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Tibial Tubercle Avulsions Indications and Techniques

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hello

the following video presentation reviews

avulsion fractures the tibial tubercle

here are disclosures in our discussion

of the evaluation and management of

tibial tubercle of Altru fractures we'll

spend some time reviewing the

epidemiology the relevant anatomy

typical findings on physical examination

and imaging and the classification of

these injuries will then discuss the

indications for growth operative and non

operative management approaches both

surgical rehabilitation and outcomes

reported in the literature the

presentation will conclude with a case

presentation tibial tubercle of aldryn

fractures are relatively rare injuries

were reported incidence of 0.4 to 2.7

percent of all facial injuries they most

commonly present in athletic males age

12 to 17 years the theory behind tibial

tubercle or bone fractures is that

increased athletic participation coupled

with higher intensity training creates

both intrinsic and extrinsic causes the

fracture at the level of tibial tubercle

slices in a scaly immature patient to

ossification centers exist within the

proximal tibia supplied by the recurrent

anterior tibial artery the tibial

tubercle faces can be exposed to

significant eccentric loads applied by

the extensor mechanism during strenuous

activity these eccentric loads generated

by quadriceps contraction during cutting

pivoting and jumping sports can

overwhelm the tibial tubercle physis

leading to an avulsion type injury when

tibial tubercle of aldrin fractures

occur they lead to the sudden onset of

Cygnet in pain and an inability to bear

weight on the affected side a large heme

arthrosis often develops quickly

following injury upon presentation the

patient is tendered to dread palpation

anteriorly will either be unable to

straight leg raise all have a

significant extensor lag present the

examining physician needs to perform a

careful vascular exam and assess the

patient's lower leg compartments as an

injury to the recurrent anterior tibial

artery may be present which can lead to

compartment syndrome the diagnosis of a

tibial tubercle emulsion fracture can

often be made solely on plain

radiographs with a displaced tibial

tubercle evident on the lateral view if

concerns for intra articular extension

exist a CT scan may be obtained for

improved characterization of the injury

and preoperative planning tibial

tubercle avulsion fractures are

classified according to the Watson Jones

classification type-1 fractures are most

common and are separated into type 1a

which show an incomplete separation of

the fragment from the metathesis and

type 1b would show a complete separation

with type 1 B fractures the impulsed

fragment of the tuberosities avulsed and

displaced approximately in type 2

fractures the tubercle epiphysis is

lifted entirely and proximally

separating the two Berg loss vacations

center as well as partially separating

the non articulate portion of the

proximal tibial epiphysis type 2a

fractures are non combinated and type 2b

show combination of the fracture

fragments with type 3 injuries the

fracture propagates from the tuberosity

in a proximal and posterior direction so

that involves the articular portion of

the proximal tibial epiphysis type 3a

fractures are often seen as a single

displaced fragment and type 3 beef show

evidence of comminution the respective

management type 1 fractures can

typically be treated non-operatively in

a cylinder cast with the knee in full

extension for a period of six weeks not

operative treatment requires that the

fracture fragment is with the knee and

extension with less than two millimeters

of displacement accepted the reduction

is evaluated on the lateral radiograph

with a knee and full extension

comparison of the position of the

tubercle and that of the patella are

made two radiographs of the

contralateral knee if greater than two

millimeters of displacement remains with

the knee and extension an operative

treatment is indicated displaced type 1b

type 2 and type 3 of ulsan fractures

require operative intervention with a

variety of techniques and approaches

reported type 3 fractures typically

require an Arthur Atum II to confirm an

anatomic particular reduction in

addition to an assessment of the menisci

which are commonly torn and associated

with higher grade injuries fixation of

the avulsed tubercle fragment can be

achieved with pins or screws inserted

perpendicular to the tubercle in the

proximal tibial metathesis for our case

presentation the patient is a healthy

active 17 year old high school soccer

player who during the soccer game

collided with the goalie and felt the

popping and harassment of his name

nearly from the injury had answered knee

pain and inability to bear weight he was

brought to the emergency room where

evidence and a displaced to tibial

tubercle of balls refraction he was

placed to a knee immobilizer admitted

overnight for cereal neurovascular

checks the following day he was brought

to the operating room for operative

management it is type 3a tibial tubercle

of vulture fracture

anatomic landmarks including the outline

of the patella the joint line and the

outline of the displays tibial tubercle

were marked out the midline incision was

made and soft tissue dissection was

performed down to the level the fracture

site straps were elevated both medially

and laterally further exposing the

displaced fracture fragment the fragment

was grasped with an ALICE clamp allowing

for exposure of the underlying fracture

bed fracture hematoma was removed from

the site of injury and the area was

thoroughly irrigated utilizing a curette

the fracture bed and the under surface

of the tibial tubercle fracture fragment

was abri did to tell the appearing bone

the cleveland tubercle fragment was then

reduced and provisionally fixed using

two threaded guide pins anatomic

reduction was confirmed using

intraoperative fluoroscopy nets the

proximal guide pin was removed and a

small vertical incision was made in the

patellar tendon allowing for insertion

of the drill guide the first four point

five millimeter cortical screw will

choose 58 millimeters in length was

inserted in Lag fashion approximately 15

millimeters distal to the first screw a

second four point five millimeter

cortical screw which was 60 millimeters

in length and a washer were similarly

inserted in lag fashion fluoroscopy

confirmed an anatomic reduction of the

tibial tubercle fracture fragment an

appropriate screw length to provide

additional distal fixation number two

high-strength suture material was passed

in cracow fashion through the distal 1.5

centimeters of the patellar tendon on

its medial side and fixed to the tibial

metathesis using a suture anchor

this was repeated on the lateral side

similarly passing number to

high-strength suture through the distal

1.5 centimeters the patellar tendon and

fixed to the tibial metathesis using a

second suture anchor the FLE suture ends

were then passed through the most distal

aspect of the torn patellar tendon

securing it to the underlying bone the

knee was taken through a gentle range of

motion confirming secure fixation in the

tibial tubercle the wounds then

thoroughly irrigated and closed in

layers starting with the power t9 layer

the skin was closed with a running

subcuticular Monaco suture and the wound

covered in surgical glue settle

dressings were then applied and the knee

was placed into hinged knee brace locked

and extension post-op early the patient

was kept non-weight-bearing with the

knee locked an extension for four weeks

at the four-week post-operative time

point he combines formal physical

therapy working on his knee range of

motion at two months postoperatively he

regained full range of motion and

started working on his quadricep

strengthening at the three-month

post-operative time point he was non

tender over Scipio tubercle at five out

of five quadricep strength and

post-operative radiographs demonstrated

a healed tibial tubercle he was allowed

back to training with a return to

support once his endurance had returned

there is little in the orthopedic

literature regarding the outcomes

following treatment of tibial tubercle

of alder fractures most studies are

small retrospective k-series the

available data indicates that excellent

results are typical with a high

percentage return to athletics with

minimal long-term sequelae potential

complications that can occur with the

management of tibial tubercle avulsion

fractures include the development of

compartment syndrome associated with the

injury acutely post-treatment

record of deformity post operative knee

stiffness hardware related complaints

including painful screw heads and

preside us over the tubercle and

recurrent fracture

thank you very much for your time and

attention

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