After discussing the findings with the family, the patient was scheduled to undergo open reduction internal fixation of a type IIIB fracture and repair of the patellar tendon three days following the initial injury. Many cases are misdiagnosed and progress to recurvatum deformity especially in open physis individuals after neglected tibial tuberosity fractures. The https:// ensures that you are connecting to the Knee Surg Sports Traumatol Arthrosc. Upon intraoperative examination of the injury site, it was noted that vascular damage was present which would have led to postoperative compartment syndrome if not addressed. No complications were noted. 6, pp. 6. A torn patellar tendon was noted in one adolescent having a stage IIIB avulsion fracture. Slobogean GP, Mulpuri K, Alvarez CM, et al. MeSH Georgiou G, Dimitrakopoulou A, Siapkara A, Kazakos K, Provelengios S, Dounis E. Knee Surg Sports Traumatol Arthrosc. 6, pp. The Authors. PMC 4. By continuing to use this website you are giving consent to cookies being used. 3, pp. Epub 2005 Oct 24. 561566, 2012. The anatomic repair of the patellar tendon was completed with two mattress sutures and tied. Most injuries in school occur during sport. Despite a locking compression plate combined with minimally invasive percutaneous plate osteosynthesis techniques to prevent the blood supply of the fracture from being destroyed, a wound dehiscence and the proximal tibia fractures experienced fragment resorption and sclerosis but ultimately healed. sharing sensitive information, make sure youre on a federal may email you for journal alerts and information, but is committed Arkader A, Schur M, Refakis C, Capraro A, Woon R, Choi P. J Pediatr Orthop. This website uses cookies. Purpose: To retrospectively study the epidemiology and treatment of acute avulsion fractures of the tibial tubercle in 12 patients. Your doctor will often prescribe medications for pain-relief for a short period of time after the injury or surgery. Upon presentation to the clinic the following day, he reported mild pain (3/10) and noted no normal function of his leg. Tibial tubercle avulsion fractures are an uncommon injury occurring due to strong contraction of the quadriceps femoris muscle during leg extension, ultimately causing failure of the physis at the patellar tendon insertion. Third, at the same time the patient's skin healed, we recommend the use of a minimally invasive lateral surgical approach to the proximal tibia with extension to the tibial tubercle to allow stable fixation of both fractures so early range of motion can be started to avoid the development of a knee arthrofibrosis and stiffness. In this report, a patient who suffered a tibial tubercle avulsion fracture while jumping and colliding with another player had concomitant patellar tendon avulsion and subacute compartment syndrome that necessitated intraoperative fascial release. Preoperative lateral X-ray with knee at 30 flexion demonstrated tibial tubercle avulsion fracture extending into the joint space with two primary fragments: (i) anterior tibial plateau and (ii) tibial tubercle. 3. The purpose of this study was to determine the long-term outcome with return to play in 8 adolescent basketball players with at least 4 years of postoperative reconditioning. However, Howarth et al. Intraoperatively multiple bone cysts were Check for errors and try again. By five months postoperatively, the patient demonstrated near-normal function, no evidence of extensor lag, and nearly full range of motion. (A) Initial lateral x-ray shows a type III tibial tubercle fracture. Risk factors, mechanism of injury, and treatment. ScienceDirect is a registered trademark of Elsevier B.V. ScienceDirect is a registered trademark of Elsevier B.V. Tibial tubercle avulsion fractures in school sports injury: A case report. Seven patients (low-stress group) had a spontaneous Part B, vol. Tibial tubercle fractures frequently require ORIF; Three dimensional imaging may help guide treatment but is not always necessary; Compartment syndrome following tibial tubercle We used a minimally invasive lateral surgical approach to the tibia and extended to the tibial tubercle to achieve these goals. WebRecovery time for a tibia fracture typically takes 4-6 months to heal completely. Following the review of radiographic imaging, an MRI was performed, which demonstrated a type IIIB tibial tubercle avulsion fracture and complete tear of the patellar tendon from its distal attachment site, as well as a hematoma at the fracture site (Figure 2). Tibial Tuberosity Avulsion Fractures (TTAF) are rare, accounting for less than 1% of pediatric fractures [1]. Epub 2020 May 8. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. E31E34, 2016. A. P. Nicolini, R. T. Carvalho, M. Ferretti, and M. Cohen, Simultaneous bilateral tibial tubercle avulsion fracture in a male teenager: case report and literature review, Journal of Pediatric Orthopaedics. 465470, 2011. The tibial tubercle is the bony attachment on the large bone of the lower leg (tibia) of the big, powerful thigh muscle (quadriceps). Tibial tubercle avulsion fractures are an uncommon injury occurring due to strong contraction of the quadriceps femoris muscle during leg extension, ultimately causing The .gov means its official. An unusual avulsion fracture of the proximal tibial epiphysis. For a complete overview of all the cookies used, please see our privacy policy. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0, where it is permissible to download, share and reproduce the work in any medium, provided it is properly cited. The mean follow-up was of 4.5 years (1.5-7.5 years). 251259, 2017. Vella D, Peretti G, Fra F. One case of fracture of the tibial tuberosity in the adult. Tibial tubercle avulsion fractures are a rare injury and can be associated with concomitant soft tissue damage, periosteal damage, and compartment syndrome leading to extensor mechanism disruption, joint laxity, or vascular compromise [6]. 