Surgical Fixation of Bilateral Simultaneous Avulsion Fractures of the Proximal Tibia in a 12-Year-Old with History of Conservatively Managed Unilateral Tibial Avulsion Fracture

Abstract

Fractures of the proximal tibial epiphysis are rare, representing less than 3% of all epiphyseal and 1% of all physeal injuries in adolescents. Bilateral injuries are extremely rare. The specific anatomical and histological features of the proximal tibial epiphysis make it vulnerable to a specific fracture pattern that occurs when the tensile force of the quadriceps is greater than the fibrocartilaginous tissue underlying the tibial tuberosity. We report the first case to our knowledge of a 12-year-old boy who sustained simultaneous bilateral tibial avulsion fractures on the background of a previous conservatively managed unilateral tibial tuberosity avulsion fracture. We report this case for its uniqueness and as an educational review of the anatomy, the mechanism of injury, and the development of classifying these fractures and discussion of the stages of the growing physis that determine the treatment approach.

Osgood-Schlatter Disease as a Possible Cause of Tibial Tuberosity Avulsion

“…While tuberosity avulsion fractures make up only 3% of all proximal tibial fractures, and generally less than 1% of all physeal injuries, the frequency of this complication of OSD is not well defined in the literature [4][5][6]. OSD is nevertheless frequently discussed as a predisposing factor for these injuries, especially in adolescents with continued activity against recommended restrictions [2,4,[6][7][8][9][10]. Case series demonstrating 20-75% of adolescents with tibial avulsion fractures were previously diagnosed with OSD [7,10].…”

Fracturas por avulsión bilateral de tuberosidades tibiales en un adolescente, reinserción y protección con banda de tensión: reporte de un caso

“…1 Hasta el momento, sólo se han reportado 28 casos desde 1955, Borsch-Madsen fue el primero en describirlo. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Ocurre en el centro de osificación anterior de la tibia, que osifica entre los 13 y 15 años en niñas y entre los 15 y 19 años en niños. 2,19 Existen dos mecanismos de lesión: contracción enérgica del cuádriceps con la rodilla en extensión o flexión forzada de la rodilla.…”

Bilateral Simultaneous Tibial Tubercle Avulsion in an Adolescent Football Player with Previous Bilateral Osgood–Schlatter Disease

“…Bilateral lesions are extremely rare with only 20 cases described in the literature [3]. They occur more frequently in male adolescents and during sport activities that require jumping and sprinting, such as football or basketball [4]. The development of the proximal epiphysis occurs through the fusion of the epiphyseal plate in late adolescence.…”

“…The columnar cells are structurally weak, and therefore, cannot withstand tensile forces exerted by the knee extensor mechanism, which explains the occurrence of avulsion fractures in adolescents. These fractures can be associated with some predisposing conditions and diseases, such as osteogenesis imperfecta [5] and Osgood–Schlatter disease [4]. It can occur in two situations: sudden knee flexion against a contracted quadriceps muscle and, as in the present case, excessive contraction of the quadriceps during extension of the knee, both of which are common during sport activities [6].…”

“…Activities such as jumping and sprinting that require landing can lead to knee locking in extension and thus create the necessary biomechanical conditions for this type of fracture to occur [3]. Several classification systems have been described to categorize these fractures, which can be confusing to the reader given the use of subcategories [4]. The Watson-Jones classification [7] used the fracture location relative to the ossification centers with types I, II, and III being distal to the ossification center, through the ossification centers, and extending proximally through the joint, respectively.…”