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Tibial Tubercle Fracture

Kelvin Lau, MA, BM, BCh, MRCS, DPhil, Specialist Registrar in Cardiothoracic Surgery, Trent Deanery
Manoj Ramachandran, MBBS, MRCS, FRCS, Consultant Trauma and Orthopaedic Surgeon, Barts and the London NHS Trust; Honorary Senior Lecturer, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary's, University of London, UK

Updated: Nov 3, 2009

Introduction

Problem

Tibial tuberosity fractures are infrequent fractures affecting physically active adolescents. Activities involving powerful contraction of the knee extensors, such as springing and jumping movements, can result in avulsion fractures of the tibial tuberosity apophysis.1,2,3 This condition should be distinguished from Osgood-Schlatter disease, a chronic apophysitis of the tibial tuberosity due to recurrent traction injury.

Recent studies

Frey et al retrospectively reviewed 20 tibial tuberosity fractures in 19 adolescents (aged 10-19 y; mean, 13.7 y) from 2000-2007 for fracture morphology, mechanism of injury, fracture management, and complications. There were 9 left-sided injuries and 11 right-sided, including 1 patient with bilateral fractures. Mechanism of injuries included 8 basketball injuries, 5 running injuries, 3 football injuries, 2 falls from a scooter, 1 high-jump injury, and 1 fall. Comorbidities included 3 patients with Osgood-Schlatter disease and 1 with osteogenesis imperfecta. All the patients were treated with open reduction and internal fixation, including arthroscopic procedures in 2 cases. Complications included 4 patients with preoperative presentation of compartment syndrome (all requiring fasciotomy), 1 case of postoperative stiffness, and 1 case of painful hardware, which required removal. Range of motion was started an average of 4.3 weeks postoperatively, and return to play was an average of 3.9monthspostoperatively.4
 
Chakraverty et al reported on the management of tibial tubercle fractures in conjunction with complex proximal tibial injuries and noted that a stable repair of the tibial tubercle fragment is essential if the extensor mechanism is to be reconstituted. The investigators outlined a technique for such injuries in which the tibial tubercle fragment is stabilized by wiring it directly to the screws of a locking plate. According to the authors, this approach allows for reduction and fixation of the tibial tubercle fragment that is stable enough to allow immediate full active range of motion. Over the past 5 years, the authors have applied this technique in 16 patients, and they reported that their preliminary results have demonstrated a high rate of clinical and radiographic union with near normal return of extensor mechanism function.5

Frequency

In the United States, the frequency of this injury is not known, although it occurs infrequently. At 1 major center, 15 cases of tibial tuberosity fractures were diagnosed in 5 years. Tibial tuberosity fractures typically occur in individuals aged 14-17 years. As the growth plate closes in late puberty, it is transiently replaced by fibrocartilaginous elements. These elements predispose the tibial tuberosity to traction injury as a result of its weakened tensile strength.

Internationally, the frequency is not known. As in the United States, the condition occurs infrequently.

Etiology

Injury from violent tensile forces on the tibial tuberosity causes this type of fracture. This is delivered through eccentric contraction of the extensor mechanism of the knee from either (1) violent contraction of the extensors without shortening (eg, springing off when jumping) or (2) forceful flexion of the knee against the powerful contraction of the quadriceps (eg, landing from a jump); in other words, it occurs when sudden acceleration or deceleration of the extensor mechanism occurs.

Patients with Osgood-Schlatter disease may be predisposed to tibial tuberosity fractures.6 Similarly, patients with these fractures may have a family history of Osgood-Schlatter disease or a history of fractures of the tibial tuberosity.

Pathophysiology

The proximal tibia has 2 ossification centers, the proximal tibial epiphysis and the tibial tuberosity, which are separated by a cartilage bridge (see Image 1). Before ossification, the tibial tuberosity is composed of fibrocartilage that has good tensile strength. However, during ossification, columnated cartilaginous cells with poor tensile strength replace the fibrocartilage, and it is within this small window between fibrocartilage and ossified matrix that the tibial tuberosity is at risk of avulsion fractures.

Ossification centers and epiphyseal cartilages of...

Ossification centers and epiphyseal cartilages of the proximal tibia and tibial tuberosity.



Classification of tibial tuberosity fractures.

