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Avulsion Fracture of the Tibial Tuberosity with Patellar Ligament Rupture in an Adolescent Patient

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Avulsion Fracture of the Tibial Tuberosity with Patellar Ligament Rupture in an Adolescent Patient http://dx.doi.org/10.14517/aosm14013 Case Report pISSN 2289-005X·eISSN 2289-0068 Avulsion fracture of the tibial tuberosity with patellar ligament rupture in an adolescent patient Seung-Suk Seo, Do-Hun Kim, Moo-Won Kim, Jin-Hyeok Seo Department of Orthopaedic Surgery, Bumin Hospital, Busan, Korea Avulsion fracture of the tibial tuberosity generally occurs in the adolescent patient during sports activities. However, avulsion fracture of the tibial tuberosity combined with patellar ligament rupture is a rare occurrence. Here, we present the diagnosis and treatment of this rare case in an adolescent male. Keywords: Avulsion fracture; Tibial tuberosity; Patellar ligament INTRODUCTION Anterior and lateral radiographs of the knee were obtained: the lateral view showed an avulsion fracture Avulsion fracture of the tibial tuberosity usually occurs of the anterior portion of the tibial tuberosity, rotation in late adolescence when the tibial physis has begun to of the bone fragment, and high-riding patella (Fig. 1). fuse. However, avulsion fracture of the tibial tuberosity Such radiographic findings led us to suspect a patellar combined with patellar ligament rupture is an infrequent ligament rupture, and thus magnetic resonance imaging event that has been rarely reported in previous studies [1–3]. Here, we present surgical treatment results of this rare case of simultaneous avulsion fracture of the tibial tuberosity and patellar ligament rupture. CASE REPORT A 14-year-old boy visited our clinic with a major complaint of right knee pain. One day prior to presentation to our clinic, he suddenly felt the right leg gave way into flexion during jumping rope and then landed on the ground on the knee. At the time of presentation, he was not able to ambulate due to pain in the injured knee and loss of strength. Physical examination revealed severe knee swelling and a 3 × 3 cm minor skin abrasion over the inferior pole of the patella. Tenderness was noted over the tibial tuberosity and the distal patellar ligament was not palpable. Active knee extension and maintenance of Fig. 1. Lateral radiograph of the right knee shows avulsion fracture of passive extension were not possible. the tibial tuberosity and high-riding patella. Received August 4, 2014; Revised October 11, 2014; Accepted November 6, 2014 Correspondence to: Jin-Hyeok Seo, Department of Orthopaedic Surgery, Bumin Hospital, 59 Mandeok-daero, Buk-gu, Busan 616- Arthroscopy and 819, Korea. Tel: +82-51-330-3000, Fax: +82-51-337-5041, E-mail: [email protected] Orthopedic Sports Medicine Copyright © 2015 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine. All rights reserved. CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ AOSM by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 48 Arthrosc Orthop Sports Med 2015;2(1):48-50 Seung-Suk Seo, et al. Avulsion of tibial tuberosity with patella ligament rupture (MRI) scan was performed for confirmation. On the T2- exercises were performed progressively within pain-free weighted sagittal view, disruption of the patellar ligament range from 6 weeks after surgery. Normal range of motion insertion at the tibia and a fracture of the tibial tuberosity was achieved at 3 months after surgery. At 6 months after were observed (Fig. 2). surgery, normal extension muscle strength was obtained A median longitudinal incision was made on the ante- without recurrence of symptoms. The internal fixation rior knee and the patellar ligament rupture and tibial hardware was removed at 15 months after surgery. At the tuberosity fracture were identified (Fig. 3). The tibial last follow-up, the lateral radiograph of the knee showed tuberosity fracture was treated with anatomical recon- the fracture had haled despite the evidence of slight struction and cancellous screw fixation. For the patellar patella alta, pain or subjective symptoms appeared to ligament rupture, anatomical reconstruction and staple have disappeared, and the extensor strength was normal fixation were performed (Fig. 4). (Fig. 5). Postoperatively, cast immobilization was applied for 6 weeks. Passive joint exercises and active extension Fig. 4. Lateral radiograph of the right knee shows fixation of the avulsion Fig. 2. T2-weighted sagittal magnetic resonance imaging shows patella fracture with a cancellous screw and repair of the patella ligament with ligament rupture at the insertion site and displaced tibial tuberosity. a staple. Fig. 3. Intraoperative findings of the patella ligament