A Rare Combination of Avulsion Fractures Around the Knee –A Case Report

Abstract

A 24-year-old male presented to Department of Orthopaedics St. Martha's hospital with a history of sustained injury to both his knees. While unloading heavy stone bars from a vehicle, the object fell on legs from behind forcing the both knee joints into flexion and external rotation, followed by hitting of his both knees to the wall in front of him. In emergency room, clinical examination revealed a marked effusion in knees, crepitus and tenderness over inferior pole patella on both sides. Lachman test was positive (grade 2) on right side and it was negative on left side, varus and valgus stress test was negative on both sides. Active extension of both legs was present. X-ray imaging of both knees showed a bilateral inferior pole of patella fracture with minimal displacement, bilateral small bony avulsion on the AP view which is elliptical in outline near the lateral tibial condylar articular margin suggested Segond fracture and tibial spine avulsion on right knee b]. MR imaging and CT scan [Table/ Fig-4] confirmed the ACL on right knee with avulsion fracture of patella with contusion of lateral tibial condyle. Further imaging of right knee was not undertaken as there was no clinical instability. Examination under anaesthesia revealed bilateral pivot shift test positive co-relating our radiological findings of bilateral ALL avulsion. Patient was treated by arthroscopic right ACL avulsion fixation with pull through technique over suture disc. Bilateral patella inferior pole fracture was treated conservatively with knee brace since the extensor mechanism was intact. Segonds fracture was treated conservatively with brace. surgical technique: Diagnostic arthroscopy was carried out to assess additional injuries like meniscal injury, chondral injury and other ligament tears. Fracture crater was adequately cleaned. Two drill holes were made with 2.7 mm guide wire with the help of ACL jig, medial and lateral to ACL and exiting out on medial tibial cortex. With the Arthroscope in lateral portal, 90 degree suture lasso was passed through medial portal and through the posterior half of ACL substance close to fragment and the suture loop retrieved through lateral portal. A ETHIBOND (no. 2) was passed through the loop and taken out through medial portal. This step was repeated in a similar manner through anterior half of substance of ACL [ Patella fractures, tibial spine avulsion and Segond fractures are mainly due to trauma to the knee which may be direct or indirect injuries. While each entity is well documented when occurring in isolation, but bilateral inferior pole patella fracture, tibial spine avulsion in the right knee and bilateral segond fracture in a same patient is a rare occurrence. We report a case of 24-year-old male with such an injury. The diagnosis was confirmed by X-ray, CT scan and MRI imaging of right knee. Then the patient was treated with arthroscopic anterior cruciate ligament (ACL) avulsion fixation with pull through technique and suture disc; bilateral inferior pole patella was treated conservative...