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CASE REPORT
Year : 2021  |  Volume : 21  |  Issue : 2  |  Page : 69-72

Posterior cruciate ligament avulsion fracture in skeletally immature patient


Department of Orthopedics, King Fahad General Hospital, Almadinah Almunawwarah, Saudi Arabia

Date of Submission12-Mar-2021
Date of Acceptance25-Apr-2021
Date of Web Publication02-Oct-2021

Correspondence Address:
Abdulmuhsen N Alshammari
Department of Orthopedics, King Fahad General Hospital, Almadinah Almunawwarah
Saudi Arabia
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DOI: 10.4103/sjsm.sjsm_8_21

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  Abstract 


Posterior cruciate ligament (PCL) avulsion fractures occurred less frequently in children than in adults. A low threshold of suspicion is required to avoid delaying or even missing the diagnosis due to the rare presentation of these cases. This report represents a rare case of a skeletally immature patient with PCL avulsion fracture from tibial attachment, which was treated surgically. Along with a case report, we also provide a review of other studies.

Keywords: Avulsion fracture, internal fixation, pediatrics, posterior cruciate ligament


How to cite this article:
Karbouji MA, Alamri TJ, Akram AS, Shams AS, Alshammari AN. Posterior cruciate ligament avulsion fracture in skeletally immature patient. Saudi J Sports Med 2021;21:69-72

How to cite this URL:
Karbouji MA, Alamri TJ, Akram AS, Shams AS, Alshammari AN. Posterior cruciate ligament avulsion fracture in skeletally immature patient. Saudi J Sports Med [serial online] 2021 [cited 2021 Dec 8];21:69-72. Available from: https://www.sjosm.org/text.asp?2021/21/2/69/327488






  Introduction Top


Posterior cruciate ligament (PCL) avulsion fracture from the tibial attachment occurred less frequently in children than in adults.[1] PCL avulsion fracture likely occurs due to the elasticity of the ligament in children. In addition, the physis and bone are relatively weaker than the ligament, which results in avulsion injury instead of mid-substance ligament tear as noticed in adults.[2] Road traffic accidents and sports activities are the leading causes of PCL avulsion injuries in the pediatric population. These injuries usually occurred either by a direct hit to the proximal leg in a flexed knee or a sudden hyperextension.[1] The physical examination can be difficult in early presentation due to pain and swelling. Therefore, a high suspicion index is required to avoid delaying or even missing the diagnosis. At presentation, especially if the injury results from high-energy trauma, it is recommended to do a thorough vascular assessment to rule out vascular injury.[2] Radiological imaging is essential for the proper diagnosis and treatment, as for this kind of fracture, no clear guidelines for managing such cases. Many treatment guidelines of PCL avulsion fracture injury are based on studies of adults due to the scarcity of relevant literature.[3] Whether to go for conservative or surgical management, both are valid options. Nonoperative management with a long leg cast has been reported with good results.[4] On the other hand, good outcomes have been reported in the literature for the operative treatment of tibial avulsion fracture of PCL in growing children.[1],[5],[6],[7] Several surgical approaches, techniques, and fixation methods have been described and reported for managing this type of injury.[1],[8] We report a skeletally immature patient with a tibial avulsion fracture of PCL, and the current literature was reviewed [Table 1]. The patient was treated surgically by open reduction and internal fixation of the avulsed fragment with a 4.5 mm cannulated screw through a posteromedial approach.
Table 1: Various options of posterior cruciate ligament avulsion management

