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Grant H. Garcia, MD

Grant H. Garcia, MD Orthopedic Surgeon & Sports Medicine Specialist View Profile

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Grant H. Garcia, MD

Grant H. Garcia, MD Orthopedic Surgeon & Sports Medicine Specialist View Doctor Profile

Pediatric Tibial Spine Avulsions

Dr. Garcia’s newest technique to fix ACL tibial spine using the new ACL tightrope system


  • 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
    • treatment is closed reduction and casting or open reduction and fixation depending on the degree of displacement and whether it can be reduced


  • incidence
    • 2-5% of knee injuries with effusion in the pediatric population
  • demographics
    • most common in ages 8-14


  • traumatic mechanism
    • rapid deceleration or hyperextension/rotation of the knee, as in sports
    • same mechanism that would cause ACL tear in adult
    • fall from bike or motorcycle (typically resulting in hyperextension)

Associated conditions

  • occur in 40% of eminence fractures
    • meniscal injury
    • collateral ligament injury
    • capsular damage
    • osteochondral fracture


  • overall prognosis is good with 85% returning to prior level of sport



  • tibial eminence
    • non-articular portion of the tibia between the medial and lateral tibial plateau
    • Consists of two spines: ACL attaches to medial spine
    • ACL insertion is 9mm posterior to the intermeniscal ligament and adjacent to anterior horns of meniscus
    • PCL does not attach to tibia spines
  • Pediatric specific
    • Intercondylar eminence in incompletely ossified and is more prone to failure than ligamentous structures
    • Failure occurs through deep cancellous bone
    • Fracture usually confined to intercondylar eminence, but it may propagate to tibial plateau, medial is most common


  • anterior cruciate ligament inserts 10-14 mm behind anterior border of tibia and extends to medial and lateral tibial eminence



  • severe swelling and pain in the knee
  • inability to bear weight

Physical exam

  • inspection
    • immediate knee effusion due to hemarthrosis
    • Knee usually in flexed position
  • ROM
    • often limited secondary to pain
    • once pain is controlled, lack of motion may indicate
      • meniscal pathology
      • displaced/entrapped fracture fragment positive anterior drawer



  • recommended views
    • AP
    • lateral
      • most useful for determining fracture displacement
    • intercondylar
    • oblique
      • helpful in determining the extent of tibial plateau involvement


  • useful for pre-operative planning
  • used when fracture displacement cannot be determined by plain radiographs


  • better at determining associated ligamentous/meniscal damage than CT or radiographs
  • Majority of fractures show no additional internal derangement (meniscus injuries)
    • 15-37% of cases have associated intra-articular pathology



Dr. Garcia demonstrates his all suture technique for ACL repair and ACL tibial spine repair.

  • closed reduction, aspiration of hemarthrosis, immobilization in full extension
    • indications
      • non-displaced type I and reducible type II fractures
    • reduction technique
      • see techniques below
    • immobilization
      • cast in extension for 3-4 weeks
        • patients get extremely stiff with prolonged immobilization
        • allows for gradual rehab program


  • ORIF vs. all-arthroscopic fixation
    • indications
      • Type III or Type II fractures that cannot be reduced
        • type II fractures may fail to reduce due to the entrapped medial meniscus, entrapped intermeniscal ligament, or the pull of the lateral meniscus attachment block to extension

Tibial Spine ACL Repair Testimonial