Classification of tibial tuberosity fractures.


As a result of the direction of pull of the patella tendon, the tibial tuberosity along with the proximal tibial epiphysis can be avulsed upward in a fracture in 1 or more fragments (see Image 2).

Watson-Jones classified the fractures into the following 3 types7 :

  • Type I: The fracture is within the most distal portion of the tibial tuberosity ossification center and usually results in avulsion of the most distal portion.
  • Type II: Extension of the fracture line occurs into the proximal end of the tibia through the cartilage bridge but does not involve the articular surface.
  • Type III: This is an intra-articular fracture in which the fracture line has propagated into the joint.

Ogden further subdivided each class into types A and B.8 Type A fractures are single, and type B fractures are comminuted.

Presentation

History

The patient may have a history of Osgood-Schlatter disease in the affected and/or contralateral knee. This fracture typically is sustained during athletic activity and results in an acute onset of pain and swelling and in difficulty extending the knee.

Physical

The injury is almost invariably closed, with swelling and tenderness over the affected tibial tuberosity. Tibial tuberosity fractures are due to avulsion and not direct impact; therefore, injury to the overlying tissue is rare.

In mild, or type I, injuries, the patient may be able to extend the knee against gravity, but he or she may not be able to extend it against resistance. In severe, or type II and type III, injuries, the patient may be unable to actively extend the knee. Type III (intra-articular) injuries are associated with hemarthrosis, and this manifests as a painful knee effusion following injury.

A high-riding patella is suggestive of tibial tuberosity fracture.

Indications

Nondisplaced type I injuries can be managed conservatively by cast immobilization in a long leg cast in full-knee extension. All other injuries are best treated by open reduction and internal fixation with cast immobilization for 6-8 weeks.

Relevant Anatomy

The extensor complex of the thigh exerts its force through the ligamentum patellae on the tibial tuberosity. During its histogenesis, the tibial tuberosity is an anterior extension of the proximal tibial epiphysis separated from the rest of the tibia by the growth plate. As the growth plate closes in late puberty, it is transiently replaced by fibrocartilaginous elements, which predispose it to traction injury as a result of its weaker tensile strength.

Workup

Laboratory Studies

  • Laboratory studies are not indicated unless other diagnoses are being evaluated.
  • Preoperative investigations are requested as required.

Imaging Studies

  • Radiography of the knee is the main imaging study.
    • Findings are diagnostic of the condition.
    • The tibial tubercle is imaged on a lateral radiograph with the leg in slight internal rotation.
    • Oblique views of the proximal tibia may help reveal the extent of the fracture.
    • Radiographs of the contralateral knee may show evidence of Osgood-Schlatter disease.
  • Other forms of imaging are not performed routinely, and they are requested as required if alternative diagnoses are being considered.

Other Tests

  • Other tests are not indicated unless other diagnoses are being considered.

Diagnostic Procedures

  • Lateral radiographs of the knee are useful in diagnosis.

Staging

The fracture is classified into 6 subtypes to guide management. See Pathophysiology, above.

Treatment

Medical Therapy

Medical therapy typically involves analgesia for pain control and thromboprophylaxis. The patient's discomfort can be controlled with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). If the pain continues, a narcotic analgesic can be added.

Surgical Therapy

Type IA injuries are treated conservatively with cast immobilization in full extension, followed by gradual rehabilitation of the quadriceps. Type IB, type II, and type III injuries are treated with open reduction and internal fixation.9 Type III injuries may also require exploration of the knee joint for meniscal and ligamentous damage, with accurate reduction of the intra-articular surface.

Preoperative Details

The surgical procedure is determined by type of fracture. The preoperative assessment is designed to identify the fracture, its displacement, and any associated injuries.

Intraoperative Details

Open reduction and internal fixation is the treatment of choice. The fracture is approached from an anterior or lateral parapatellar incision. Interposed soft tissue is cleared to promote accurate reduction. The tibial tuberosity is reduced and fixed to the tibia by using 1 or 2 screws.

Arthroscopy or arthrotomy may be required to repair damaged menisci and to refashion a smooth articular surface, particularly in type III injuries.

Postoperative Details

Analgesia is required for control of postoperative pain.

