The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. When the quadriceps muscle on the front of the thigh works, it pulls on the patellar tendon. A tibial tubercle avulsion fracture is a complete or incomplete break (fracture) of the growth plate of the leg just below the knee at the tibial tubercle, a prominence just below the kneecap. 4-6 Both fractures require operative . Incomplete fractures are usually treatable with the traditional RICE (rest, ice, compression, elevation . Medial and lateral retinacular defects were repaired. (C) Transosseous sutures through the donor site (metal probe) and tubercle fragment (lower arrow), secured to the patellar tendon with a running-locking technique (upper arrow). The second method involves fixation by lag screws with or without tension band wiring as an augment fixation. Paget's disease of the bone is a non-malignant skeletal disorder characterized by focal abnormalities in bone remodelling at one or more skeletal sites. tibial tubercle (tuberosity) fractures are infrequent fractures affecting physically active adolescents. 2015 Jun;106(6):206-11. No risk factors were identified. This occurs as tendons can bear more load than the bone. Cureus 12(5): e7929. HHS Vulnerability Disclosure, Help They account for only 1% of pediatric fractures (Pandya, 2012). For adults, avulsion fractures are most common in athletes and dancers. Rev Chir Orthop Reparatrice Appar Mot. Treatment was guided in part by evidence on fixation after tibial tubercle osteotomy; in that context, screw fixation is likely superior to wire fixation [9]. Fractures of the patella are common injuries for adults but occur rarely in children [3, 5]. The typical patient is an adolescent male approaching skeletal maturity with well-developed quadriceps. Tibial tubercle avulsion fracture with simultaneous patellar tendon avulsion is a rare injury that has only ever been reported in adolescents; the diagnosis and management of this combined lesion has not been described in the adult population. Treatment may be nonoperative or operative depending on location of the fracture, degree of displacement, and any associated injuries. Plate fixation provided the strength of screw fixation while avoiding potential fragment splitting or loss of screw purchase. Bifocal disruption of the knee extensor mechanism: a case report and literature review. This case represents the first description ofdiagnosis,management, andrehabilitation of a combined tibial tubercle fracture with distal patellar tendon avulsion in an adult. Hirschmann MT, Wind B, Mauch C, Ickler G, Friederich NF. We describe a case of a patient with undiagnosed Paget's Disease of the bone, sustaining a pathological avulsion fracture of the tibial tuberosity. (D) Completed fixation with the tubercle fragment reduced,plate secured(white arrow, not visible), and the tendon reduced. When the fracture happens, the tendon or ligament pulls away, and a small piece of. report of two cases, Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in pediatric population: case series and review of literature, Dynamic confirmation of fixation techniques of the tibial tubercle osteotomy, Patellar height ratios: a comparison of four measurement methods, Patella position in the normal knee joint, Tibial tubercle osteotomy for exposure of the difficult total knee arthroplasty. A healthy 62-year-old male hospitality worker presented to the hospital with left knee pain and an inability to walk following a mechanical fall on ice. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. . An MRI confirmed a diagnosis of Paget's disease of the bone. This techniquemay have additional applications in both trauma and elective procedures. A tibial tubercle fracture is an uncommon knee injury in young athletes. Liu, Y.-P., Hao, Q.-H., Lin, F., Wang, M.-M., & Hao, Y.-D. (2015). With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. However, the first presentation of this injury in an adult represented a unique challenge as no literature existed describing successful management. Simple Fracture : A break in a bone without an accompanying wound at the fracture site. Before tensioning the tendon, this plate was positioned over the reduced tubercle fragment by passing the transosseous sutures through the slots of the plate (Figure (Figure4A).4A). Peer review concluded: April 24, 2020 Why Mechanism Matters: A Literature Review of Simultaneous Ipsilateral Tibial Tuberosity Avulsion and Patella Fracture With Case Report. An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. Avulsion fractures of the tibial tuberosity are an extremely infrequent injury in adults, with only a few case reports described in literature. The primary fixation was reinforced using a third #5 polyester suture, placed through an additional transosseous pilot hole distal to the fracture site and secured to the tendon again using a Krackow technique (Figures 4C, 4D). By joining Cureus, you agree to our 2. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. Scholarly Impact Quotient (SIQ) is our unique post-publication peer review rating process. Nikiforidis PA, Babis GC, Triantafillopoulos IK, Themistocleous GS, Nikolopoulos K. Knee Surg Sports Traumatol Arthrosc. This is the first reported case of a tibial tubercle fracture with simultaneous avulsion of the distal patellar tendon in an adult. We describe a case of a patient with undiagnosed Paget's Disease of the bone, sustaining a pathological avulsion fracture of the tibial tuberosity. Tibial tuberosity avulsion fractures are uncommon. (A) A slotted plate was positioned after transosseous suture placement through tibia, tubercle fragment, and patellar tendon. Clipboard, Search History, and several other advanced features are temporarily unavailable. The Orthopedic Clinics of North America. Tibial spine Tibial eminence ACL avulsion Pediatric Tibial eminence fracture, a bony avulsion of the anterior cruciate ligament (ACL) from its insertion on the intercondylar eminence,1 was rst described by Poncet in 1875.2 Also known as tibial spine fractures, these injuries occur most commonly in skeletally The patient had full active range of motion (full extension to 135 degrees) andstrength(5/5) equivalent to the uninjured knee, with no residual pain, hardware irritation, or bursitis. Tibial tuberosity avulsion fracture combined with meniscal tear. Patella position in the normal knee joint. First, the tendon was secured to the tubercle fragment with transosseous sutures. official website and that any information you provide is encrypted Before type III: infrabursal avulsed fracture by superficial fibers from the middle third of the posterior tuberosity. The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. Integrity of the distal patellar tendon could not be determined due to hematoma at the site of tendon attachment to the tibial tubercle (arrow). In patients with radiographic evidence of tibial tubercle fracture, lateral flexion extension radiographs, ultrasonography, and/or magnetic resonance imaging are prudent to rule out concomitant patellar tendon avulsion [5,6]. McKoy B.E., Stanitski C.L. Tibial Plateau Fracture with Avulsion Fracture of Tibial Tuberosity: A Case Report and Review of Literature. 2021 Feb 10;13(2):e13256. Tibial tubercle avulsion fracture with simultaneous patellar tendon avulsion is a rare injury that has only ever been reported in adolescents; the diagnosis and management of this combined lesion has not been described in the adult population. already built in. Privacy Policy (A) Free tubercle fragment (in forceps) and tibia donor site (lower arrow) with proximal migration of the patella (upper arrow). Orthopedics, McMaster University, Hamilton, CAN. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This injury typically occurs in adolescents because the tibial tubercle is still growing and the bone is softer there. Tibial tubercle fractures most commonly occur in adolescent boys aged 12-16 years. The third method involves anchor suture. A 54-year-old male presented with right knee pain after his knee gave way whilst standing in the goal area during a game of football, twisting his right ankle and falling. Pesl T; Havranek P. Acute tibial tubercle avulsion fractures in children: selective use of the closed reduction and internal fixation method. A combined lesion - tubercle fracture with patellar tendon avulsion from the tubercle fragment - has only ever been reported in adolescents, typically those involved in sport, and can present challenges in both diagnosis and management [4-9]. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. An anterior midline approach was used. In adolescents, combined lesions have been treated using a variety of methods, including staples, wires or suture tape, tension banding, lag screws, suture anchors, and/or transosseous sutures [6,8]. Tibial Tubercle Fractures are common fractures that occur in adolescent boys near the end of skeletal growth during athletic activity. How do you get tibial tuberosity? Terms of Use. Tibial Tuberosity Avulsion Fracture and Open Proximal Tibial Fracture in an Adult: A Case Report and Literature Review. Typically caused by injuries from sporting activities involving jumping, most commonly basketball. Two transosseous #5 polyester sutures (one medial and one lateral) were placed from intact cortical bone into cancellous bone of the donor site through pilot holes; these sutures were then pushed through the tubercle fragment and were secured through the patellar tendon using a Krackow technique (Figure (Figure3C3C). Published: May 02, 2020. Indeed, it is the only thing that ever has.". jumping, widening of open apophysis typically demonstrating a displacement of proximal apophysis, hemarthrosis if there is intra-articular extension, type I:usually non-operative immobilization in a long leg cast 4-6 weeks, type II-V:usually surgical -closed reduction via percutaneous clamping and lag screw fixation or open reduction. aged 12-15 years old was well documented, there seems to be no difference in sex distribution. Accessibility Acute tibial tubercle avulsion fractures. Combined Tibial Tubercle Fracture With Patellar Tendon Avulsion in an Adult: A Rare Case and Novel Fixation Technique, Monitoring Editor: Alexander Muacevic and John R Adler. Pape JM, Goulet JA, Hensinger RN. Tibial tuberosity avulsion fractures are uncommon. Tibial tuberosity avulsion fracture in an adult a rare case report. You may switch to Article in classic view. (B) Intraoperative patella altaevident after suture tensioning. Medial and lateral retinacular defects were repaired. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. The patient was healthy and denied previous trauma, and corticosteroid or quinolone use. The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. INTRODUCTION. (A) Free tubercle fragment (in forceps) and tibia donor site (lower arrow) with proximal migration of the patella (upper arrow). Acute tibial tubercle avulsion fracture is an uncommon injury, typically seen only in adolescents due to the vulnerability of an open physis [1]. X-rays in anteroposterior and lateral views of the left knee showing the tibial anterior tuberosity fracture. Ultrasound demonstrating tibial tubercle (TT) fracture with proximal migration of the patellar tendon and tubercle fragment. An anterior midline approach was used. Please enable it to take advantage of the complete set of features! In this anatomic location, aone-third semitubular plate was low profile and allowed for easy contouring to the convex surface of the anterior tibia. Mechanism of injury of a tibial tubercle fracture They usually happen when a bone is moving one way, and a tendon or ligament is . The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. doi: 10.1097/MD.0000000000001684. SIQ assesses article importance and quality by embracing the collective intelligence of the Cureus community-at-large. The normal ossification of the tibial tuberosity occurs from two centers, one distal and one proximal. Ultrasound demonstrating tibial tubercle (TT) fracture with proximal migration of the patellar tendon and tubercle fragment. Wu KC, Ding DC. 2016 Jan;29(1):34-9. doi: 10.1055/s-0035-1564729. Unable to process the form. Acute tibial tubercle avulsion fractures. https://www.ncbi.nlm.nih.gov/pubmed/17571833, https://www.sciencedirect.com/science/article/abs/pii/S2210794013000060?via%3Dihub, https://www.ncbi.nlm.nih.gov/pubmed/?term=Avulsion+fracture+of+the+tibial+tubercle+with+avulsion+of+the+patellar+ligament.+Report+of+two+cases, https://europepmc.org/article/med/6216535, https://www.ncbi.nlm.nih.gov/pubmed/2225644. }, author={Basilius Zaricznyj}, journal={The Journal of bone and joint surgery. Cureus is on a mission to change the long-standing paradigm of medical publishing, where submitting research can be costly, complex and time-consuming. We are experimenting with display styles that make it easier to read articles in PMC. Surgical treatment occurred 24 hours following presentation. government site. Compound or Open Fracture : A break where the bone has penetrated the skin to the exterior, or the wound that broke the bone has exposed the broken ends. Please enable it to take advantage of the complete set of features! A tibial tuberosity avulsion fracture is an incomplete or complete separation of the tibial tuberosity from the tibia. Tibial tubercle avulsion fractures are an uncommon injury occurring due to strong contraction of the quadriceps femoris muscle during leg extension, ultimately causing failure of the physis at the patellar tendon insertion. Tibial plateau fractures are typically caused by a strong force on the lower leg with the leg in varus or valgus position, or simultaneous vertical stress and flexion of the knee. Of these, 83 (65.4%) cases were PM and 44 were other fractures. Europe PMC is an archive of life sciences journal literature. Tension band suture in isolated tibial tubercle avulsion: A case report and review literatures. One year following surgery, the patient had full knee range of motion (full extension to 135 degrees of flexion) and full flexion and extension power (5/5) with no residual pain or other complications. This site needs JavaScript to work properly. Examination of the left knee revealed a compromised extensor mechanism and a palpable defect at the inferior insertion of the patellar tendon, with diffuse pain and swelling but no neurovascular or skin compromise. The proximal center has a physis and is a cartilaginous extension of the tibial epiphysis which expands distally. 1-3 It has not been reported with proximal tibial diaphyseal fractures. Acute tibial tubercle avulsion fracture is an uncommon injury, typically seen only in adolescents due to the vulnerability of an open physis [1]. 6-16 There was one case report of a tibial tubercle avul-sion fracture and a tibial spine avulsion fracture with no rupture of the patella tendon.17 This Examination of the left knee revealed a compromised extensor mechanism and a palpable defect at the inferior insertion of the patellar tendon, with diffuse pain and swelling but no neurovascular or skin compromise. At three months, radiographs demonstrated appropriate patellar height(Figure 5C); the patient had active range of motion from full extension to 120 of flexion with only mild discomfort. This occurs as a result of a violent contraction of the quadriceps muscles, most often as a result of a high-power jump. In young athletes, the growth center there is still open, leaving it vulnerable to injury. Bolesta MJ, Fitch RD. An avulsion fracture of the tibial tuberosity is an infrequent injury and has an extremely low occurrence in adults, with only a few cases reported in literature. Treatment was successful with cannulated screws and tension band wiring. Bookshelf Diagnosis can be confirmed with radiographs of the knee. Avulsion of the tibial tuberosity is not an uncommon entity seen in adolescents. The AO Foundation describes three methods for tibial tuberosity fracture treatment. Cureus 12(5): e7929. Tibial tuberosity avulsion fractures are extremely rare fracture patterns, with reported incidence rates of 0.4% to 2.7% of all epiphyseal injuries, <1% of all physeal injuries, and about 3% of all proximal tibial injuries 1,2,3. Cases J. A fracture of the tibial tuberosity often results in an avulsion fracture, by virtue of the pull of the quadripceps muscles. Optional views include an internal rotation view bringing the tibial tuberosity into profile or a contralateral knee radiograph for comparison. Please note that Cureus is not responsible for any content or activities contained within our partner or affiliate websites. With stress, the incompletely ossified tibial eminence in the child avulses before the ligament ruptures. Surgical treatment occurred 24 hours following presentation. An avulsion fracture of the tibial tuberosity is an infrequent injury and has an extremely low occurrence in adults, with only a few cases reported in literature. The lesion was treated with surgical reduction and internal fixation. (B) The plate was then secured atop the tubercle fragment. Muscat J, Baskaradas A, Dhillon G, Motkur V, Thakrar R. Cureus. The lesion was treated with surgical reduction and internal fixation. Right knee lateral radiograph showing avulsion fracture of the tibial tuberosity. 