2020 Sep 16;3(3):e000169. Proximal tibial fractures: current treatment, results, and problems. 2004. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2020 Mar 16;2020:8650927. doi: 10.1155/2020/8650927. government site. 94% of patients (248 total) return to their preinjury level at a mean of 28.9 weeks, 98% of patients (250 total) regained full knee range of motion at 22.3 weeks, and 99% of cases (334 out of 336) reported fracture union [8]. 2002 Jan-Feb;22(1):36-40. For more information, please refer to our Privacy Policy. During the operative management of these injuries, it was noted that fascial tissue avulsed through the injury site causing subacute extensive bleeding within the anterolateral compartments. This patient is a 14-year-old male, who felt a popping sensation and significant right knee pain while jumping and colliding with another player during a basketball game the previous day. This allowed for the insertion of the locked plate and reduction and fixation of the tuberosity. Tibial tuberosity avulsion fractures are uncommon. A. Yousef, Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in pediatric population: case series and review of literature, European Journal of Orthopaedic Surgery and Traumatology, vol. The work cannot be changed in any way or used commercially. WebAbstract. J. Schiller, S. DeFroda, and T. Blood, Lower extremity avulsion fractures in the pediatric and adolescent athlete, The Journal of the American Academy of Orthopaedic Surgeons, vol. Disclaimer, National Library of Medicine He reported that he had no pain (0/10) and had 5% of his normal function at this time. Simultaneous bilateral tibial tubercle avulsion fracture in an adolescent: a case report and review of the literature. This case report describes the successful management of such a fracture pattern in a 45-year old male using an open reduction and lag screw fixation of the tuberosity with a minimally invasive reduction and plate fixation of the proximal tibial diaphyseal fracture. J Pediatr Orthop. This is an open access article distributed under the. 32, no. Fixation is achieved under anesthesia by cutting the skin, exposing the fracture site & fixing the displaced piece of bone in position using pins & tension wire. eCollection 2020. On physical examination, incisional sites were clean, dry, and intact and a small fracture blister was noted on the posterior aspect of the kneewhich was cleaned and redressed. Mirbey J, Besancenot J, Chambers RT, et al. However, there were no such reports of patients suffering multiple injuries in addition to a tubercle avulsion fracture. Avulsion fracture of the tibial tuberosity is an infrequent injury in adolescents and an extremely rare occurrence in adults. The fascial incision was extended posteriorly into the peroneal compartment and then was extended proximally and distally to the midtibia. The authors declare that they have no conflicts of interest. An avulsion fracture to your foot or ankle may require a cast or walking boot. These steps were repeated for the midpoint and distal incision sites. less common pattern of temporal bone fracture (10-30%) the fracture line is perpendicular to the long axis of the petrous Rest the area during that time. An official website of the United States government. sharing sensitive information, make sure youre on a federal Tibial tubercle avulsion fracture (TTAF) is a rare condition frequently occur in adolescent male, this stage of development corresponds to the pre-ossification period, trauma No complications were noted. This injury typically occurs in adolescents because the tibial tubercle is still growing and the bone is softer there. Minimally invasive plate osteosynthesis for open fractures of the proximal tibia. your express consent. X-rays will be taken after surgery to assess the position of the implants & the realignment of the bone. Rodriguez I, Seplveda M, Birrer E, Tuca MJ. Please try again soon. D. O. Clarke, S. A. Franklin, and D. E. Wright, Avulsion fracture of the tibial tubercle associated with patellar tendon avulsion, Orthopedics, vol. The patient was allowed full weight bearing at 6 months, and at 12 months after operation he was asymptomatic with a full range of motion and good strength and has returned to work with no limitations (Figure 5). A. Khoriati, S. Guo, R. Thakrar, R. S. Deol, and K. Y. Shah, Bilateral atraumatic tibial tubercle avulsion fractures: case report and review of the literature, Injury, vol. The patient was seen 1 week postoperatively and noted moderate pain (6/10) and 0% normal function. This case report is limited in the duration of follow-up. Biomechanically, the degree of flexion of the knee at the time of injury was considered closely related to the fracture pattern and the size of the avulsed fragments. This wound was dressed and closed on the 14th postoperative day from fixation and by 6 weeks had finally healed. Pedrazzini A, Maserati I, Cesaro G, Visigalli A, Casalini D, Bertoni N, Yewo SH, Pogliacomi F. Acta Biomed. Two patients presented symptoms of homolateral Osgood-Schlatter's disease before the lesion. Radiographs at 3 months showed resorption of both fracture fragments of the proximal tibial fracture and this fractures eventually healed by 12 months (Figures 3, 4). The fracture occurred in 6 out of the 7, after an abrupt tension of the patellar tendon in male sporting adolescents (age 13-17 years). Kim JW, Oh CW, Jung WJ, et al. Case report and proposed addition to the Watson-Jones classification. 11. The results were satisfactory: complete functional recovery, resumption of sport at the previous level and absence of recurvatum. No risk factors were identified. 