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Tibial Tubercle Fracture with Avulsion of the Patellar Ligament: a Case Report Renny Uppal, MD and E

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Tibial Tubercle Fracture with Avulsion of the Patellar Ligament: a Case Report Renny Uppal, MD and E (aspects of sports medicine • a case report & literature review) Tibial Tubercle Fracture With Avulsion of the Patellar Ligament: A Case Report Renny Uppal, MD and E. Dennis Lyne, MD Abstract extend his knee, and x-rays showed effusion, tenderness over the tibial Fractures of the tibial tubercle are a tibial tubercle fracture superior- tubercle, and a high-riding patella infrequent injuries in adolescents. A ly rotated 180° (Figure 1). He was and was still unable to extend the combined injury of the tibial tubercle instructed to follow up with a pediat- injured knee. On further evaluation, a and patellar ligament is an even more ric orthopedist. palpable defect was found in the loca- rare event. The literature includes At follow-up, the patient denied tion of the patellar ligament. Further only a few case reports of this injury preexisting knee symptoms. On scrutiny of the x-rays revealed patella pattern. In this article, we describe physical examination, he had a large alta and a calcification between the another case and a repair technique tibial tubercle and the patella (Figure 1). and try to increase awareness of this The patient was diagnosed with an combined injury. Ogden IIB6 tibial tubercle fracture associated with either a sleeve frac- ractures of the tibial tuber- ture or a patellar ligament avulsion, cle are infrequent injuries and surgery was recommended. in adolescents. A combined At surgery, the tibial tubercle was injury of the tibial tubercle completely displaced, and the patella Fand patellar ligament is an even more ligament had pulled off its distal rare event. The literature includes attachment with a small amount of only a few case reports of this injury bone (Figure 2). The surgeon reduced pattern.1-5 In this article, we describe the tubercle and fixed it with a par- a repair technique and try to increase tially threaded cancellous screw. The awareness of this combined injury. patella ligament was repaired back to the tubercle with a running and CASE REPORT locking No. 1 nonabsorbable suture An adolescent boy was running up through a bone tunnel in the tibia a hill and suddenly felt a pop in the Figure 1. Emergency department x-rays (Figures 3, 4). Length was deter- right knee, which gave out. The boy show displaced tibial tubercle fracture mined radiographically. The repair with calcification between patella and fell to the ground and was unable tibial tubercle. was reinforced with absorbable suture to stand on the extremity. He was taken to the emergency department for evaluation. He could not actively Dr. Uppal is Orthopaedic Surgeon, Reno Orthopaedic Clinic, Reno, Nevada. Dr. Lyne is Program Director, Orthopaedic Surgery, Michigan State University/ Kalamazoo Center for Medical Studies, Kalamazoo, Michigan. Requests for reprints: Renny Uppal, MD, Reno Orthopaedic Clinic, 555 N Arlington Ave, Reno, NV 89523 (tel, 775-786-3040; fax, 775-768-1358; e-mail, ruppal@gmail. com). Am J Orthop. 2007;36(5):273-274. Copyright 2007, Quadrant HealthCom Figure 2. Displaced tibial tubercle and Figure 3. Repaired tibial tubercle and Inc. avulsed patella ligament. patella ligament. May 2007 273 Tibial Tubercle Fracture With Avulsion of the Patellar Ligament perichondrium, and periosteum, and those with type III injuries in resulting in a tibial tubercle fracture. 4 to 6 months.12 Complications are It is proposed that, after 180° of rare. They include compartment syn- rotation, the soft-tissue attachments drome, loss of flexion, malunion, around the tibial tubercle prevent nonunion, patella infera, and frac- further displacement, and then the ture through the fixation device. A patella ligament avulses with contin- hypothetical complication in a young ued force. patient is genu recurvatum. The initial classification of tibial To the best of our knowledge, the lit- tubercle avulsions by Watson-Jones9 erature includes only a few case reports was modified by Ogden and col- of this combined injury pattern.1-3,5,13 leagues.6 Frankl and colleagues1 added We believe that the repair technique we type IC, which is a patella ligament have described allows for early reha- avulsion in addition to a IB injury. bilitation and