rupture at the Fig. 5. The knee extensor strength returned to normal. insertion site and tibial tuberosity fracture. www.e-aosm.org 49 Seung-Suk Seo, et al. Avulsion of tibial tuberosity with patella ligament rupture DISCUSSION when combined with other conditions, such as patellar ligament ruptures, open surgery is more conducive Avulsion fracture of the tibial tuberosity frequently occurs to reposition of the displaced fragments under direct in late adolescent patients approaching physeal closure visualization of the patellar ligament [6]. For fixation of the due to eccentric contraction of the extensor mechanism. displaced fragments, screws, K-wires, and tension band In contrast, avulsion fracture of the tibial tuberosity with wires are available. Transosseous suturing, stapling, suture associated patellar ligament rupture has been rarely anchoring, and augmentation with a semitendinosus reported [1,2]. Regarding the mechanism of injury, Kaneko tendon graft are possible options for patellar ligament et al. [1] described that eccentric contraction of the ruptures and Achilles tendon grafting can be considered extensor mechanism initially results in avulsion fracture in cases of chronic ruptures [1,7–9]. In our patient, the of the tibial tuberosity, and further intensifies to the bone fragment was fixed with a cancellous screw, and point of causing a rupture of the patellar ligament. In our the patellar ligament was fixed with a staple for simple patient, it appeared that the tibial tuberosity fracture was and effective procedure. We did not perform additional caused by contraction of the extensor mechanism during augmentation after staple fixation based on the reports by jum ping rope, and hyperflexion of the knee upon landing Kaneko et al. [1] and Sie et al. [2], but augmentation may on the ground resulted in the patellar ligament rupture. improve the treatment outcome. As in previous studies Tibial tuberosity fractures can be easily diagnosed with [1,2,5], the treatment outcomes were successful in our radiography, but associated patellar ligament ruptures case: the patient did not exhibit any subjective symptoms are difficult to detect. Effusions disrupt palpation of the or muscle strength weakness during the 15-month follow- patellar ligament. Although flexion/extension lateral up, although the radiographic evidence of slight patella radiographs can be useful for diagnosis, these views are alta requires continuous follow-up. difficult to obtain due to patient pain and discomfort [3]. Based on the treatment experience, we believe avulsion Radiographic findings of patella alta and avulsion of the fracture of the tibial tuberosity with associated patellar tibial tuberosity can be clues to patellar ligament ruptures ligament rupture is rare but can be managed successfully [3], which can be confirmed with the use of arthroscopy, with proper diagnosis and treatment. MRI, and sonography [4,5]. In our case, MRI was conducted to confirm the patellar ligament rupture and CONFLICT OF INTEREST the absence of other cartilage damage. Tibial tuberosity fractures without other associated injuries can be treated No potential conflict of interest relevant to this article was by closed reduction or arthroscopic surgery; however, reported. REFERENCES 1. Kaneko K, Miyazaki H, Yamaguchi T. Avulsion fracture of the tibial 6. Zrig M, Annabi H, Ammari T, Trabelsi M, Mbarek M, Ben Hassine tubercle with avulsion of the patellar ligament in an adolescent H. Acute tibial tubercle avulsion fractures in the sporting adole- female athlete. Clin J Sport Med 2000;10:144-5. scent. Arch Orthop Trauma Surg 2008;128:1437-42. 2. Sie EJ, Kacou AD, Sery BL, Lambin Y. Avulsion fracture of the 7. Bushnell BD, Byram IR, Weinhold PS, Creighton RA. The use tibial tubercle associated with patellar ligament avulsion treated of suture anchors in repair of the ruptured patellar tendon: a by staples. Afr J Paediatr Surg 2011;8:105-8. biomechanical study. Am J Sports Med 2006;34:1492-9. 3. Kramer DE, Chang TL, Miller NH, Sponseller PD. Tibial tubercle 8. Falconiero RP, Pallis MP. Chronic rupture of a patellar tendon: a fragmentation: a clue to simultaneous patellar ligament avulsion technique for reconstruction with Achilles allograft. Arthroscopy in pediatric tibial tubercle fractures. Orthopedics 2008;31:501. 1996;12:623-6. 4. Hall BT, McArthur T. Ultrasound diagnosis of a patellar tendon 9. Larson RV, Simonian PT. Semitendinosus augmentation of acute rupture. Mil Med 2010;175:1037-8. patellar tendon repair with immediate mobilization. Am J Sports 5. Swan K Jr, Rizio L. Combined avulsion fracture of the tibial tubercle Med 1995;23:82-6. and avulsion of the patellar ligament. Orthopedics 2007;30:571-2. 50 www.e-aosm.org.
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