1. The avulsion fracture of the tibial tuberosity is regarded as a substantial injury to the extensor mechanism as the patellar tendon is attached to the tibial tuberosity. (The Ethics Committee of Tengzhou Central People's Hospital approved the study. On physical examination, he was nontender to palpation along the joint line. This scenario raised concern for impending compartment syndrome, and an anterolateral compartment release was planned. Two fractures were type IA, one type IB, 2 type IIB, 5 type IIIA, 2 type IIIB, and one type IV. A literature search was done to determine the expected clinical outcome of this fracture pattern. We believed that the tibial tuberosity avulsion fracture should be considered an intraarticular fracture, because a malunion will affect the trajectory of the patella resulting in patellar subluxation and poor extension power. Int J Surg Case Rep. 2020;71:1-5. doi: 10.1016/j.ijscr.2020.04.029. The first was located 3 centimeters distal to the neck of the fibula, the second was located 10 centimeters above the distal fibula tip, and the third was located at the midpoint between the two. Often, percutaneous or open reduction can be performed to maintain motion within the knee. [Avulsion fracture of the tibial tubercle in adolescents: 22 cases and review of the literature]. The anterior tibial plateau fragment was anatomically reduced using two fully threaded noncannulated screws (Arthrex, Naples, FL), while the tibial tubercle fragment was reduced via bicortical fixation with a 50mm fully threaded 3.5mm cortical screw (Arthrex, Naples, FL). While there are various concomitant injuries, patients experiencing more than one concurrent injury with tibial tubercle avulsion fracture have not been reported in the literature. Isolated, noncomminuted tibial tubercle fractures (types IA, IB, and IIA) can be treated with closed reduction for 46 weeks, whereas tibial tubercle fractures that are comminuted or extend intraarticularly should be repaired via open reduction internal fixation [11]. (B) Follow-up 4 weeks after closed reduction and internal fixation demonstrates adequate fixation and interval healing. A debridement of the open fracture was performed and the laceration was closed. Liu, Yu-Ping MD; Hao, Qing-Hai MD; Lin, Feng MD; Wang, Ming-Ming MD; Hao, Yue-Dong MD. Rev Chir Orthop Reparatrice Appar Mot. Epub 2003 Oct 3. The injuries were managed with an open reduction internal fixation (ORIF) of the tibial tubercle and distal patellar tendon repair. J Pediatr Orthop B. WebA 1-month cast immobilisation on an extended knee gives good results in the management of nondisplaced fractures. Open reductions and stable screw fixations precede a 3-week immobilisation for displaced fractures. Three 3-centimeter incisions were made along the anterolateral aspect of the leg. WebAndrew Parker, MD 1120 Raintree Circle, Suite 280 Allen, TX 75013 Phone: (214) 383 9356 Fax: (214) 383 9886 ORIF TIBIAL TUBERCLE PROTOCOL 2, pp. A. The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. In this case report, we discuss a patient who suffered a tibial tubercle avulsion fracture with multiple serious concomitant injuries, a presentation which, to our knowledge, has not previously been reported in the literature. If your ankle or hip is fractured, you may need to use crutches W. R. Howarth, H. P. Gottschalk, and H. S. Hosalkar, Tibial tubercle fractures in children with intra-articular involvement: surgical tips for technical ease, Journal of Children's Orthopaedics, vol. Avulsion fractures of the tibial tuberosity in the adolescent athlete. While there lacks evidence to support an association between compartment syndrome and the type of tibial tubercle avulsion fracture and due to the variability in the temporal presentation of compartment syndrome, it is paramount that careful evaluation of vascular integrity and a low threshold for fasciotomy be in place to prevent vascular compromise. 4046, 2018. In this case, our patient reported 95% of normal function, near-full return of range of motion, and fracture union 20 weeks following operative management. He had an active range of motion from 0 to 130 degrees of flexion, and there was no lag with straight leg raise. eCollection 2020. The remaining 9 fractures were treated with open reduction and internal fixation. In addition to the avulsion of the patellar tendon and periosteum, it was noted that fascial tissue with tibialis anterior muscle belly avulsed through the injury site causing subacute extensive bleeding within the anterolateral compartments (Figure 3). In minor displacements, such immobilisations follow closed external reductions. e561e564, 2016. TTAF remains rare accounting for <3% of all epiphyseal injuries, it is frequent in teenage boys with open physis during school sport. Partial sleeve fractures of the tibia in children: an unusual fracture pattern. To restore the native footprint of the patellar tendon, a 4.5mm PEEK (polyetheretherketone) corkscrew anchor (Arthrex, Naples, FL) was placed slightly lateral to the anatomic insertion site to avoid a stress riser on the anterior tibial cortex. Ryu RK, Debenham JO. to maintaining your privacy and will not share your personal information without S. Frey, H. Hosalkar, D. B. Cameron, A. Heath, B. David Horn, and T. J. Ganley, Tibial tuberosity fractures in adolescents, Journal of Children's Orthopaedics, vol. As a 14-year old patient at the time of initial consultation, this patient was not skeletally mature at the time of follow-up. Methods: 692696, 2012. 