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  Case Report Top


A 16-year-old boy was brought to our trauma bay after involving in a head-on car collision. The primary survey indicated a stable patient. The secondary survey revealed knee pain and swelling. Physical examination revealed diffuse knee tenderness, especially over the popliteal fossa with restriction of range of motion. Knee stability could not be adequately examined due to pain. The plain radiograph showed a posterior tibial plateau avulsion fracture at the PCL attachment [Figure 1]a and [Figure 1]b. Computed tomography (CT) scan [Figure 2] and magnetic resonance imaging (MRI) [Figure 3] confirmed posterior tibial plateau epiphyseal avulsion fracture at the PCL attachment. The fracture extends to the growth plate with intra-articular extension and few bony fragments representing Salter-Harris Type III. The other knee structures including ligaments, menisci, and the extensor mechanism were normal. The tibial fragment presented a maximal displacement of 5.8 mm, which was measured on the sagittal view of the CT [Figure 2]. Operative management was recommended to the guardian, and written consent was taken. The surgery was performed under general anesthesia. The knee examination under anesthesia revealed a positive posterior drawer test. Then, the patient was moved into a prone position with 30° flexion at the knee joint, and a tourniquet was applied. Hockey-stick incision was used with a posteromedial approach of Burks and Schaffer to the knee. The interval was identified between the medial head of the gastrocnemius muscle and the semimembranosus tendon. The medial head of the gastrocnemius was gently retracted to the lateral side with the neurovascular bundle using a large, broad retractor. Careful deep dissection was done until the posterior knee capsule was recognized and vertically incised. After identifying the fracture site, the avulsed fragment was reduced using a pointed reduction tool [Figure 4], and a 4.5 mm cannulated partially threaded screw with a washer was applied. Wound closed in layers. Dressing and knee immobilizer in 30° flexion was applied. Postoperatively, the patient was on a knee immobilizer in 30° flexion for 2 weeks. At the first follow-up in 2 weeks postoperatively, quadriceps strengthening and limited prone knee range of motion were initiated. However, the knee immobilizer was continued and was removed only during the physiotherapy sessions. At 8 weeks postoperatively, with a view to overwhelm knee extension lag and stiffness, the patient was encouraged to do closed chain quadriceps exercise and gradual weight-bearing. Full knee flexion and extension were regained by the end of the 7th month, and plain radiographs indicated fracture healing with no hardware complications [Figure 5]a and [Figure 5]b. By the end of 1 year, the patient regained his whole strength and returned to daily activities.
Figure 1: Initial posttraumatic anteroposterior (a) and lateral (b) radiographs of the knee showing posterior tibial plateau avulsion fracture at the Posterior cruciate ligament attachment

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Figure 2: Computed tomography knee, Sagittal view showing posterior tibial plateau epiphyseal avulsion fracture at the Posterior cruciate ligament attachment extends to the growth plate with intra-articular extension

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Figure 3: Sagittal T2-weighted Spin-Echo magnetic resonance image showing proximal tibia Salter-Harris type III fracture with Posterior cruciate ligament bony avulsion injury

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Figure 4: Intraoperative photograph demonstrating the avulsed fragment (asterisks) reduced using a pointed reduction tool directing caudal

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Figure 5: Anteroposterior (a) and lateral (b) radiographs of the knee at 7 months postoperatively showing adequate fracture healing with accepted sagittal and coronal alignment

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  Discussion Top


Diagnosis of PCL avulsion fracture is based mainly on radiographic analysis. The MRI scan is the confirmatory study for the diagnosis of PCL injury. The plain radiograph can detect the PCL avulsion fracture if it is primarily a bony fragment. However, the unremarkable plain radiograph images cannot exclude these injuries.[9] Three-dimensional CT is used to detect the amount of displacement of the fragment and any comminution.[5],[10] Clinical examinations such as positive posterior drawer and quadriceps-active tests indicate PCL injury but cannot differentiate an avulsion fracture from a ligamentous tear.[3] PCL avulsion injuries can be treated operatively or nonoperatively, depending on the amount of the avulsed fragment's displacement. Yoon et al. reported in a study that was conducted in the adult population. If the displacement is <6.7 mm on the sagittal view of the MRI image, the nonoperative treatment should be considered.[11] Otherwise, this fragment will not unite and need open reduction and surgical fixation.[12]

Hurni et al. reported an 11-year-old boy with an isolated avulsion fracture of the PCL after a fall while skiing. The tibial fragment's displacement was 7 mm and was treated conservatively with a long leg cast in 30° of knee flexion for 6 weeks. MRI was repeated after 10 months which showed a complete union of the tibial attachment of PCL. After a 14-month follow-up, physical examination was unremarkable, and the patient was doing the daily activities with no symptoms.[4] Abdulaziz Al-Ahaideb reported an 11-year-old boy with an avulsion of PCL tibial attachment who underwent surgical fixation using a 3.5 mm cannulated screw. After a 4-year follow-up, the patient could do all the daily activities and participate in sports activities.[1]

Ugutmen et al. reported a 13-year-old boy with isolated avulsion of the PCLs tibial attachment after a fall from a bicycle. The patient underwent surgical fixation by a 3.5 mm cancellous screw parallel to the physis. The outcome was excellent during follow-up that extends until the physis is closed.[6] Pandya et al. reported a 14-year-old boy with a PCL avulsion of tibial attachment after falling while playing football. The case was treated surgically, and the fragment was fixed by bioabsorbable anchors. Another study reported a 12-year-old girl who had a PCL avulsion from tibial attachment after trauma to a flexed knee. The patient was managed surgically by a 4.0 mm cannulated screw and washer. Both patients returned to full sporting activities.[5]