Physiotherapy is also part of the patients' postoperative care. Progressive rehabilitation of the quadriceps is required after cast immobilization. Physiotherapy and progressive weightbearing exercises can be performed soon after open reduction and internal fixation is completed. Early mobilization attenuates joint stiffness and weakness due to prolonged immobilization.

Follow-up

An orthopedic surgeon should follow-up patients to ensure the fracture is healing correctly and that any complications are managed.

Complications

Complications are rare and include those related to trauma (eg, thromboembolism) or effects specific to the fracture. The latter includes meniscal damage in type III injuries, bursitis over metalwork, malunion, nonunion, recurrence, early degenerative change, genu recurvatum, and leg-length discrepancy.

Outcome and Prognosis

The prognosis is excellent, and most patients recover full function within a year.

Multimedia

Ossification centers and epiphyseal cartilages of...

Media file 1: Ossification centers and epiphyseal cartilages of the proximal tibia and tibial tuberosity.

Classification of tibial tuberosity fractures.

Media file 2: Classification of tibial tuberosity fractures.

References

  1. 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].

  2. 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].

  3. Hanley C, Roche SJ, Chhabra J. Acute simultaneous bilateral avulsion fractures of the tibial tubercles in a 15-year-old male hurler: case report and literature review. Ir J Med Sci. Dec 4 2008;[Medline].

  4. Frey S, Hosalkar H, Cameron DB, Heath A, David Horn B, Ganley TJ. Tibial tuberosity fractures in adolescents. J Child Orthop. Dec 2008;2(6):469-74. [Medline].

  5. Chakraverty JK, Weaver MJ, Smith RM, Vrahas MS. Surgical management of tibial tubercle fractures in association with tibial plateau fractures fixed by direct wiring to a locking plate. J Orthop Trauma. Mar 2009;23(3):221-5. [Medline].

  6. 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].

  7. Watson-Jones R. Fractures and Joint Injuries. 6th ed. New York:. Churchill Livingstone;1982.

  8. 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].

  9. 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].

  10. Buhari SA, Singh S, Wong HP, Low YP. Tibial tuberosity fractures in adolescents. Singapore Med J. Oct 1993;34(5):421-4. [Medline].

  11. Mirbey J, Besancenot J, Chambers RT, et al. Avulsion fractures of the tibial tuberosity in the adolescent athlete. Risk factors, mechanism of injury, and treatment. Am J Sports Med. Jul-Aug 1988;16(4):336-40. [Medline].

  12. Nimityongskul P, Montague WL, Anderson LD. Avulsion fracture of the tibial tuberosity in late adolescence. J Trauma. Apr 1988;28(4):505-9. [Medline].

  13. Wiss DA, Schilz JL, Zionts L. Type III fractures of the tibial tubercle in adolescents. J Orthop Trauma. 1991;5(4):475-9. [Medline].

  14. Zionts LE. Fractures around the knee in children. J Am Acad Orthop Surg. Sep-Oct 2002;10(5):345-55. [Medline].

Keywords

tibial tuberosity avulsion, Osgood-Schlatter disease, tibial tuberosity apophysis

Contributor Information and Disclosures

Author

Kelvin Lau, MA, BM, BCh, MRCS, DPhil, Specialist Registrar in Cardiothoracic Surgery, Trent Deanery
Kelvin Lau, MA, BM, BCh, MRCS, DPhil is a member of the following medical societies: Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Manoj Ramachandran, MBBS, MRCS, FRCS, Consultant Trauma and Orthopaedic Surgeon, Barts and the London NHS Trust; Honorary Senior Lecturer, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary's, University of London, UK
Manoj Ramachandran, MBBS, MRCS, FRCS is a member of the following medical societies: British Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

Robert D Bronstein, MD, Associate Professor, Department of Orthopedic Surgery, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M DeBerardino, MD, Associate Professor of Orthopaedic Surgery, 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. Honoraria Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None; Arthrex, Inc. Consulting fee Speaking and teaching

CME Editor

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, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of 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

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Dr Fergal Monsell to the development and writing of this article.

Further Reading

Related eMedicine topics

 Tibial Tubercle Avulsion (Orthopedic Surgery)

Tibial Plateau Fractures (Orthopedic Surgery)

Osgood-Schlatter Disease (Sports Medicine)

Osgood-Schlatter Disease (Emergency Medicine)

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