5, pp. Copyright 2018 Avinesh Agarwalla et al. WebThe avulsion fracture of the tibial tuberosity is regarded as a substantial injury to the extensor mechanism as the patellar tendon is attached to the tibial tuberosity. Orthop Clin North Am. Methods: We reviewed a consecutive series of patients with tibial tubercle fractures treated surgically at 2 level-1 pediatric tertiary care centers over a 12.5-year period. He was unable to stand and was sent to the emergency department after the wound was dressed. Reference article, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-57064. WebA tibial tubercle fracture is a break or crack at this location, which usually occurs as a result of the patellar tendon pulling off a piece of the bone. describe a technique of patellar tendon reconstruction in an adolescent patient with a tibial tubercle fracture in which bioabsorbable suture anchors were placed above the growth plate on either side of the fracture site [12]. While this technique provides additional fixation on the proximal aspect of the fracture and assists with meniscal repair, it carries the risk of growth plate disruption or articular surface penetration. complications are occasional and functional recuperation is common after closed reduction and cast immobilization for slightly or no displaced fractures, otherwise open reduction and internal fixation for displaced fractures. Case report and proposed addition to the WatsonJones classification, European Journal of Orthopaedic Surgery & Traumatology, The American Journal of Emergency Medicine, Revista Brasileira de Ortopedia (English Edition), Tibial Tubercle Avulsion Fractures in Adolescent Basketball Players, https://doi.org/10.3928/01477447-20120725-07, Adolescent tibial tubercle fractures in the time of the COVID 19: A single orthopedic trauma center experience, Fracture of tibial tuberosity in an adult with Paget's disease of the bone An interesting case and review of literature, Tibial Tuberosity Fracture in an Elderly Gentleman: An Unusual Injury Pattern, Management of Knee Injuries in Adolescent Basketball Players, Fracture of the anterior tibial tuberosity in children, Tibial tubercle avulsion fractures in children, Outcomes of surgical treatment of the tibial tuberosity fractures in skeletally immature patients: an update, Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures, Tibial tubercle avulsion fracture according to different mechanisms of injury in adolescents, Bilateral tibial tubercle avulsion fractures: A pediatric orthopedic injury at high risk for compartment syndrome, Tibial Tubercle Avulsion Fracture with Multiple Concomitant Injuries in an Adolescent Male Athlete, Le fratture articolari ed extra-articolari del ginocchio, Articular and extra-articular knee fractures, Avulsion Fracture of the Tibial Tuberosity Combined with Lateral Tibial Plateau in an Adolescent, Fraturaavulso tuberosidade anterior da tbia em adolescente Relato de dois casos, Anterior avulsion fracture of the tibial tuberosity in adolescents Two case reports, Avulsionsverletzungen der proximalen Tibia, Outcomes and Complications of Tibial Tubercle Fractures in Pediatric Patients: A Systematic Review of the Literature, Tibial Tuberosity Fracture Combined With Entrapped Meniscus. Surgical Therapy. Types IB, II, and III tibial tubercle fractures require open reduction with internal fixation (ORIF). An anterior approach to the knee is followed over the proximal tibia. Fixation is best accomplished with one or two screws through the tibial tubercle into the proximal tibia. Careers. Two and a half weeks after surgery, the patient presented to the clinic for evaluation. Type II lesions The .gov means its official. Previous reports of tibial tubercle avulsion fractures noted patients who had concomitant tendon avulsion, meniscal damage, ligament injury, and vascular compromise. M. T. Stepanovich and J. Please enable it to take advantage of the complete set of features! 1, pp. Tension band suture in isolated tibial tubercle avulsion: A case report and review literatures. 46, no. In cases of tibial tubercle avulsion fracture, clinicians should have a high index of suspicion to evaluate for additional injuries that may be present. A medical and endocrinological examination was performed with negative results and no systemic diseases and predisposing factors were found during patient's hospitalization. 2005. Under endoscopic visualization, the intramuscular septum was identified and Metzenbaum scissors were used to cut through the fascial compartment beginning in the anterior compartment and extending proximally then distally to the midtibia (Figure 4). Case Rep Orthop. He demonstrated 5/5 quadriceps strength with no evidence of an extensor lag. 2020 Sep 16;3(3):e000169. In the emergency room he had left anterior knee swelling, a proximal tibial deformity, loss of active knee extension, and severe pain to palpation along the proximal tibial and anterolateral tibial tuberosity. If physical examination cannot be performed due to cast immobilization or pain, the presence of patella alta on radiographic imaging as well as calcified fragments below the patella may indicate the presence of patellar tendon rupture [7, 9]. Krieg JC. Additionally, upon presentation to the ER and initial clinic visit, the patient had a stable neurovascular examination, which alleviated concern regarding compartment syndrome. Most injuries in adolescent occur during school sports like volleyball, football or basketball. Tibial Tubercle Avulsion Fracture. Longitudinal vs transverse petrous temporal bone fracture. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. We present a unique case of a 14-year-old male who suffered a tibial tubercle avulsion fracture while jumping and colliding with another player during a basketball game. J Pediatr Orthop. government site. Wolters Kluwer Health Postoperative anteroposterior and lateral film radiographs in 3 months after operation showed absorption of tibial fracture fragments for the cut of the patients at the time of injured breakdown. Tibial tubercle avulsion fractures can cause disruption to the growth plate which can cause skeletal deformities such as genu recurvatum or limb-length discrepancy, which can present in 4% and 5% of cases, respectively [8]. eCollection 2020. Intraoperatively, it was noted that extensive bleeding accumulated subacutely within the anterior and lateral compartments. The high energy nature of the athletic injury is associated with compartment syndrome from bleeding into the anterior compartment, vascular injury [6], patellar tendon avulsion [7], and meniscal injuryexhibited only with fracture types that extend intra-articularly [8]. doi: 10.1097/BPO.0000000000001269. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Preoperative sagittal view of MRI demonstrating tibial tubercle avulsion fracture (red asterisk), distal patellar tendon rupture (blue asterisk), and hematoma formation (yellow asterisk) at the site of injury. Tibial tubercle avulsion fracture during sport activities in adolescent: a case report. 8. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. China (e-mail: [emailprotected]). doi: 10.23750/abm.v92iS3.12580. Due to the severity of compartment syndrome and the variability in its temporal presentation from the initial injury, it is paramount that careful evaluation of vascular integrity and a low threshold for fasciotomy be in place to prevent vascular compromise. Unicortical Fixation is Sufficient for Surgical Treatment of Tibial Tubercle Avulsion Fractures in Children. Operative management included ORIF of the tibial tubercle and patellar tendon repair, as well as fascial release which was performed for impending compartment syndrome under arthroscopic guidance. 2007. 27, no. World J Pediatr Surg. Correspondence: Yu-Ping Liu, Department of Trauma Orthopedics, Tengzhou Central People's Hospital, Shandong 277500, P.R. This site needs JavaScript to work properly. Would you like email updates of new search results? doi: 10.7759/cureus.13256. The authors report 7 cases of acute tibial tubercle avulsion fractures. Tibial tubercle avulsion fractures (TTAF) are an unusual condition, resulting from a forced extension of the knee opposed to fixed leg. 36, no. He had full range of motion in left knee after 12 weeks. Acute tibial tubercle avulsion fractures. 2010 Nov;19(6):492-6. doi: 10.1097/BPB.0b013e32833cb764. doi: 10.1136/wjps-2020-000169. Intraoperative arthroscopic view of Metzenbaum scissors releasing fascial tissue (a) and the site of injury following fascial tissue release (b). Compartment syndrome is a potentially devastating injury that can occur with tibial tubercle avulsion fracture due to soft tissue injury or the fractured component damaging the anterior tibial recurrent artery [4, 13]. Sferopoulos NK, Rafailidis D, Traios S, Christoforides J. On physical examination, he noted no tenderness to palpation of the knee joint, and he had 40 degrees of knee flexion. On postoperative day number two, the patients Hemovac drain was removed by a family member. Rehabilitative exercises and progressive weight bearing were begun according to the imaging results. Postoperative anteroposterior and lateral film radiographs in 12 months showed that fractures eventually healed. G. Tulic, J. Sopta, M. Bumbasirevic, A. Todorovic, and C. Vucetic, Simultaneous bilateral avulsion fracture of the tibial tubercle in adolescent: a case report, Journal of Pediatric Orthopaedics. He was placed in a cast and sought a second opinion regarding findings and management. Compartment syndrome is associated with fractures that extend proximally (Type II), fractures that encompass the entire proximal tibial physis (type IV), and displaced fractures [6, 11, 13]. If the fracture is open or comminuted, healing time may take longer. Careers. 39, no. Overall, there is a 28% reported complication rate following tibial tubercle avulsion fracture repair, with the most commonly reported complications being bursitis (56%) and tenderness overlying the tibial tubercle (18%) [8, 13]. http://creativecommons.org/licenses/by-nc-nd/4.0. On the 10th day postinjury the proximal tibial fracture was treated with a locked proximal tibial plate inserted with a minimally invasive technique while the tuberosity fracture was reduced and fixed with 2 lag screws (Figure 2). 2020 May 5;5(5):260-267. doi: 10.1302/2058-5241.5.190026. 2021 Feb 10;13(2):e13256. Following the injury, he was evaluated in an outside emergency department, where anterior, posterior, and lateral radiographs obtained in the emergency department demonstrated a tibial fracture consisting of two primary components (Figure 1). [Bony knee injuries in childhood and adolescence]. Unable to process the form. A. Jakoi, M. Freidl, A. 6, pp. 8600 Rockville Pike 19, no. Unlike previously reported cases, this is the first report of a patient who suffered such an injury with multiple concomitant injuries to the neighboring structures. Limited range of motion due to pain or effusion from the avulsed tubercle can cause the variation in reported incidence. Tibial tubercle avulsion fractures are managed operatively in most cases, and long-term outcomes are favorable with the resumption of sport to the previous level [4]. Closed reduction and cast immobilisation for minimally displaced fractures, and open reduction and internal fixation for displaced fractures resulted in favourable outcomes. What causes this injury? The screws should be inserted angular to the proximal tibia, which can increase the screw holding force. The patient felt immediate anterior knee and proximal tibial pain, and there was a bleeding laceration (about 8 cm) on the lateral side of the injured proximal tibial. Data is temporarily unavailable. Consequently an anatomical reduction and stable fixation is required to assure it heals anatomically. This case report reviews the rehabilitation program, and 2005. WebThe fracture occurred in 6 out of the 7, after an abrupt tension of the patellar tendon in male sporting adolescents (age 13-17 years). The left knee appearance at 12 months postoperatively was showed in (A), the left knee function at 12 months postoperatively was showed in (B). The overall complication rate was 25.5%, and it was not different between ORIF and CRIF ( P = 0.79). Please enable it to take advantage of the complete set of features! In a series of 336 tibial avulsion fractures in adolescent patients, there were 8 (2%) patellar or quadriceps tendon avulsions, 6 (2%) meniscal tears, 3 (1%) increased ligamentous laxity, and 12 (4%) compartment syndromes [8]. Results with return to play at the preinjury level are favorable after treatment of acute tibial avulsion fractures in adolescent basketball players. An 8-centimeter anterior incision was made at the superior aspect of the tibial tubercle and extended distally. A 16 years old male was hurt during school basketball, X-rays displayed avulsion fracture of tibial tuberosity of left knee, the treatment was operative using two cancellous screws, results were good including complete knee mobility and early coming back to school sport at 6 months. Bauer T, Milet A, Odent T, Padovani JP, Glorion C. Rev Chir Orthop Reparatrice Appar Mot. 7. 