Where is the tibial tuberosity
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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