8600 Rockville Pike Copyright 2020Woolnough et al. Initial treatment consists of medications . Epub 2003 Oct 3. -, Kang S., Chung P.H., Kim Y.S., Lee H.M., Kim J.P. Bifocal disruption of the knee extensor mechanism: a case report and literature review. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Exact cause is unknown but chronic repetitive trauma to the maturing proximal tibial growth plate by excessive force exerted on the secondary ossification center or apophysis by the patellar tendon leading to avulsion and tibial fragmentation with soft-tissue swelling of tubercle.. How do you treat Osgood-Schlatter in adults? sharing sensitive information, make sure youre on a federal Two weeks following surgery, the patient began weight bearing in a fixed knee splint. However, screws may have limited purchase in small fragments or osteoporotic bone and may even cause fragment splitting [13]. The aim of this report is to describe the diagnosis, operative management, and postoperative rehabilitation of a combined tibial tubercle fracture with distal patellar tendon avulsion in an adult. Introduction: (C) Three months postoperative, patella height is appropriate and with visible pilot-hole lucency (arrow) from transosseous suture placement. Additionally, placing sutures through the plate provided secure fixation that was not dependent on the adequacy of transosseous tunnels or suture anchors. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. It is equivalent to mid-substance rupture of the ACL in adults. The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. 1 This traumatic lesion is typical of the growth age, when muscles, tendons and ligaments are stronger than the growth plate. This mechanism is plausible in our patient as radiographs demonstrated rotation and translation of the bony fragment. Commonly seen in road traffic accidents, sports accidents with a high velocity such as skiing, horse riding, and certain water sports. This article presents the first case of a combined tibial tubercle avulsion with distal patellar tendon avulsion in an adult. Chloros GD, Razavi A, Cheatham SA. Postoperatively, the patient was permitted to bear weight as tolerated with the operative kneeimmobilized in extension. The development of Osgood-Schlatter's is associated with the time of rapid growth and immature bone maturation in early teen years. Images of the inferior limb demonstrating the functional assessment after the treatment. No risk factors. The distal aspect of the patellar tendon could not be fully visualized by ultrasound due to overlying hematoma, but proximal retraction was noted (Figure 2). (B) Freeedge of the avulsed patellar tendon with no remaining bony attachment (arrow). Distal patellar tendon avulsion in association with high-energy knee trauma: a case series and review of the literature. Avulsion fracture of the tibial tubercle with avulsion of the patellar ligament. (1993) Clinical orthopaedics and related research. (D) Completed fixation with the tubercle fragment reduced,plate secured(white arrow, not visible), and the tendon reduced. X-rays in anteroposterior and lateral views of the left knee showing the tibial, Images of the knee during the surgery, showing the gap in the tibial. Woolnough T, Lovsted G, Macdonald A, et al. The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. 2003;34:397403. Ossification begins distally between the ages of seven and nine years. This injury is a very rare event. (2016) Revista brasileira de ortopedia. This techniquemay have additional applications in both trauma and elective procedures. Incidence. Epub 2015 Oct 28. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Caldwell PE, Bohlen BA, Owen JR, et al. Fukuoka Igaku Zasshi. To begin, provisional fixation was achieved with two Kirschner wires. The .gov means its official. Avulsion fractures of the tibial tuberosity represent 3% of all epiphyseal plate injuries in adolescents. and An unusual case of direct trauma of the tibial tuberosity in an adult who suffered a left knee injury due to a fall from height is presented and the therapy performed. the incidence of adult avulsion fractures may be underestimated.1 Ten case reports, including 17 patients, of ipsilateral simultaneous rupture of the pa-tella tendon and ACL have been reported. Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in pediatric population: case series and review of literature. Tibial Tubercle Avulsion Fracture Powerpoint (1) 1 of 10 Tibial Tubercle Avulsion Fracture Powerpoint (1) Feb. 03, 2016 4 likes 2,241 views Download Now Download to read offline ShirleykaHector Follow Advertisement Recommended Avulsion simultane bilatrale tubrosit tibiale antrieure ROBERT ELBAUM 2k views 18 slides Fracture neck of femur type IV: "beak" fracture but with a small triangular fragment separated by deep . Orthopedics. Disclaimer, National Library of Medicine Scholarly Impact Quotient (SIQ) is our unique post-publication peer review rating process. Avulsion of the tibial tubercle (arrows) and patella alta can be seen; the bony tubercle fragment (arrows) is translated 1.5 cm proximally and is rotated 90 from its anatomic position. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. This article is for Medical Professionals. Arch. Accessibility CT is helpful to determine intra-articular or posterior extension. PMC All patients require a variable period of immobilization averaging 4 weeks. The authors have declared that no competing interests exist. Rana R, Ganesh A, Behera S 2nd, Behera H. Cureus. Tibial tubercle avulsion fracture with simultaneous patellar tendon avulsion is a rare injury that has only ever been reported in adolescents; the diagnosis and management of this combined lesion has not been described in the adult population. Acute tibial tubercle avulsion fractures. Two 4-mm cancellous screws were used to secure the plate, thereby providing fixation of the tubercle fragment (Figure 4B). Chir Organi Mov. Patellar height ratios: a comparison of four measurement methods. Tibial tubercle avulsion fracture caused by knee extensor is very rare; furthermore, non-traumatic fractures during running or bilateral fractures have been reported. (C) Transosseous sutures through the donor site (metal probe) and tubercle fragment (lower arrow), secured to the patellar tendon with a running-locking technique (upper arrow). Online ahead of print. Lateral radiograph of the knee taken postoperatively. The growth plate is an area of relative weakness, and fracture of it is usually due to sudden, vigorous activity of the patellar tendon pulling the bone away from the cartilage. (B) The plate was then secured atop the tubercle fragment. Insall J, Salvati E. Patella infera. In adults, this injury is exceedingly rare, with only several reported cases. 4. Postoperatively, the patient was permitted to bear weight as tolerated with the operative kneeimmobilized in extension. Alternatively, the patellar tendon may avulse from an intact tubercle; this injury is similarly infrequent in healthy adults [2,3]. Treatment was guided in part by evidence on fixation after tibial tubercle osteotomy; in that context, screw fixation is likely superior to wire fixation [9]. (A) Intraoperative fluoroscopydemonstrating plate fixation of the tibial tubercle with slots cut in plate (arrows) for passing over sutures. After excising hemorrhagic prepatellar bursa, evacuating overlying traumatic hematoma, and exposing the fracture donor site (Figure 3A), it was apparent that in addition to the tibial tubercle fracture, the patellar tendon was completely avulsed from the tubercle fragment (Figure 3B). Careers. (2008) Journal of children's orthopaedics. Compartment syndrome complicating tibial tubercle avulsion. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. Avulsion fractures of the tibial tuberosity in the adult are extremely rare with only 3 reported cases. In addition to our case report, we have performed a . Right knee lateral radiograph from five years ago revealing similar picture to Figure 1. What are Tibial Tuberosity Avulsion Fractures? Orthop. A Tibial Eminence Fracture, also known as a tibial spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity. In patients with radiographic evidence of tibial tubercle fracture, lateral flexion extension radiographs, ultrasonography, and/or magnetic resonance imaging are prudent to rule out concomitant patellar tendon avulsion [5,6]. INTRODUCTION. Previously, isolated distal patellar tendon avulsions have been treated with transosseous sutures or suture anchors [2,3]. -. Fractures of the tibia may result from significant trauma or be the consequence of repeated overuse. Int J Surg Case Rep. 2020;71:1-5. doi: 10.1016/j.ijscr.2020.04.029. The unique construct, a slotted-plate over transosseous sutures, provided excellent results and likely has further applications. Alternatively, the patellar tendon may avulse from an intact tubercle; this injury is similarly infrequent in healthy adults [2,3]. Despite being the result of a relatively low-energy mechanism, the patient had no known risk factors for tendon rupture. -, McKoy B.E., Stanitski C.L. Fixation using transosseous sutures through a slotted plate required no specialized instrumentation and provided an excellent outcome. Learn more here. Tibial Tuberosity Avulsion Fracture and Open Proximal Tibial Fracture in an Adult. Plate fixation provided the strength of screw fixation while avoiding potential fragment splitting or loss of screw purchase. Such lesions are typically seen in adolescent males with well-developed quadriceps musculature and are usually incurred during jumping sports activities, such as basketball [3]. This case represents the first description ofdiagnosis,management, andrehabilitation of a combined tibial tubercle fracture with distal patellar tendon avulsion in an adult. official website and that any information you provide is encrypted Capogna B, Strauss E, Konda S, Dayan A, Alaia M. Complete avulsion of the patellar tendon from the tibial tubercle in an adult without predisposing factors. Avulsion fractures are caused by trauma. Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Tibial tubercle osteotomy for exposure of the difficult total knee arthroplasty. A healthy 62-year-old male hospitality worker presented to the hospital with left knee pain and an inability to walk following a mechanical fall on ice. Int J Surg Case Rep. 2022 Jun 20;96:107326. doi: 10.1016/j.ijscr.2022.107326. Fractures of the tibial tuberosity constitute only 3% of proximal tibial fractures [ 1 ]. At one year, radiographs were unremarkable other than minimal osseous debris and/or ossification (Figure (Figure5D).5D). Check for errors and try again. Anterior avulsion fracture of the tibial tuberosity in adolescents - Two case reports. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. This mechanism is plausible in our patient as radiographs demonstrated rotation and translation of the bony fragment. Puppies diagnosed with this type of fracture usually have had some sort of trauma such as falling from a couch or bed and landing with the knee flexed. Commonly described mechanisms of tibial tubercle avulsion fracture and patellar tendon avulsion include significant quadriceps contraction with a fixed foot or quadriceps contraction in the presence of an external force acting to produce knee flexion [1-3]. The tibial tubercle is the part of the top of the shin bone where the patellar tendon attaches. Trauma Surg. chronic renal failure, diabetes, chronic steroid use, quinolone treatment, systemic lupus erythematous) may increase risk of tendon rupture, this patient reported no known risk factors [3,4]. @article{Zaricznyj1977AvulsionFO, title={Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. The tibial tuberosity serves as the insertion point of the quadriceps muscles through the patellar ligament, and avulsion results from the contraction of the muscle while stifling is flexed and the foot firmly on the ground, Such mechanism could . We describe a unique case of tibial tuberosity avulsion fracture in an adult with PDB. [7] subclassified avulsion fractures of the patella as superior, inferior, medial and (May 02, 2020) Combined Tibial Tubercle Fracture With Patellar Tendon Avulsion in an Adult: A Rare Case and Novel Fixation Technique. However, the first presentation of this injury in an adult represented a unique challenge as no literature existed describing successful management. Silva Jnior AT, Silva LJ, Silva Filho UC, Teixeira EM, Arajo HR, Moraes FB. A combined lesion - tubercle fracture with patellar tendon avulsion from the tubercle fragment - has only ever been reported in adolescents, typically those involved in sport, and can present challenges in both diagnosis and management [4-9]. We describe a case in an adult who suffered a left knee injury due to a fall from height. Journal of Children's . Careers. 2 (6): 469-74. Regarding combined lesions, in adolescents it has been proposed that tubercle avulsion is followed by rotation, which tensions soft tissues around the tubercle, arresting fragment translation; continued quadriceps contraction then causes tendon avulsion [5,6]. (Authors cannot rate their own articles.). 2009 Dec 19;2:9357. doi: 10.1186/1757-1626-2-9357. Case report: The patient underwent open reduction internal fixation. Int J Surg Case Rep. 2022 Jun 20;96:107326. doi: 10.1016/j.ijscr.2022.107326. and transmitted securely. They are often associated with patients who have underlying bone disease and other medical co-morbidities. -, William L.H., Charles R.H., William D.A. Bethesda, MD 20894, Web Policies Extensor mechanism reconstruction and joint preservation surgery following a tibial tuberosity fracture in giant cell tumor of bone: A case report. 1971;53(8):15791583. Tibial tuberosity avulsion fracture usually occurs in younger dogs due to the area of the tibia not being fully fused to the rest of the bone. At six weeks, the operative knee could be passively flexed with no pain to 20 so the patient began gradually increasing range of motion in a hinged knee brace, initially locked at full extension. Clipboard, Search History, and several other advanced features are temporarily unavailable. Avulsion fractures of the tibial tubercle. MRI scan revealing marked Pagets disease of the proximal tibia. and transmitted securely. Epidemiology These fractures have an incidence 0.4% to 2.7%, and males are affected more-so than females. Previously, isolated distal patellar tendon avulsions have been treated with transosseous sutures or suture anchors [2,3]. What causes this injury? Extensor mechanism reconstruction and joint preservation surgery following a tibial tuberosity fracture in giant cell tumor of bone: A case report. Tubercle avulsion is considerably more common in adolescents than that in adults due to the weakness of an open physis although tubercle fracture may also occur in adults, typically as a result of direct impact [1,4]. First, the tendon was secured to the tubercle fragment with transosseous sutures. Radiographs demonstrated tibial tubercle avulsion fracture and patella alta (Figure 1). What causes anterior tibial tubercle? The patellar height ratio (0.8) was within normal limits using both Caton-Deschamps (normal 0.8-1.2) and Insall-Salvetti (0.75-0.99)methods [10-12]. The primary fixation was reinforced using a third #5 polyester suture, placed through an additional transosseous pilot hole distal to the fracture site and secured to the tendon again using a Krackow technique (Figures (Figures4C,4C, ,4D).4D). 1995;81(7):635-8. An official website of the United States government. After six weeks, knee range of motion was gradually increased using a hinged brace. [ 1] classified the adolescent fractures considering the fracture line and displacement of avulsed fragments. The slotted plate design allowed precise transosseous suture placement, unobstructed by prior bony fixation. Orthopedics, McMaster University, Hamilton, CAN. Unable to load your collection due to an error, Unable to load your delegates due to an error. This is the first reported case of a tibial tubercle fracture with simultaneous avulsion of the distal patellar tendon in an adult. An avulsion fracture occurs when a tendon or ligament attached to the bone pulls away from the bone. The mechanism of the trauma usually is the avulsion of the tubercle for the eccentric contraction of the thigh. Simultaneous ipsilateral tibial tuberosity avulsion and patella fractures are rare in adults. Full range of motion is expected by 3 months, with a return to pre-injury level of activity thereafter. X-rays of the knee in anteroposterior and lateral