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CASE REPORT
Year : 2017  |  Volume : 17  |  Issue : 1  |  Page : 57-59

Displaced closed avulsion of tibial tuberosity in a parkour enthusiast


1 Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
2 Department of Orthopaedics, Dr. B. R. Ambedkar Medical College, New Delhi, India

Date of Web Publication3-Jan-2017

Correspondence Address:
Dr. Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
India
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DOI: 10.4103/1319-6308.197473

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  Abstract 

Tibial tuberosity avulsion injury in isolation is a rare form of knee trauma. The associated damage to the knee extensor mechanism calls for adequate management for good functional regain. Most of the reported cases in literature consist of children and adolescent patients and the injury in adults is an uncommon pattern. Very few of the tuberosity fractures have concomitant patellar tendon avulsion. We present a case of this rare injury in a parkour learner who sustained this injury while practicing one of his stunts. The operative management and compliant physiotherapy ensured a satisfactory outcome.

  Abstract in Arabic 

القلع المغلق المزاح لحدبة عظم الساق الاعظم - تقرير حالة
اصابة اقتلاع حدبة الساق العظم المنفردة من الاصابات النادرة للركبة. والعطب المرافق لعملية مد الركبة يتطلب معالجة كافية لاستعادة الوظيقة جيداً. أغلب الحالات التي سجلت في الكتب تتكون من المرضى الاطفال واليافعين حيث ان الاصابة في البالفين غير شائعة. القليل جداُ من كسور الحدبة يصاحبها اقتلاع لأوتار العظم المتحرك للركبة. نقدم حالة لهذه الاصابة النادرة لمتدرب حدثت اصابته اثناء ممارسته لأحدى ألعابه. المعالجة الجراحية و العلاج

Keywords: Avulsion fracture, injury, internal fixation, jumping sports, management, open reduction, tibial tuberosity, trauma


How to cite this article:
Dharmshaktu GS, Khan I. Displaced closed avulsion of tibial tuberosity in a parkour enthusiast. Saudi J Sports Med 2017;17:57-9

How to cite this URL:
Dharmshaktu GS, Khan I. Displaced closed avulsion of tibial tuberosity in a parkour enthusiast. Saudi J Sports Med [serial online] 2017 [cited 2019 Jun 19];17:57-9. Available from: http://www.sjosm.org/text.asp?2017/17/1/57/197473


  Introduction Top


Parkour or free running is a sport involving acrobatic moves with the body to navigate around objects while the body is moved through spaces overcoming obstacles. It requires the use of muscular power, agility, and speed to succeed in this highly physically demanding hobby. The sport has gained popularity through various entertainment media with many youngsters trying to learn and perfect this art form. The tibial tuberosity avulsion results from an excessive knee flexion in the setting of contracted quadriceps with fixed feet.[1] The spectrum of the injury may involve rupture of patellar tendon in the continuum. The appropriate management with repair of the extensor mechanism of the knee is vital element to manage this injury. The misstep or misjudgmental landing in the parkour may lead to abnormal stress over knee extensor mechanism which may at times yield to various forms of related injuries.


  Case Report Top


A 28-year-old male patient was brought to our emergency department with complaints of difficulty in bearing weight and ambulation from left lower extremity. There was a history of injury to the left knee area while undergoing physical practice of parkour training. The injury took place during one of the drill involving heavy jumping over a wall that rendered him abandon the practice further. There was immediate pain followed by the disability. On clinical examination, there were no signs of skin breakdown, wound or ecchymosis. There was mild swelling in the infrapatellar area that was tender. On careful palpation, there was a defect noted in the continuity of patellar tendon with the suggestion of a bony fragment in the infrapatellar area. There was no patellar tenderness. The active and passive range of motion was limited with pain, and distal neurovascular status was intact. There was a history of no history of pain over the affected area. History of any chronic disease, medication or substance abuse was negative. The patient has been practicing parkour training since 6 months as part of a group.

