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CASE REPORT
Year : 2013  |  Volume : 13  |  Issue : 2  |  Page : 102-104

Avulsion fracture of tibial spine: A case report and review of literature


1 Department of Orthopedics and Traumatology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India
2 Department of Otorhinolaryngology and Head Neck Surgery, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India

Date of Web Publication20-Dec-2013

Correspondence Address:
Manoj Kumar
Department of Orthopedics and Traumatology, Mahatma Gandhi Institute of Medical Sciences, Sewagram - 442 102, Maharashtra
India
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DOI: 10.4103/1319-6308.123394

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  Abstract 

Fracture of the tibial spine is an uncommon injury, with an incidence estimated at 3:1,00,000 children per year. Sports and bicycling are the usual activities resulting in this fracture. The anterior spine is fractured many times more than the posterior. We are reporting a case of a 12-year-old female who presented with complaints of pain and swelling over left knee after falling from bicycle. Plane radiography and computed tomography scan showed tibial spine fracture with anterior cruciate ligament avulsion. Closed method was tried but reduction can not be achieved, finally open reduction and internal fixation done using 18 G stainless steel wires. Intraoperative movements of knee checked and fixation was found stable. The patient recovered progressively without any clinical signs of joint instability and returned to the same sport activity level that they had before the fracture.

  Abstract in Arabic 

إن كسر شوكة الظنبوب هي إصابة غير شائعة، بنسبة حدوث تقدر بـ 3 : 1000000 طفل في كل عام . الرياضة وركوب الدراجات هما من النشاطات الشائعة التي تسبب حدوث هذه الكسر. يحدث كسر الشوك الأمامي للظنبوب أكثر من كسر الشوك الخلفي . نقدم هنا حالة طفلة عمرها 12 عاما والتي طلبت العلاج بسبب ألم وانتفاخ في الركبة أليسري بعد السقوط من الدراجة الهوائية. أظهرت صور الأشعة السينية والتصوير الطبقي المحوسب كسر الشوكة الظنبوبية الأمامية مع قلع الرباط الصليبي الأمامي محاولة الرد المغلق لم تنجح . أخيرا تم فتح جراحي وتثبيت داخلي باستخدام سلك من الفولاذ المقاوم للصدأ مقاسهً 18 . تم مراقبة حركة الركبة أثناء العملية والتأكد من استقرار التثبيت. ولقد تعافت المريضة تدريجيا بدون أي علامات سريريه لعدم استقرار المفصل وعادت إلى نفس المستوي من النشاط الرياضي قبل حدوث الكسر




Keywords: Anterior cruciate ligament injury, cartilaginous avulsion, tibial spine


How to cite this article:
Kumar M, Malgonde M, Jain P. Avulsion fracture of tibial spine: A case report and review of literature. Saudi J Sports Med 2013;13:102-4

How to cite this URL:
Kumar M, Malgonde M, Jain P. Avulsion fracture of tibial spine: A case report and review of literature. Saudi J Sports Med [serial online] 2013 [cited 2021 Jun 25];13:102-4. Available from: https://www.sjosm.org/text.asp?2013/13/2/102/123394


  Introduction Top


The prevalence of avulsion injuries continues to rise as our population has become increasingly involved in sporting and other athletic activities, particularly over the past few decades. Although adolescents are particularly vulnerable to such injuries due to the weakness of their apophyses, adults may also be subject to avulsion fractures secondary to minor trauma or more substantial events such as motor vehicle collisions. The knee joint remains particularly susceptible to avulsion fractures due to its numerous tendinous, ligamentous, and meniscal attachments. The tibial spine or intercondylar eminence is the nonarticular bony prominence between the articular surfaces of the medial and lateral plateaux and serves as an attachment for the cruciate ligaments. Fractures of the intercondylar eminence of the tibia were first described by Poncet in 1875 [1] and have been considered to be the childhood equivalent of anterior cruciate ligament (ACL) ruptures in adults and may occur as a result of abnormal outward bending or twist, injuries caused by sudden halt of moving joints, excessive flexion and internal rotation as happens in skiing and also in motor vehicle accidents. Before ossification of proximal tibia is complete, the surface of spine is cartilaginous. When excessive stresses are applied to the ACL, the incompletely ossified tibial spine offers less resistance than does the ligament, resulting in a fracture through the cancellous bone beneath the tibial spine. [2] Traumatic forces that would cause a tear of the ACL in an adult commonly lead to a tibial spine fracture in a child. Tibial spine fracture may be associated with medial collateral ligament injury or meniscal injury.


  Case Report Top


A 12-year-old female child presented to our emergency department with pain, swelling in left knee and is reluctant to bear weight on affected extremity after having fallen off from her bicycle. Physical examination reveals a swollen left knee and decreased range of motion. Skin was intact. There was tenderness to palpation diffusely about the knee. Valgus stress at full extension and at 30° revealed an increased laxity on the left. Anterior draw and Lachman tests were also asymmetric with an increased excursion on the left. Neurovascular exam was unremarkable. Laboratory studies demonstrated a normal white blood cell count, erythrocyte sedimentation rate, and C-reactive protein level. Plane radiography showed avulsion of tibial spine without any posterior hinge. The anterior portion was completely separated and included a small amount of cancellous bone appeared to be a type III tibial eminence fracture as classified by Meyers and McKeever [Figure 1].
Figure 1: Plane radiograph of left knee antero‑posterior and lateral view showing avulsion fracture of tibial spine

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Computed tomography (CT) showed comminuted fracture of medial and lateral tibial spine with displacement of fracture fragments into knee joint. Fat blood interface sign was present in the knee joint. Rest of the visualized bones appeared normal [Figure 2].
Figure 2: CT scan left knee, axial sections showing displaced comminuted fracture of tibial spine