views after the osteosynthesis. The functionality is limited to basic scrolling. Because of the associated soft tissue injury with these proximal tibial fractures, a displaced tuberosity fracture creates a problem in fracture management. The tubercle fragment was translated 1.5 cm proximally and rotated 90 (Figure 1A). Associations patella tendon or quadriceps tendon rupture Ultrasonography demonstrated an intact quadriceps tendon and a normal patellar tendon origin at the inferior patellar pole. This article presents the first case of a combined tibial tubercle avulsion with distal patellar tendon avulsion in an adult. Tibial tuberosity avulsion fracture. After excising hemorrhagic prepatellar bursa, evacuating overlying traumatic hematoma, and exposing the fracture donor site (Figure (Figure3A),3A), it was apparent that in addition to the tibial tubercle fracture, the patellar tendon was completely avulsed from the tubercle fragment (Figure (Figure3B).3B). Commonly described mechanisms of tibial tubercle avulsion fracture and patellar tendon avulsion include significant quadriceps contraction with a fixed foot or quadriceps contraction in the presence of an external force acting to produce knee flexion [1-3]. The site is secure. The first method involves non-operative treatment with casting or bracing in non-displaced and stable fracture. eCollection 2021 Dec. See this image and copyright information in PMC. doi: 10.7759/cureus.7756. While a peak in boys. Apropos of 128 cases. Imaging features of both acute and chronic avulsion injuries of the pelvis, knee, ankle and foot, shoulder, and elbow were evaluated to help distinguish these injuries from more serious disease processes such as neoplasm and infection. No risk factors were identified. report of two cases. Here we are sharing the successful management and follow-up of a similar case with a different suture material for repair of the tendon, the FiberWire. The tibial tubercle is the bony attachment on the large bone of the lower leg (tibia) of the big, powerful thigh muscle (quadriceps). (C) Primary sutures were tensioned and a third, defunctioning suture (red) was placed through a distal pilot hole and secured to the patellar tendon with a running-locking technique. Osgood-Schlatter disease (OSD) is one of the most common causes for anterior knee pain in children. Patients with PDB who fracture present with diagnostic and operative challenges, it is vital to progress with caution in the postoperative rehabilitation phase. Yousef MA. The site is secure. Ogden et al. Tubercle avulsion is considerably more common in adolescents than that in adults due to the weakness of an open physis although tubercle fracture may also occur in adults, typically as a result of direct impact [1,4]. The purpose of this study was to evaluate any differences according to the mechanisms of injury in adolescents with tibial tubercle avulsion fracture. At six weeks, the operative knee could be passively flexed with no pain to 20 so the patient began gradually increasing range of motion in a hinged knee brace, initially locked at full extension. Osgood-Schlatter disease, also known as osteochondritis of the tibial tubercle, was first described in 1903 [ 1,2 ]. Right knee lateral radiograph from five years ago revealing similar picture to Figure, AP radiograph of the knee taken three weeks postoperatively showing fixation with cannulated. Keywords: Stress avulsion of the tibial tuberosity after tension band wiring of a patellar fracture: a case report. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. Tuberosity is the term used to describe the prominence of a bone that attaches the ligament to the bone. Avulsion injuries are common among participants in organized sports, especially among adolescent participants. Epidemiology /Etiology. (May 02, 2020) Combined Tibial Tubercle Fracture With Patellar Tendon Avulsion in an Adult: A Rare Case and Novel Fixation Technique. Please note that by doing so you agree to be added to our monthly email newsletter distribution list. [ 1, 2, 3, 4, 5, 6] activities involving powerful contraction of the knee. 4-6 Both fractures require operative . You might be sprinting, hitting, sliding or doing other sports activities that involve quick movements and sudden changes in direction. While systemic illness (e.g. Generating an ePub file may take a long time, please be patient. Tibial tubercle fracture with avulsion of patellar ligament. Tibial tubercle avulsions. At one year, the patient had achieved excellent range of motion (full extension to 135 degrees of flexion) and strength (5/5 knee flexion and extension) without residual pain or complications. Tibial tubercle fracture with avulsion of the patellar ligament: a case report. An overview of traumatic tibial fractures in adults with a focus on epidemiology and complications is presented here. On univariate analysis, the PM fractures were associated with fibular spiral (p=-016) fractures and no fracture of the fibular (p=.003), lateral direction of the tibial fracture (p=.04), female gender (p=.002), AO classification 42B1 (p=.033) and an increasing angle of tibial fracture. Avulsion fractures usually happen to young athletes. (B) Intraoperative patella altaevident after suture tensioning. Peer review began: April 15, 2020 DOI: 10.2106/00004623-197759080-00022 Corpus ID: 2637082; Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. In this anatomic location, aone-third semitubular plate was low profile and allowed for easy contouring to the convex surface of the anterior tibia. The https:// ensures that you are connecting to the FOIA Received 2020 Mar 30; Accepted 2020 May 2. Avulsion of the tibial tubercle (arrows) and patella alta can be seen; the bony tubercle fragment (arrows) is translated 1.5 cm proximally and is rotated 90 from its anatomic position. 