Rev. bras. ortop. vol.51 número5

r e v b r a s o r t o p . 2016;51(5):610–613

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Anterior

avulsion

fracture

of

the

tibial

tuberosity

in

adolescents

–

Two

case

reports

夽

Aleilimar

Teixeira

da

Silva

Júnior,

Leonardo

Jorge

da

Silva,

Ulbiramar

Correia

da

Silva

Filho,

Edmundo

Medeiros

Teixeira,

Helder

Rocha

Silva

Araújo,

Frederico

Barra

de

Moraes

UniversidadeFederaldeGoiás,FaculdadedeMedicina,Goiânia,GO,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received15October2015

Accepted30October2015

Availableonline10August2016

Keywords:

Tibialfractures/surgery

Tibialfractures/radiography

X-raycomputedtomography

Kneeinjuries

a

b

s

t

r

a

c

t

Theobjectiveherewastoreporttworarecasesofanterioravulsionfractureofthetibial

tuberosityinadolescents.Case1wasa15-year-oldmalewhobecameinjuredthrough

land-ingonhisleftkneeandpresentedlimitedextension.Case2wasa16-year-oldbasketball

playerwhopresentedsuddenpainintherightkneeandfunctionalincapacity,afterajump.

Imagingexaminations(radiographsandcomputedtomography)showedanterioravulsion

fracturesofthetibialtuberosity.Surgicalfixationwasperformedusingscrewsandanchors,

whileavoidinggrowthplateinjury.Thecasesevolvedwithoutlower-limbdeformities.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Fratura-avulsão

tuberosidade

anterior

da

tíbia

em

adolescente

–

Relato

de

dois

casos

Palavras-chave:

Fraturasdatíbia/cirurgia

Fraturasdatíbia/radiografia

Tomografiacomputadorizadapor

raiosX

Traumatismosdojoelho

r

e

s

u

m

o

Oobjetivoérelatardoiscasosrarosdefratura-avulsãodatuberosidadeanteriordatíbiaem

adolescentes.Caso1:15anos,masculino,apresentoutraumaematerrissagememjoelho

esquerdo,comlimitac¸ãodaextensão.Caso2:16anos,jogadordebasquetecomdorsúbita

joelhodireitoeincapacidadefuncionalapóssalto.Examesdeimagem(radiografiase

tomo-grafias)evidenciaramasfraturas-avulsãodatuberosidadeanteriordatíbia.Feitafixac¸ão

cirúrgicacomparafusoseâncorasqueevitoualesãofisária.Evoluíramsemdeformidades

emmembrosinferiores.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora

Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudycarriedoutattheUniversidadeFederaldeGoiás,FaculdadedeMedicina,HospitaldasClínicas,DepartamentodeOrtopediae

Traumatologia,Goiânia,GO,Brazil.

∗ _{Correspondingauthor.}

E-mail:fredericobarra@yahoo.com.br(F.B.Moraes).

http://dx.doi.org/10.1016/j.rboe.2016.08.001

2255-4971/©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle

rev bras ortop.2016;51(5):610–613

611

Introduction

Theanteriortibialtuberosity(ATT)developsfromasecondary

ossificationcenterintheanterolateralaspectofthetibiain

contrasttotheossificationcenteroftheproximaltibia.The

ATTisanapophysisanddevelopsundertraction,1_whilethe

proximal tibial core is developed under compression. The

developmentofATTisdividedintofourstages:cartilaginous,

apophyseal,epiphysealandbony.2

ATT avulsion-fractures in children and adolescents are

rare,withfewcasesdescribedintheliterature,corresponding

to1%ofallgrowthplateinjuries,3_{occurringpredominantlyin}

males(approximately98%).4_{Theyaretheresultoftwo}

pos-sible mechanisms: (1) abruptknee flexion with quadriceps

contraction,typicalofjumplanding; (2)violent quadriceps

contractionwithafixedfoot,asinjumping.5–7

Theaimofthisstudyistoreporttworarecasesofavulsion

fractureoftheanteriortibialtuberosityinadolescentstreated

surgically.