1, pp. 8600 Rockville Pike The main factors of bone healing were as follows, first, the blood supply of proximal of tibia was better than the distal. According to Ogden's classification, the tibial tubercle avulsion fracture was not displaced in 3 cases (stage IA) and was treated conservatively by immobilization for 6 weeks. Osgood-Schlatter Disease as a Possible Cause of Tibial Tuberosity Avulsion. Due to concerns of compartment syndrome, a fascial release was performed along the anterolateral compartments. A 45-year-old man was hit on the left proximal tibia in a traffic accident. Biomechanically, the degree of flexion of the knee at the time of injury was considered closely related to the fracture pattern and the size of the avulsed fragments. official website and that any information you provide is encrypted 118121, 2010. HHS Vulnerability Disclosure, Help Roentgenographic examination revealed a tibial tuberosity avulsion fractures similar to a Type I (Watson-Jones)12 with internal rotation displacement of the fracture fragment combined with a proximal tibial and fibula fracture (Figure 1). Federal government websites often end in .gov or .mil. Federal government websites often end in .gov or .mil. Clipboard, Search History, and several other advanced features are temporarily unavailable. 5. In 4 cases, the fracture was displaced and necessitated an internal fixation with plaster for about 6 weeks. In this case, our patient presented with a displaced fracture of the tibial tubercle that extended proximally into the joint space (type IIIB). Extensor mechanism deficit can occur concomitantly in patients with a tibial tubercle avulsion fracture due to patellar tendon rupture [9]. Tibial Tuberosity Fracture in an Elderly Gentleman: An Unusual Injury Pattern. Accessibility Ten patients had excellent results and 2 had fair results. Petrous temporal bone fractures are classically divided into longitudinal, transverse or mixed fracture patterns, depending on the direction of fracture plane with respect to the long axis of the petrous temporal bone. Method: According to Ogden's classification, the tibial tubercle avulsion fracture was not displaced in 3 cases (stage IA) and was treated conservatively by immobilization for 6 weeks. 2, no. Anterior-posterior and lateral X-rays were taken which showed evidence of callus formation in the bone (Figure 5). This injury is most commonly seen in adolescent males during athletic activity but may also be associated in patients with osteogenesis imperfecta and Osgood-Schlatter disease [3, 4]. Injury. In such avulsion fractures, landing on the ground with the knee fully extended after a jump is the most likely cause. The remaining 9 fractures were treated with open reduction and internal fixation. Avulsion fracture of the tibial tuberosity with articular extension in an adult: a novel method of fixation. Records of 12 patients aged 11 to 17 (mean, 14) years with avulsion fractures of the tibial tubercle presenting to our hospital from April 1998 to September 2004 were studied. Also read: Tibial plateau Epub 2006 Aug 18. As soon as pain begins to improve, these medications can be stopped. 2022 Mar 10;92(S3):e2021571. There was no laxity with varus or valgus stress. 2004 Mar-Apr;24(2):181-4. doi: 10.1097/00004694-200403000-00009. WebThe purpose of this study is to compare the outcomes of unicortical versus bicortical fixation in a series of pediatric tibial tubercle avulsion fractures. Fastest Recovery Time in Pediatric Tibial Tubercle Avulsion Fracture Repair Using SpeedBridge Double-Row Technique: A Case Report 8, pp. 25, no. The follow-up was uneventful till three months after surgery when the patient noticed a spontaneous avulsion fracture of the tibial tuberosity (Ogden type 3). Avulsion occurs with the violent active extension of the knee or passive flexion against contracted quadriceps muscles. Although an acute injury, tibial tuberosity avulsion is most frequently seen in young adolescents with ongoing Osgood-Schlatter disease. The site is secure. WebThree patients with type-I fractures and one with a type-IIB fracture were treated with closed reduction and cast immobilisation for 3 to 4 (mean, 3.8) weeks. The https:// ensures that you are connecting to the {"url":"/signup-modal-props.json?lang=us\u0026email="}, Thapa S, Glick Y, Smith D, et al. The tibial tuberosity fragment was reattached with two non-resorbable sutures looped around two modified AO cortical 3.5 mm long neck screws. Bauer T, Milet A, Odent T, Padovani JP, Glorion C. Rev Chir Orthop Reparatrice Appar Mot. Then CT scan is needed to evaluate the fracture extension to the articular joint. In this instance, the patient did not suffer postoperative complications. N. K. Pandya, E. W. Edmonds, J. H. Roocroft, and S. J. Mubarak, Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment, Journal of Pediatric Orthopedics, vol. Preoperative anteroposterior and lateral film radiographs of the left knee showing tibial tuberosity avulsion fracture and proximal tibial fracture. 2004 Jul;12(4):271-6. doi: 10.1007/s00167-003-0417-0. He was diagnosed with a displaced tibial tubercle avulsion fracture with proximal extension into the knee joint (Ogden type IIIB), as well as a patellar tendon avulsion. Nonsurgical treatments may cause fracture malunion, anterior knee pain, and even patellar dislocation. Fracture of the anterior tibial tuberosity in children. 8, pp. X-ray is the key to diagnosis. An official website of the United States government. 749759, 2012. The presence of a palpable defect between the inferior pole of the patella and tibial tuberosity should heighten clinical suspicion for associated patellar tendon rupture [7]. 