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After complete evaluation, fracture tibial spine was managed by open technique using medial parapatellar incision. Capsule opened medially to expose the fracture fragments and the defect in the proximal tibia. There was a large cartilaginous fracture fragment with small cancellous bone attached with distal part of ACL insertion. Knee was placed in extension and fracture fragment was reduced after clearing the clots and small cancellous bone pieces. Two holes drilled from distal to proximal through tibial epiphysis medial and lateral to the fracture fragment. A 18-gauge wire passed through most distal portion of ACL just proximal to the fracture fragments and through drill holes and tied them after satisfactory reduction. After fixation, flexion and extension movement checked to ensure stable reduction [Figure 3].
Figure 3: Postoperative radiograph showing anatomical reduction of tibia spine avulsion fracture using stainless steel wire of 18 G through open method

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A cast was applied with the knee in full extension. At 6 weeks, the cast was removed and range-of-motion exercises started [Figure 4].
Figure 4: Six weeks postoperative radiograph showing union at fracture site

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  Discussion Top


Tibial spine fractures are characterized by fractures at the insertion site of the (ACL) on the tibia. In children, this injury usually occurs secondary to forced flexion of the knee with internal rotation of the tibia and is not associated with other knee injuries. In adults, the injury results from severe hyperextension, such as that seen after motor vehicle collisions, and has a higher prevalence of associated injuries. Meyers and McKeever have described three main types of intercondylar fractures in children based on the amount of displacement and the fracture pattern seen in the initial radiographs. Type I is nondisplaced and does not interfere with knee extension. The type II fracture has a posterior hinge with the anterior portion being elevated. In this type, knee extension is generally limited, and there is a possibility that the anterior horn of the meniscus is caught under the anterior fracture fragment. A type III fracture is fully displaced, usually with the knee held in a mildly flexed position. [3],[4] On conventional radiographs, avulsion fractures of the ACL may be difficult to recognize. The appearance of a tiny bone fragment in the intercondylar notch with cortical irregularity of the adjacent tibial eminence suggesting a donor site for the fragment are the usual findings in this entity. CT and magnetic resonance imaging is useful to confirm that the fragment does in fact arise from the tibia and that the entire substance of the ACL is intact, as well as assessing for associated injuries. [5] The first two types can easily be managed by casting; there are recommendations both for casting in complete extension and in 10-20° of knee flexion. Operative reduction is indicated for all displaced [type II/III] fractures. The goal for operative treatment is to remove the soft tissue [usually the meniscus and blood clot] that is blocking reduction and to secure the reduction. Surgical treatment has included fixation with screws, sutures, or wires performed through either open or arthroscopic approaches. Optimal treatment methods remain controversial and are varied by classification type, surgeon preference, and patient age. [1],[3],[4],[6],[7],[8] No significant differences were found favoring one technique versus another.

ACL laxity has often been objectively noted on follow-up of type III injuries, but complaints or subjective instability is infrequent. Laxity specific to the ACL has been thought to be due to elongation and attenuation associated with tibial eminence fractures, [9],[10],[11],[12] whether such knees fare well over the course of a lifetime is not known.


  Conclusions Top


Patients with type I and II tibial spine fracture, if treated inappropriately, may still result in ACL laxity and knee muscle strength deficiency. Type III tibial spine fractures, if treated well by open reduction and internal fixation tend to recover nearly normal ACL function and muscle strength. With appropriate treatment, follow-up results are very good. Non-union is rare. Although mild, asymptomatic laxity of the ACL is often present after the final healing of the fracture. An anatomical reduction of the fracture does not eliminate the cruciate laxity or the loss of full knee extension. The overall prognosis is remarkably good even if the fracture fragment has been completely displaced.

 
  References Top

1.Burstein DB, Viola A, Fulkerson JP. Entrapment of the medial meniscus in a fracture of the tibial eminence. Arthroscopy 1988;4:47-50.  Back to cited text no. 1
[PUBMED]    
2.Kim JR, Song JH, Lee JH, Lee SY, Yoo WH. Cartilaginous avulsion fracture of the tibial spine in a 5-year-old girl. Skeletal Radiol 2008;37:343-5.   Back to cited text no. 2
[PUBMED]    
3.Meyers MH, Mc Keever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41:209-20.   Back to cited text no. 3
    
4.Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-84.  Back to cited text no. 4
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5.Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester D. Avulsion fractures of the knee: Imaging findings and clinical significance. Radiographics 2008;28:1755-70.   Back to cited text no. 5
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6.Eggers AK, Becker C, Weimann A, Herbort M, Zantop T, Raschke MJ, et al. Biomechanical evaluation of different fixation methods for tibial eminence fractures. Am J Sports Med 2007;35:404-10.  Back to cited text no. 6
[PUBMED]    
7.McLennan JG. The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Br 1982;64:477-80.  Back to cited text no. 7
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8.Berg EE. Pediatric tibial eminence fractures: Arthroscopic cannulated screw fixation. Arthroscopy 1995;11:328-31.   Back to cited text no. 8
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9.Baxter MP, Wiley JJ. Fractures of the tibial spine in children. An evaluation of knee stability. J Bone Joint Surg Br 1988;70:228-30.  Back to cited text no. 9
[PUBMED]    
10.Mah JY, Adili A, Otsuka NY, Ogilvie R. Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures. J Pediatr Orthop 1998;18:475-7.  Back to cited text no. 10
[PUBMED]    
11.Kocher MS, Foreman ES, Micheli LJ. Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children. Arthroscopy 2003;19:1085-90.  Back to cited text no. 11
[PUBMED]    
12.Mulhall KJ, Dowdall J, Grannell M, McCabe JP. Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-92.  Back to cited text no. 12
[PUBMED]    


    Figures

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



 

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