Case

reports

Case1

A15-year-oldmalepatientunderwenttraumawhilelanding

onhisleftkneeduringsoccerpractice;hedevelopedleftleg

edemaandextensionlimitation.Duringexaminationhe

pre-sentedbruising,painonpalpationoftheATT,edema2+/4+

leftlegextensionimpairment.Radiographies(Fig.1)andCT

scan(Fig.2)ofthekneedisclosuredavulsionfractureofthe

anteriortibialtuberositywithavulsionofthebonefragment.

Thepatient underwent surgicaltreatment through

fixa-tion ofthe avulsed bone fragment with amalleolar screw

andwasher,andreinsertionofthepatellartendonwiththree

anchors (Fig. 3). Early rehabilitationwith fullload and full

rangeofmotionwasperformedwithintwomonths.Sports

practiceresumedaftersixmonthspostoperatively.The

radio-graphic controlshowed normal growth without lower-limb

discrepancy. Thepatientdevelopednorecurvatumor

ante-curvatum.

Case2

A16-year-oldpatient,avarsitybasketballplayer,had

sudden-onset pain intheright kneeand functional disabilityafter

jumpingduringagame.Anavulsionfracturewasdiagnosed,

with the ATT fragment extending into the joint (Fig. 4A

andB).Immediatecarewascarriedoutwithimmobilization

and surgical treatmentwas accomplished sevendaysafter

traumaduetosignificantedema.Fixationusingscrewsand

anchors wasperformed underfluoroscopy controltoavoid

growthplatelesion(Fig.4CandD).Physicaltherapy

rehabil-itationstartedontheseventhpostoperativeday;thepatient

Fig.1–Clinicalaspectoftheleftknee(A)comparedwiththecontralateralone,showingsevereedemaintheanterior region;anteroposteriorradiographyoftheleftknee(B)demonstratingsofttissueedema;inprofile(C)showingtheATT fragmentavulsion.

612

Fig.3–Intraoperativeimage(A)showingavulsedfragmentoftheATT;postoperativecontrolradiographiesin anteroposterior(B)andlateral(C)viewwithfixationusingscrewandanchors.

Fig.4–RadiographiesinAPandprofileoftherightkneeshowingATTavulsionfractureOgdentype3B(AandB); postoperativecontrolradiographies(CandD)after90daysofevolutionshowingconsolidationofATT.

developednolower-limbdeformitiesandreturnedtosports

practiceeightweeksafterthetrauma.

Discussion

Theavulsionfracturesoftheanteriortibialtuberosity

com-prehendahigher numberofinjuriesinmen,probably due

tothe highernumberofmenpracticingactivitiesinvolving

jumping.Inourcases,theyweretheresultsoftwopossible

mechanismsofaction:(1)abruptkneeflexionwithquadriceps

contraction,typicalofjump landing;(2)violent quadriceps

contractionwithafixedfoot,asinjumping.

Theoriginalclassificationsystemwascreatedby

Watson-Jones,8 _{whodefined threetypes.Type Iisan avulsionofa}

smallportionofthetibialtuberosity,distaltothephysisof

theproximaltibia;TypeIIinvolvesthewholephysis,butdoes

notextendtothekneejoint;typeIIIcorrespondstoavulsion

thatextendsproximallytothekneegrowthplate.

ThisclassificationwasmodifiedbyOgdenandSouthwick,1

aimingatamoreaccuratedefinitionofthespecificfracture

patternsandprovidingtreatmentfordifferenttypesof

frac-tures, including displacement and fragmentation. Ryu and

Debenham3_{thensuggestedaddingatypeIV,whichisa}

frac-tureofthetibialtuberositythatextendsposteriorlyalongthe

proximaltibialgrowthplate andcreatesanavulsionofthe

entireproximalepiphysis.Subsequently,theadditionofatype

CwasproposedbyFranklinetal.,9_{forfractureswith}

associ-atedavulsionofthepatellarligament.Finally,atypeVwas

suggestedbyMcKoyandStanitski10_{alsodescribedbyCurtis,}11

whichconsistedofafracturetypeIIIBwithanassociated

frac-turetypeIV,creatingaYconfiguration.