successful outcomes. Associated injuries are infrequent. Figure 4. Postoperative x-ray. They include collateral ligament, AUTHORS’ DISclOSURE anterior cruciate ligament, meniscus, STATEMENT and knee extensor tendon avulsions. The authors report no actual or poten- to the periosteum. The knee was Compartment syndrome has been tial conflict of interest in relation to immobilized in extension in a cylin- reported, but only in type III injuries. this article. der cast for 4 weeks, then the patient It is postulated that the anterior tibial was placed in a hinged knee brace. recurrent artery is lacerated and retracts REFERENCES Quadriceps strengthening and active into the anterior compartment of 1. Frankl U, Wasilewski SA, Healy WL. Avulsion fracture of the tibial tubercle with avulsion of 10,11 motion were gradually advanced. the leg. the patellar ligament. J Bone Joint Surg Am. Four months after surgery, the patient The history often reveals an athlet- 1990;72:1411-1413. 2. Goodier D, Maffulli N, Good J. Tibial tuberosity was pain-free and had normal motion ic, mature-appearing male involved in avulsion associated with patellar tendon avul- and strength. He was instructed to jumping sports. The physical exami- sion. Acta Orthop Belg. 1994;60:235-237. 3. Mayaba J. Avulsion fracture of the tibial gradually resume activities as toler- nation demonstrates an effusion and tubercle apophysis with avulsion of patellar ated. One year after surgery, he was a palpable fragment, and the patient ligament. Pediatr Orthop. 1982;2:303-305. symptom-free. cannot actively extend the knee. 4. Mirbey J, Besancenot J, Chambers RT, Durey A, Vichard P. Avulsion fractures of the tibial Anteroposterior and lateral x-rays are tuberosity in the adolescent athlete. Am J LITERATURE REVIEW critical in the diagnosis. Flexion and Sports Med. 1988;16:336-340. 5. Schiedts D, Mukisi M, Bastaraud H. Avulsion Tibial tubercle fractures account for extension radiography or magnetic fracture of the tibial tubercle associated to less than 1% of physeal fractures resonance imaging may be indicated if an avulsion of the patellar ligament. Rev Chir Orthop Reparatrice Appar Mot. 1995;81:635- and approximately 3% of proximal associated injuries are suspected. 638. tibia fractures.7,8 Whether there is Management focuses on restora- 6. Ogden JA, Tross RB, Murphy MJ. Fractures an association with Osgood-Schlatter tion of the extensor mechanism. Type of the tibial tuberosity in adolescents. J Bone Joint Surg Am. 1980;62:205-215. disease is unclear. IA, IB, and IIA injuries are immobi- 7. Bolesta MJ, Fitch RD. Tibial tubercle avul- The developmental anatomy is crit- lized in a long leg cast for 4 weeks. sions. J Pediatr Orthop. 1986;6:186-192. 8. Hand WL, Hand CR, Dunn AW. Avulsion frac- ical in this injury. The proximal tibial Type IIB, IIIA, and IIIB injuries are tures of the tibial tubercle. J Bone Joint Surg physis extends anteriorly and distally treated with open reduction and inter- Am. 1971;53:1579-1583. 9. Watson-Jones R. Fractures and Joint Injuries, 4th below the tubercle. Physeal closure nal fixation (ORIF). Type IC injuries ed. Edinburgh: E. and S. Livingstone, 1955-56. begins centrally and extends periph- require ORIF of the tubercle. In addi- 10. Pape JM, Goulet JA, Hensinger RN. erally and then distally. Closure of tion, reattachment of the patella liga- Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop. 1993;295:201- the physis is complete at age 15 in ment is necessary. A tension band, 204. girls and age 17 in boys. screws, or Kirschner wires can be 11. Wiss DA, Schilz JL, Zionts L. Type III fractures of the tibial tubercle in adolescents. J Orthop The mechanism of injury is either used to obtain ORIF. Postoperative Trauma. 1991;5:475-479. quadriceps contraction with the leg management consists of a long leg 12. McKoy B, Stanitski C. Acute tibial tubercle avulsion fractures. Orthop Clin North Am. extended or rapid passive knee flex- cast for 3 to 4 weeks and then active 2003;34:397-403. ion with the quadriceps contract- range-of-motion exercises at 4 weeks. 13. Sullivan L, Lee CB, Simonian PT. Simultaneous ing. Traction by the patella ligament Patients with type I and type II inju- avulsion fracture of the tibial tubercle with avulsion of the patellar ligament. Am J Knee exceeds the strength of the physis, ries can return to sports in 2 months, Surg. 2000;13:156-158. 274 The American Journal of Orthopedics®.
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