Fracture of the anterior tibial tuberosity in children

Overview

This review by Rodriguez, Sepúlveda, Birrer and Tuca, published in EFORT Open Reviews in 2020, covers fractures of the anterior tibial tuberosity in children. They are uncommon, accounting for about 3% of proximal tibial fractures and under 1% of epiphyseal injuries, but are becoming more frequent, likely because of sports. They are most often seen in boys aged 12 to 14. The tuberosity is the site of patellar tendon insertion, and the fracture pattern depends on skeletal maturity and knee flexion at injury.

Presentation and associated injuries

Typical symptoms are sudden pain during a jump or sprint, inability to load or move the knee, swelling and, in intra-articular fractures, haemarthrosis. Osgood-Schlatter disease has been reported as a predisposing factor in up to 23% of cases. Because of the nearby popliteal artery, vascular status must be checked. Compartment syndrome is rare, at up to 4% before surgery in one systematic review, but can be devastating, and doctors should look for it in every case. Meniscal injuries occur mostly with intra-articular (Ogden type III and IV) fractures.

Imaging and classification

Frontal and lateral radiographs are the basis, with a high patella on the lateral view as a clue. CT helps show the extent of the fracture and any joint involvement, and MRI is reserved for suspected non-displaced fractures or meniscal injury. The Ogden classification, modified from Watson-Jones, is the most popular, with type IV added by Ryu and type V by McKoy.

Treatment

The goals are to restore the joint surface and the extensor mechanism and avoid damage to the proximal tibial physis. Non-operative treatment in extension for six weeks suits Ogden type I or II fractures with under 2 mm displacement. Otherwise, open reduction and internal fixation with cancellous partially threaded screws (ideally 4.0 mm) is the most common option, with periosteal repair in extensive avulsions, and 88% of published cases were treated surgically. After surgery the knee is protected for four to six weeks and rehabilitation takes about three months before sport.

Outcomes

Results are generally excellent, with union in 99% in one study. Complications occur in around 28%, mostly minor implant irritation or bursitis, with refracture in about 6% and genu recurvatum in under 4%.