Thetreatmentoftheseinjuriesusingmethodsthatdonot

compromisefuturegrowthofthisregionrenderssome

diffi-cultyinmaintainingasatisfactoryfracturereductionagainst

the constant quadriceps pullforce. However, patientswith

thistypeofinjuryareoftenveryclosetotheendof

cartilagi-nousgrowth,whichallowsreductionandopenfixation,when

indicated,tobecarriedoutsafely.

Thus,typeIAOgdenfracturesareusuallytreated

conserva-tivelywithimmobilizationinextension,whileopenreduction

and rigidinternal fixation are recommended forthe other

types,withearlyphysicaltherapyrehabilitation.12_Webelieve

thatearlydiagnosisandearlysurgicaltreatmentallowedgood

functionalresultsandreturntosportspracticeinthesecases.

Among the possible complications of this injury are:

limbdiscrepancy,genorecurvatum,3,4_{patellabaja,nonunion,}

calcificationofthepatellartendonandanteriorcruciate

liga-mentinstability.1_{Complications,suchasthetibialtuberosity}

fractures are relatively uncommon. However,compartment

syndromeisapotentiallyseverecomplicationthatshouldbe

consideredimmediatelyafterinjury.3–5

Conflicts

of

interest

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1. OgdenJA,SouthwickWO.Osgood–Schlatter’sdiseaseand tibialtuberositydevelopment.ClinOrthopRelatRes. 1976;(116):180–9.

2. EhrenborgG,EngfeldtB.Theinsertionoftheligamentum patellaeonthetibialtuberosity.Someviewsinconnection withtheOsgood–Schlatterlesion.ActaChirScand. 1961;121:491–9.

3. RyuRK,DebenhamJO.Anunusualavulsionfractureofthe proximaltibialepiphysis.Casereportandproposedaddition totheWatson–Jonesclassification.ClinOrthopRelatRes. 1985;194:181–4.

4. PeslT,HavranekP.Acutetibialtubercleavulsionfracturesin children:selectiveuseoftheclosedreductionandinternal fixationmethod.JChildOrthop.2008;2(5):353–6.

5. AlbuquerqueRP,GiordanoV,CarvalhoACP,PuellT, AlbuquerqueMIP,AmaralNP.Fraturaavulsãobilaterale simultâneadatuberosidadetibialemumaadolescente:relato decasoeterapêuticaadotada.RevBrasOrtop.

2012;47(3):56–60.

6.CarvalhoJúniorLH,BenevidesWA,NogueiraFCS,Fonseca WV,AndradeRP.Fraturasdatuberosidadetibialanteriorem adolescentes.Relatodecasoserevisãodaliteratura.RevBras Ortop.1995;30(1):70–3.

7.JakoiA,FreidlM,OldA,JavandelM,TomJ,RealyvasquezJ. Tibialtubercleavulsionfracturesinadolescentbasketball players.Orthopedics.2012;35(8):692–6.

8.Watson-JonesR.Fracturesandjointinjuries.4thed. Baltimore:Williams&Wilkins;1955.

9.FranklU,WasilewskiSA,HealyWL.Avulsionfractureofthe tibialtuberclewithavulsionofthepatellarligament.Report oftwocases.JBoneJointSurgAm.1990;72(9):1411–3.

10.McKoyBE,StanitskiCL.Acutetibialtubercleavulsion fractures.OrthopClinNorthAm.2003;34(3):397–403.

11.CurtisJF.TypeIVtibialtuberclefracturerevisited:acase report.ClinOrthopRelatRes.2001;389:191–5.