orthopedic specialists of seattle
Grant H. Garcia, MD

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

Grant H. Garcia, MD

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

Pediatric Tibial Spine Avulsions

Overview

  • 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

Epidemiology

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

Pathophysiology

  • 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

Prognosis

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

Anatomy

Osteology

  • 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

Ligaments

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

Presentations

Symptoms

  • 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

Imaging

Radiographs

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

CT

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

MRI

  • 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

Treatment

Non-operative

  • 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

Operative

  • 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
  • Brown University
  • University of Pennsylvania
  • Cornell University
  • Hospital for Special Surgery
  • Rush University Medical Center
  • American Orthopaedic Society for Sports Medicine
  • American Academy of Orthopaedic Surgeons
  • American Association of Nurse Anesthetists