Tibial Tubercle Avulsion Workup

  • Author: Janos P Ertl, MD; Chief Editor: Carlos J Lavernia, MD, FAAOS   more...
 
Updated: Feb 10, 2012
 

Imaging Studies

  • Standard radiographs, including anteroposterior (AP), lateral, oblique, and 15 º cephalad views of the knee, are recommended.
  • Tibial tubercle avulsion injuries usually are isolated, and any additional injuries require further evaluation as indicated for that injury.
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Staging

Classifications have been described by Watson-Jones based on size and amount of displacement,[6] as follows:

  • Type I is a small fragment that is proximally displaced.
  • In type II injuries, the secondary center of ossification has coalesced with the proximal tibial epiphysis, with the fracture occurring at this junction. The articular surface remains intact.
  • In type III injuries, the fracture extends through the articular surface. Comminution and meniscal disruption may be present.

Ogden further subdivided the above Watson-Jones classification into A and B categories to account for the degree of displacement (A) and comminution (B).[7, 8]

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Contributor Information and Disclosures
Author

Janos P Ertl, MD  Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert D Bronstein, MD  Associate Professor, Department of Orthopedics, Division of Athletic Medicine, University of Rochester School of Medicine

Robert D Bronstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Thomas M DeBerardino, MD  Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine

Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS  Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital

Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society

Disclosure: Zimmer Stock Implant Designer

References

  1. Huang YC, Chao YH, Lien FC. Sequential avulsions of the tibial tubercle in an adolescent basketball player. J Pediatr Orthop B. May 2010;19(3):231-3. [Medline].

  2. Cohen DA, Hinton RY. Bilateral tibial tubercle avulsion fractures associated with Osgood-Schlatter's disease. Am J Orthop. Feb 2008;37(2):92-3. [Medline].

  3. Pesl T, Havranek P. Acute tibial tubercle avulsion fractures in children: selective use of the closed reduction and internal fixation method. J Child Orthop. Oct 2008;2(5):353-6. [Medline].

  4. Abalo A, Akakpo-numado KG, Dossim A, Walla A, Gnassingbe K, Tekou AH. Avulsion fractures of the tibial tubercle. J Orthop Surg (Hong Kong). Dec 2008;16(3):308-11. [Medline].

  5. Zrig M, Annabi H, Ammari T, Trabelsi M, Mbarek M, Ben Hassine H. Acute tibial tubercle avulsion fractures in the sporting adolescent. Arch Orthop Trauma Surg. Dec 2008;128(12):1437-42. [Medline].

  6. Watson-Jones R. The classic: "Fractures and Joint Injuries" by Sir Reginald Watson-Jones, taken from "Fractures and Joint Injuries," by R. Watson-Jones, Vol. II, 4th ed., Baltimore, Williams and Wilkins Company, 1955. Clin Orthop Relat Res. Nov-Dec 1974;4-10. [Medline].

  7. Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am. Mar 1980;62(2):205-15. [Medline].

  8. Elbaum R. Simultaneous bilateral tibial tubercle avulsion fracture in an adolescent: a case report. Acta Orthop Belg. Oct 2011;77(5):696-701. [Medline].

  9. Bolesta MJ, Fitch RD. Tibial tubercle avulsions. J Pediatr Orthop. Mar-Apr 1986;6(2):186-92. [Medline].

  10. Christie MJ, Dvonch VM. Tibial tuberosity avulsion fracture in adolescents. J Pediatr Orthop. 1981;1(4):391-4. [Medline].

  11. Roberts JM. Avulsion fracture of the proximal tibial epiphysis. In: Kennedy JC (ed). The injured Adolescent Knee. Williams & Wilkens: Baltimore;1979.

  12. Roberts JM. Fractures and dislocations of the knee. In: Rockwood CA Jr, Wilkens KE, King RE (eds). Fractures in Children. JB Lippincott: Philadelphia;1984.

  13. Kramer DE, Chang TL, Miller NH, Sponseller PD. Tibial tubercle fragmentation: a clue to simultaneous patellar ligament avulsion in pediatric tibial tubercle fractures. Orthopedics. May 2008;31(5):[Medline].

  14. Sie EJ, Kacou AD, Sery BL, Lambin Y. Avulsion fracture of the tibial tubercle associated with patellar ligament avulsion treated by staples. Afr J Paediatr Surg. Jan-Apr 2011;8(1):105-8. [Medline].

 
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Diagrammatic view of tibial tubercle avulsion classification types I, II, and III.
Type III tibial tubercle avulsion. Note intra-articular fracture extension and anterior elevation.
Anteroposterior view of a type II tibial tubercle avulsion. The injury could be missed if a lateral view is not obtained.
Intraoperative view after open reduction and internal fixation of a type III tibial tubercle avulsion.
 
 
 
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