767769, 2015. 28, no. Before B. Slakey, Combined tibial tubercle avulsion fracture and patellar avulsion fracture: an unusual variant in an adolescent patient, American Journal of Orthopedics, vol. A medium Hemovac drain was placed along the length of the lateral compartment, exiting in the posterolateral proximal leg. Your message has been successfully sent to your colleague. Would you like email updates of new search results? Repeat anterior-posterior and lateral X-rays demonstrated a well-reduced tibial tubercle fracture as well as well-positioned and nondisplaced hardware (Figure 6). At this time, it was recommended that the patient begin gentle active range of motion exercises with extension and light flexion. Drs Jakoi, Freidl, Old, Javandel, Tom, and Realyvasquez are from the Department of Orthopaedic Surgery, Drexel College of Medicine, and Dr Realyvasquez is also from the Department of Orthopaedic Surgery, St Christophers Hospital for Children, Philadelphia, Pennsylvania. Unable to load your collection due to an error, Unable to load your delegates due to an error. PMC Tibial tubercle avulsions. We use cookies to help provide and enhance our service and tailor content and ads. HHS Vulnerability Disclosure, Help FOIA Case Rep Orthop. At the patellar tendon insertion site on the tibia, the tendon was noted to be completely avulsed from the bone cortex distally, while proximally, the tendon remained attached to the displaced tubercle. We use cookies on this site to enhance your user experience. Clinical and epidemiological features of tibial tubercle avulsion fracture in Chinese adolescents. The primary goal in treating this injury is to restore the extensor mechanism and, if the joint space is involved (as seen in types III and IV), to restore the integrity of the joint surface [10]. You may be trying to access this site from a secured browser on the server. Please try after some time. and transmitted securely. Avulsion fractures of the tibial tuberosity in the adult are extremely rare with only 3 reported cases.13 It has not been reported with proximal tibial diaphyseal fractures. China (e-mail: [emailprotected]). A physical exam was performed but was limited due to pain. Vyas S, Ebramzadeh E, Behrend C, Silva M, Zionts LE. Accessibility Brown E, Sohail MT, West J, Davies B, Mamarelis G, Sohail MZ. The tibial tubercle ossifies in a systematic mechanism from the superior aspect of the epiphysis to the inferior margin [3]. Due to the severity of compartment syndrome, each patient who undergoes ORIF should be evaluated at that time for compartment syndrome. The reported incidence of patellar tendon rupture ranges from 2%15.7% [8]. 5, no. He initially reported to the emergency department and then presented to our practice, where he was diagnosed with a tibial tubercle avulsion fracture with patellar tendon rupture. A displaced tibial tuberosity avulsion fracture associated with an open extra-articular proximal tibial diaphyseal fracture is an uncommon fracture pattern. However, close observation in the first 2 weeks is necessary. Introduction: The patient was placed in a hinged knee brace which was locked in extension. Old, M. Javandel, J. Tom, and J. Realyvasquez, Tibial tubercle avulsion fractures in adolescent basketball players, Orthopedics, vol. Anterior-Posterior (a) and lateral (b) X-rays 6 months following operative management demonstrates well-positioned screws with callus formation at the site of injury. Get new journal Tables of Contents sent right to your email inbox, http://creativecommons.org/licenses/by-nc-nd/4.0, September 2015 - Volume 94 - Issue 39 - p e1684-0, Tibial Tuberosity Avulsion Fracture and Open Proximal Tibial Fracture in an Adult: A Case Report and Literature Review, Articles in Google Scholar by Yu-Ping Liu, MD, Other articles in this journal by Yu-Ping Liu, MD. We describe a case in an adult who suffered a left knee injury due to a fall from height. Bookshelf Patient age, gender, involved side, injury mechanism, clinical and radiographic records, treatment, complications, and outcomes were reviewed. Cureus. Mounasamy V, Brown TE. Distally, the course of the superficial perineal nerve was identified and the nerve itself was protected during the distal release of the anterior compartment. Knee Surg Sports Traumatol Arthrosc. Drs Jakoi, Freidl, Old, Javandel, Tom, and Realyvasquez have no relevant financial relationships to disclose. 2005 Dec;91(8):758-67. doi: 10.1016/s0035-1040(05)84487-3. Clinical and epidemiological features of tibial tubercle avulsion fracture in Chinese adolescents. For an avulsion fracture in your pelvis or anywhere else where your healthcare provider cant apply a cast, a short period official website and that any information you provide is encrypted Avulsion fractures of the lateral tibial condyle in children. Because of the associated soft tissue injury with these proximal tibial fractures, a displaced tuberosity fracture creates a problem in fracture management.46 Both fractures require operative management but the avulsion fracture will need an anatomical reduction to assure proper knee function.7,8 The operative management of the high energy proximal tibia fracture has been associated with a high complication rate especially with the soft tissue healing and infection.911 As a result this fracture maybe best treated with a minimally invasive technique. Result: Simultaneous bilateral tibial tubercle avulsion fracture in an adolescent: a case report and review of the literature. On the 4th day following fixation the open fracture wound broke down, but the bacteria culture was negative. eCollection 2020 May. 4, pp. K AJ, L P. Avulsion fracture of the tibial tubercle in an adult treated with tension-band wiring: a case report. This site needs JavaScript to work properly. Five months postoperatively, the patient reported no pain (0/10) and possessed 95% of his normal function at this time. To retrospectively study the epidemiology and treatment of acute avulsion fractures of the tibial tubercle in 12 patients. 