A radiograph of the affected knee in two planes was evaluated to show a displaced avulsion of tibial tubercle [Figure 1]. There was no associated bony trauma. The avulsed fragment was displaced and rotated ninety degree from its native position. Surgical management was advised and written informed consent was taken. Any further investigations apart from that required for anesthesia fitness were declined by the patient. The surgical incision of about 6 cm. over the affected tuberosity and distal patellar pole was made followed by careful superficial and deep dissection to reach the avulsed fragment and the native site. There was ruptured patellar tendon injury which was repaired with absorbable sutures [Figure 2]a. The avulsed fragment was put back to the site and held with a towel clip and was fixed with guidewire over which a cannulated cancellous screw was secured into the fragment [Figure 2]b. Only one screw could be inserted without damaging the small fragment. The screw engaged into proximal tibial metaphysic with adequate stability. The position of the screw was confirmed on fluoroscopy and radiograph postoperatively [Figure 2]c and d. An above knee plaster slab was given for 2 weeks till sutures were removed uneventfully. A cast for 2 more weeks was given for adequate healing and quadriceps strengthening exercises started. It was followed by a functional knee brace was given with weight bearing to tolerance. After 6 weeks, a supervised physical therapy and rehabilitation was undertaken with a gradual increase in the range of movement and strength.
Figure 1: Radiograph in both planes showing the avulsion of tuberosity

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Figure 2: Operative images showing patellar tendon avulsion (a) and its provisional fixation with Kirschner wire before screw insertion (b). Postoperative biplanar radiographs showing the fixation with a cannulated screw (c and d)

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  Results Top


The results of a meticulous and compliant physiotherapy resulted in full regain of a range of motion with no extension lag. The fracture showed gradual radiographic union [Figure 3]. The patient could squat, stand and ambulate without support and pain [Figure 4]. He joined the sport after 4 months with guarded prognosis. At last follow-up, he willingly withdrew from the parkour group and was engaged in other sports activities.
Figure 3: Radiograph at 1 year follow up showing united avulsed fragment

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Figure 4: Functional regain shown with full extension and ability to squat and stand independently

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  Discussion Top


Tibial tuberosity injury is rare and accounts for only 3% of proximal tibia fractures.[2] The immature skeleton is susceptible to injuries in this region as most of the cases are reported in pediatric age, but that too are uncommon with less than 1% of all epiphyseal injuries.[3] The injury may have associated concomitant injuries to adjacent soft tissues or patellar tendon.[4] The injury pattern has been extensively reported in the adolescent population. The occurrence of the injury in adults is uncommon with fewer reports.[5] Many of such injuries in adults have been described in patients with advanced age or chronic health problems like diabetes mellitus.[6] Care should be taken to rule out bifocal patellar tendon avulsion from both lower patellar and tuberosity. The injury has been associated with various other underlying comorbidities such as  Osgood-Schlatter disease More Details, Paget's disease, osteomalacia, and occurrence in healthy subjects is rare posttraumatic event. The knowledge and anticipation of a pattern of injury associated with high-risk sports might help prevent or mitigate the injury. This report also underlines the importance of appropriate management and compliant rehabilitation program as crucial element to recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Levi JH, Coleman CR. Fracture of the tibial tubercle. Am J Sports Med 1976;4:254-63.  Back to cited text no. 1
    
2.
Bolesta MJ, Fitch RD. Tibial tubercle avulsions. J Pediatr Orthop 1986;6:186-92.  Back to cited text no. 2
    
3.
Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop 1990;10:713-6.  Back to cited text no. 3
    
4.
Uppal R, Lyne ED. Tibial tubercle fracture with avulsion of the patellar ligament: A case report. Am J Orthop (Belle Mead NJ) 2007;36:273-4.  Back to cited text no. 4
    
5.
Vella D, Peretti G, Fra F. One case of fracture of the tibial tuberosity in the adult. Chir Organi Mov 1992;77:299-301.  Back to cited text no. 5
    
6.
Chautems R, Michel J, Barraud GE, Burdet A. Bifocal avulsion of the patellar tendon in an adult: A case report. Rev Chir Orthop Reparatrice Appar Mot 2001;87:388-91.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Results
Discussion
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