluid extravasation, leading to the potential for lower-extremity compartment syndrome. The use of the arthroscopy fluid pump should be avoided in this situation.

The most frequently reported complication is ACL laxity. The cause of this laxity could be fixation in a nonanatomic position (thereby functionally lengthening the ACL) or microtearing of the ACL prior to eminence fracture. Although many studies report an increase in KT1000 knee ligament arthrometer measurements, patients do not report associated symptoms of instability.

Another complication is diminished range of motion, caused by immobilization. Most authors report an extensor lag, which can be minimized by secure fixation and an early, aggressive rehabilitation program.

Most studies report good results from the use of open or arthroscopic reduction and fixation of displaced intercondylar eminence fractures, or, in the case of minimal displacement, from the employment of closed treatment.^[14] Although some studies have demonstrated an increased, treatment-related ACL laxity by objective measures, these results do not correlate with patients' symptoms.

The future of surgical management of displaced intercondylar eminence fractures is the arthroscopic approach. As arthroscopic skills advance, the need for an arthrotomy to fix these types of fractures will decrease.

Another future direction is the use of bioabsorbable implants for fixation of such injuries, which would provide rigid fixation but eliminate the need for hardware removal.