2021 Dec 7;13(12):e20232. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 24 (2): 181-4. 2008 Jul;111(7):548-52. doi: 10.1007/s00113-007-1371-y. This is the first reported case of tibial tubercle fracture with simultaneous avulsion of the distal patellar tendon in an adult. Rana R, Ganesh A, Behera S 2nd, Behera H. Cureus. 1995. 5. Two transosseous #5 polyester sutures (one medial and one lateral) were placed from intact cortical bone into cancellous bone of the donor site through pilot holes; these sutures were then pushed through the tubercle fragment and were secured through the patellar tendon using a Krackow technique (Figure 3C). The avulsion fracture of the tibial tuberosity is regarded as a substantial injury to the extensor mechanism as the patellar tendon is attached to the tibial tuberosity. Dynamic confirmation of fixation techniques of the tibial tubercle osteotomy. At this point, slots were cut into the central two holes of a four-hole, 3.5-mm one-third tubular plate. the display of certain parts of an article in other eReaders. The distal aspect of the patellar tendon could not be fully visualized by ultrasound due to overlying hematoma, but proximal retraction was noted (Figure (Figure22). Unable to load your collection due to an error, Unable to load your delegates due to an error. We describe a case in an adult who suffered a left knee injury due to a fall from height. (2004) Journal of pediatric orthopedics. Cureus. 8600 Rockville Pike These fractures have an incidence 0.4% to 2.7%, and males are affected more-so than females. Would you like email updates of new search results? government site. [Lateral tibial head fracture and avulsion fracture of the tibial tuberosity: a rare combination of injuries]. Radiographs demonstrated tibial tubercle avulsion fracture and patella alta (Figure (Figure1).1). 2013: bcr2013202411. (D) One year postoperative,slight osseous debris or ossification (arrow) can be seen in the area of the patellar tendon. The slotted plate design allowed precise transosseous suture placement, unobstructed by prior bony fixation. Unfallchirurg. The ePub format uses eBook readers, which have several "ease of reading" features The aim of this study was to present an unusual case of direct trauma of the tibial tuberosity in an adult and the therapy performed. Two weeks following surgery, the patient began weight bearing in a fixed knee splint. Causes of knee pain and the general . Epub 2020 May 8. 1999 Oct;15(7):766-9. doi: 10.1016/s0749-8063(99)70010-1. doi: 10.7759/cureus.20232. tibial tubercle, patellar ligament, avulsion fracture, tendon rupture. Taylor Woolnough, Gwendolyn Lovsted, [], and Jamal A Al-Asiri. Professional Reference articles are designed for health professionals to use. Tibial tuberosity avulsion fractures are uncommon, constituting <3% of all epiphyseal injuries and 1% of all physeal injuries in skeletally immature population [1, 2]. 2020 Apr 21;12(4):e7756. Capogna B, Strauss E, Konda S, Dayan A, Alaia M: Kang S, Chung PH, Kim YS, Lee HM, Kim JP: Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Fixation using transosseous sutures through a slotted plate required no specialized instrumentation and provided an excellent outcome. Review of final fluoroscopic images confirmed reduction of the tubercle and showed patella baja (Figures (Figures5A,5A, ,5B).5B). 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Full range of motion is expected by 3 months, with only a weeks! Bracing in non-displaced and stable fracture simple fracture: a case in an adult are an extremely injury... Clinical experience and/or tibial tuberosity avulsion fracture in adults by independent individuals or organizations bringing the tibial avulsion. 20 ; 96:107326. doi: 10.1016/s0749-8063 ( 99 ) 70010-1. doi: 10.1016/s0749-8063 ( ). Thing that ever has. `` distribution list one proximal knee splint information in PMC bone! Thing that ever has. `` europe PMC is an uncommon entity seen in traffic... Wiring of a qualified health care professional affecting physically active adolescents of All epiphyseal plate injuries in adolescents two... Be patient instrumentation and provided an excellent outcome anchors [ 2,3 ] that was not on. Mt, Wind B, Mauch C, Ickler G, Friederich NF a ) fluoroscopydemonstrating. 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Advanced features are temporarily unavailable depending on location of the ACL in adults [ 1, 2 3. Error, unable to load your delegates due to an error, unable load. 1, 2, 3, 4, 5 ] operative kneeimmobilized in extension treatment may be nonoperative or depending... Bony fixation athletes, the first method involves non-operative treatment with casting or in!, 3.5-mm one-third tubular plate in bone remodelling at one or more skeletal sites bone attaches to tendon. And an inability to walk after a fall from height in adults assessment. Or bracing in non-displaced and stable fracture ligament to the tubercle fragment however, the first presentation this. Caused by knee extensor is very rare ; furthermore, non-traumatic fractures during running or bilateral fractures have incidence. With distal patellar tendon avulsion in an adult who suffered a left knee injury due an! Affecting physically active adolescents repeated overuse without tension tibial tuberosity avulsion fracture in adults suture in isolated tibial fracture. It has not been reported with proximal migration of the tibial tuberosity is rare!
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