Tibial Tubercle Avulsion Treatment & Management

For all fracture types, ice therapy, splint immobilization, and elevation should be initiated to avoid significant swelling.^{[9, 10, 11, 12]}

Types IB, II, and III tibial tubercle fractures require open reduction and internal fixation. An anterior approach to the knee is used over the proximal tibia. Fixation is best accomplished with 1 or 2 screws through the tibial tubercle into the proximal tibia. C-arm control is recommended to avoid overpenetration of the posterior tibial cortex.

Growth arrest is uncommon, as this fracture usually occurs at the end of physeal closure. Should significant growth remain, smooth K-wires may be used temporarily to allow continued growth and avoid the possibility of recurvatum (hyperextension). In younger patients, the periosteum and retinaculum may be sutured. The screws should be placed at a right angle to the avulsed fragment, proximally and posterior, not inclined distally, to avoid a tendency to pull out.

In type III fractures, comminution and meniscal disruption may be present. An anterior medial arthrotomy is recommended for visualization and exploration. Anatomic reduction should be the goal. Temporary fixation with K-wires may be applied and radiographically evaluated prior to definitive fixation. Repair meniscal tears, and reestablish tibial plateau articular continuity. See the image below.

An advanced approach to evaluation and treatment is arthroscopic-assisted reduction and internal fixation. The tibial plateau can be visualized, fragments repositioned, and meniscal pathology addressed. Cross training in both arthroscopic techniques and fracture treatment are necessary.

Should a compartment syndrome be identified, preparation is made for release of all the affected compartments. Because of the large vascular bone surface involved, this may be found in type 3 patterns.

A study of 12 children with acute tibial tubercle avulsion was undertaken by Pesl and Havranek to determine optimal treatment for various types of the injury. They found that in patients with displaced extra-articular injury (types 1B and 2A), open reduction and internal fixation was required. Closed reduction and internal fixation was found to be sufficient in intra-articular fractures (types 3A and 3B), except for one case.^[3]

Abalo et al found that closed reduction and cast immobilization were acceptable therapy for minimally displaced tibial tubercle fractures and that open reduction and internal fixation was favored for displaced fractures.^[4]

Zrig et al treated nondisplaced tibial tubercle fractures conservatively, with immobilization for 6 weeks, and displaced fractures with internal fixation with plaster for 6 weeks and noted satisfactory results in all cases, consisting of functional recovery, resumption of sports activities to previous levels, and an absence of recurvatum.^[5]

Surgical preparation should include a preoperative planning for the following:

• Anterior surgical approach
• Removal of interposed soft tissue (periosteum)
• Evaluation for intra-articular extension, comminution, or meniscal tear, usually type III injuries
• Reduction of fragment with bone reduction forceps
• Evaluation of reduction under fluoroscopic control
• Placement of 1-2 interfragmentary compression screws; possible washers, cannulated or noncannulated
• Evaluation of fixation with fluoroscopy
• Repair of periosteum
• Evaluation of fixation stability
• Wound closure
• Placement of range of motion brace

In all open reductions, check for interposed periosteum, remove from the fracture site, and maintain the periosteal attachment for later repair. In type III fractures, a medial peripatellar arthrotomy may be necessary to evaluate the articular surface for comminution, as well as for possible meniscal tear.

If the fixation is believed to be stable, range-of-motion therapy is initiated. Consultation with a physical therapist (PT) is requested for crutch-assisted touchdown weight bearing (TDWB) ambulation. Heel slides under PT assistance or continuous passive motion (CPM) is initiated. CPM is started from 0-45° at 2 cycles per minute. CPM is increased incrementally over a 1- to 2-week period or as the patient tolerates. TDWB is continued for a minimum of 5-6 weeks, at which time progressive full weight bearing may be resumed. Lower-extremity strengthening and hamstring stretching exercises also are started at this time.

The patient is discharged from the hospital when pain is manageable on an outpatient basis. Follow-up evaluations are performed at 10-14 days, 4 weeks, 2 months, 3 months, and 6 months, with AP and lateral radiographs obtained until the fracture has healed. Additional visits may be required, depending on patient progress. The brace is removed after 5-6 weeks. Physical therapy is continued as an outpatient as outlined above.

Complications of treatment of tibial tubercle avulsion fracture include genu recurvatum (hyperextension) due to premature physeal closure of the anterior physis. However, this complication is rare, as the fracture usually occurs in the transitional physis, near the end of closure and growth.

Residual knee stiffness may occur secondary to prolonged immobilization and arthrofibrosis.

Patella alta may occur if the reduction is not anatomic or if fixation is not stable enough, leading to proximal migration of the tubercle fragment.^{[13, 14]}

An episode of a type III injury in an athlete that led to compartment syndrome is described: The patient was playing basketball and sustained an acute type III injury. The patient was seen in an emergency department, placed on crutches, and told to follow-up at his home of record. No immobilization was given. The patient was placed on a commercial airplane with his leg maintained in a dependent position. Upon arrival, the patient exhibited a full-blown compartment syndrome, necessitating a 4-compartment fasciotomy. Arthroscopy and internal fixation of the fracture was performed.

With appropriate surgical treatment and postoperative therapy, a complete recovery without residual symptoms is expected. A return to sports may be expected once the lower extremity strength is 90% that of the unaffected extremity, usually 4-6 months after injury.