Tibia tubercle avulsion fractures
BILATERAL TIBIAL TUBERCLE AVULSION FRACTURE IN A HIGH SCHOOL ATHLETE
Miles Gilbreath, PA-S
Special Thanks to Ann F Beach, MD- Children’s Healthcare of Atlanta
Tibial tubercle avulsion fracture is a rare complication of Osgood-Schlatter disease (OSD) commonly associated with a forceful eccentric contraction of the quadriceps during the landing phase of a jump in sports such as gymnastics and basketball. It is most common between the 14-16 years old during the physeal transition and close to the cessation of growth. Physical exam findings include swelling/tenderness over the anterior tibia, palpable bone fragment and hemarthrosis. In cases of significant fracture displacement, a high riding patella and lack of knee extension can also be appreciated. Tibial avulsion fractures can be described using the Ogden classification. These classifications are worth reviewing if managing a patient with this condition, working closely with pediatric patients or managing care of OSD patients. Bilateral tubercle avulsions, first described in 1954, have only been seldomly documented. A 2012 study reported only 15 cases published.
14 year 8 month old high school football player presented to a pediatric emergency department after transport by EMS. He had been 2.5 hours into his second football practice of the season when his legs “locked up” causing him to fall to his knees. His calved were exquisitely tender and he could not move. Paramedics were unable to straighten his legs on scene. He had limited water intake at practice due to “having to share”, had skipped breakfast and ate a normal lunch, he reports drinking protein shakes and muscle milk but was unaware of creatine content and had never experienced anything like this before.
Physical exam reveals 119 kg individual with significant musculature, exquisitely tender but supple calves, inability to move legs (including hip flexion) secondary to pain, non-wait bearing status, and 2+ dorsalis pedis pulses. Labs including CBC, CMP and CRP are unremarkable. CPK is slightly elevated at 1142 and the patient is hospitalized with a provisional diagnosis of Rhabdomyolysis with plan to repeat CPK the following day. At that time, lab values and physical exams are unchanged. Patient continues to refuse moving his legs and has tender shins. Orthopedics was consulted and radiographs were performed revealing bilateral tibial avulsion fractures extending posteriorly across the primary ossification centers (Ogden III).
The patient was taken to the operating room for ORIF. The procedure included fracture fixation achieved with partially threaded cortical screws and patellar tendon tether with the Mitek SuperAnchor.
A significant complication of the above repair is the potential for genu recurvatum deformity in which the anterior growth is arrested while the posterior growth continues resulting in decreased tibial slope
In cases of OSD, while common, patients should be advised of the risk of tubercle avulsion and in severe cases limit strenuous activity until radiographic resolution or skeletal maturity.
Elbaum R. Simultaneous bilateral tibial tubercle avulsion fracture in an adolescent: a case report. Acta Orthop Belg. 2011 Oct;77(5):696-701.
Maar DC, Kernex CB, Pierce RO. Simultaneous bilateral tibial tubercle avulsion fracture. Orthopedics. 1988 Nov;11(11):1599-601.
Steffes M, Shirley E. Tibial Tubercle Fracture. Orthobullets. orthobullets.com/pediatrics/4023/tibial-tubercle-fracture. Updated 11/17/2018.