Solayar and Kapoor reported a 13-year-old boy who directly hit the knee while playing soccer. MRI showed PCL tibial attachment avulsion and medial meniscus tear of the posterior horn. Three days after the injury, the patient underwent surgical fixation of the avulsed fragment through a posterior knee approach and fixation by a 3.5 mm partially threaded cancellous screw that did not cross the physis. The medial meniscus tear was repaired. After 6 months of follow-up, the patient had a stable knee and returned to sporting activities.[7] In the present case, we decided to utilize the posteromedial approach because it is safe, away from the neurovascular bundle, and provides good exposure to the fragment. Because our patient is near skeletal maturity, we did cross the physis, but we recommend avoiding it if possible, in younger children. If the size of the fragment allows, adding another screw to avoid rotation of the fragment is preferred. At 1-year follow-up, the patient regained his full strength and returned to full daily activities. Beginning with a postoperative progressive physical therapy program in such cases will spare the patient the consequences of knee stiffness and limitation of range of motion, which speeds up the recovery process and regaining the knee movement.


  Conclusion Top


Based on the review of available current literature and our case report, surgical management can be considered in the skeletally immature patient with displaced PCL avulsion injury. Complete clinical assessment and analysis of images are crucial to confirm the diagnosis and exclude other knee injuries. A posteromedial surgical approach to the knee as described by Burks and Schaffer, is safe, away from the neurovascular bundle, and provides good exposure to the fractured fragment in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Al-Ahaideb A. Posterior cruciate ligament avulsion fracture in children: A case report with long-term follow-up and comprehensive literature review. Eur J Orthop Surg Traumatol 2012;23 Suppl 2:257-60.  Back to cited text no. 1
    
2.
Hesse E, Bastian L, Zeichen J, Pertschy S, Bosch U, Krettek C. Femoral avulsion fracture of the posterior cruciate ligament in association with a rupture of the popliteal artery in a 9-year-old boy: A case report. Knee Surg Sports Traumatol Arthrosc 2006;14:335-9.  Back to cited text no. 2
    
3.
Kannus P, Bergfeld J, Järvinen M, Johnson RJ, Pope M, Renström P, et al. Injuries to the posterior cruciate ligament of the knee. Sports Med 1991;12:110-31.  Back to cited text no. 3
    
4.
Hurni Y, De Rosa V, Gonzalez JG, Mendoza-Sagaon M, Hamitaga F, Pellanda G. Pediatric posterior cruciate ligament avulsion fracture of the tibial insertion: Case report and review of the literature. Surg J (N Y) 2017;3:e134-8.  Back to cited text no. 4
    
5.
Pandya NK, Janik L, Chan G, Wells L. Case reports: Pediatric PCL insufficiency from tibial insertion osteochondral avulsions. Clin Orthop Relat Res 2008;466:2878-83.  Back to cited text no. 5
    
6.
Ugutmen E, Sener N, Eren A, Beksac B, Altintas F. Avulsion fracture of the posterior cruciate ligament at the tibial insertion in a child: A case report. Knee Surg Sports Traumatol Arthrosc 2006;14:340-2.  Back to cited text no. 6
    
7.
Solayar GN, Kapoor H. PCL tibial avulsion with an associated medial meniscal tear in a child: A case report on diagnosis and management. J Pediatr Orthop B 2012;21:356-8.  Back to cited text no. 7
    
8.
Gavaskar AS, Karthik B, Gopalan H, Srinivasan P, Tummala NC. A novel MIS technique for posterior cruciate ligament avulsion fractures. Knee 2017;24:890-6.  Back to cited text no. 8
    
9.
Loos WC, Fox JM, Blazina ME, Del Pizzo W, Friedman MJ. Acute posterior cruciate ligament injuries. Am J Sports Med 1981;9:86-92.  Back to cited text no. 9
    
10.
Quintart C, Elbaum R. A case of isolated avulsion fracture of the posterior cruciate ligament in a child. Rev Chir Orthop Reparatrice Appar Mot 1999;85:617-20.  Back to cited text no. 10
    
11.
Yoon KH, Kim SG, Park JY. The amount of displacement can determine non-operative treatment in posterior cruciate ligament avulsion fracture. Knee Surg Sports Traumatol Arthrosc 2021;29:1269-75.  Back to cited text no. 11
    
12.
Trickey EL. Injuries to the posterior cruciate ligament: Diagnosis and treatment of early injuries and reconstruction of late instability. Clin Orthop Relat Res 1980;(147):76-81.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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Case Report
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