32, no. J. M. Brey, J. Conoley, S. T. Canale et al., Tibial tuberosity fractures in adolescents: is a posterior metaphyseal fracture component a predictor of complications? Journal of Pediatric Orthopedics, vol. Bethesda, MD 20894, Web Policies They all engaged in sports or active play during the injury. The tibial tubercle represents the most inferior aspect of the extensor mechanism, and adolescents are at increased risk of injury due to the relative weakness of the physis compared to the tendon insertion [7]. Rev Chir Orthop Reparatrice Appar Mot. Avulsion fractures of the tibial tubercle are uncommon school sports injuries. Brown E, Sohail MT, West J, Davies B, Mamarelis G, Sohail MZ. Unable to load your collection due to an error, Unable to load your delegates due to an error. The mean follow-up period was 39 (range, 23-59) months. Bethesda, MD 20894, Web Policies Tibial tubercle avulsion fractures most commonly occur in adolescent boys and usually result from pushing off or landing while jumping. Published by Wolters Kluwer Health, Inc. 1, pp. We review the pathophysiology, mechanism, classification, diagnosis, and management of this injury. Bolesta MJ, Fitch RD. They typically occur in adolescent males by Thirty patients with tibial tubercle avulsion fractures were reviewed and the average age was 13 years 1 month. Bookshelf Part B, vol. EFORT Open Rev. [Avulsion fracture of the tibial tubercle in adolescents: 22 cases and review of the literature]. The purpose of this study was to determine the long-term outcome with return to play in 8 adolescent basketball players with at least 4 years of postoperative reconditioning. Tibial tuberosity fractures (TTF) typically occur in adolescent males by avulsion of the bony insertion of the patellar tendon, caused by sudden violent con-traction of the quadriceps Comminuted simultaneous bilateral tibial tubercle avulsion fractures: a case report. The lesion was treated with surgical reduction and internal fixation. Correspondence should be addressed to: Andre Jakoi, MD, Department of Orthopaedic Surgery, Drexel College of Medicine, 245 N 15th St, Mail Stop 420, Philadelphia, PA 19102 (, Avulsion fractures of the tibial tubercle, Fractures of the tibial tuberosity in adolescents, Fracture of the tibial tubercle in the adolescent, Tibial tuberosity fractures in adolescents, Acute tibial tubercle avulsion fractures in children: selective use of the closed reduction and internal fixation method, Acute tibial tubercle avulsion fractures in the sporting adolescent, The SF-36 Health Survey: development and use in mental health research and the IQOLA Project, Rating systems in the evaluation of knee ligament injuries, Reliability, validity and responsiveness of the Lysholm knee scale and various chondral disorders of the knee, An unusual avulsion fracture of the proximal tibial epiphysis. Depending on your injury, it may take eight weeks or more for the fracture to heal. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username, Enter your email address below and we will send you the reset instructions, If the address matches an existing account you will receive an email with instructions to reset your password. 317323, 2018. This injury has been previously reported with various concomitant injuries, such as compartment syndrome from bleeding into the anterior compartment, vascular injury, patellar tendon avulsion, and meniscal injuryexhibited only with fracture types that extend intra-articularly. 2006 Jan;37(1):57-60. doi: 10.1016/j.injury.2005.05.021. The distal patellar tendon was completely avulsed through two-thirds of its length. Tibial Tuberosity Fracture in an Elderly Gentleman: An Unusual Injury Pattern. We report the case of a 14-year-old healthy adolescent male basketball player who sustained this injury as a result of a collision with another player. By continuing you agree to the use of cookies. Informed written consent was obtained from the patient). 2019 Jan;39(1):e18-e22. eCollection 2020. Avulsion fracture of the tibial tuberosity in late adolescence. Copyright 2022 Elsevier B.V. or its licensors or contributors. Eight cases of tibial tubercle avulsion fracture have been treated during the last 5 years. Postinjury follow-up ranged from 18 months to 5 1/2 years. All patients were functioning well at the time of reexamination. Five of eight injuries were treated with open reduction and internal fixation. These fractures are relatively uncommon but can have a significant functional effect. If your pet is 4 months or under at the time of surgery, a radiograph should be taken around 3-4 weeks after surgery to evaluate the growth plate and remove the tension band wire if one was Method: Some features may aid in distinguishing them. Some error has occurred while processing your request. Long-term outcome was excellent in all patients regardless of fracture type. Second, by 3 months, the fibula fracture had almost healed relieving some of stress from the tibial plate and helped to ensure the stability of the construct and provided a better environment for tibial fracture healed. Bauer J, Orendi I, Ladenhauf HN, Neubauer T. Unfallchirurg. FOIA Radiographic imaging revealed well-positioned screws, no evidence of new fractures or foreign bodies, and early evidence of callus formation. Disclaimer, National Library of Medicine Yue-Dong Hao, Department of Orthopedics, Huaian First People's Hospital, Jiangsu, P.R. Staged external and internal less-invasive stabilisation system plating for open proximal tibial fractures. In this report, we present a 14-year-old male who experienced sharp pain in his knee while jumping and colliding with another player during a basketball game. 2003 Jul;34(3):397-403. doi: 10.1016/s0030-5898(02)00061-5. This is the first reported adult case of an avulsion fractures of the tibial tuberosity associated with an open proximal tibial diaphyseal fracture successfully treated by an anatomical reduction and fixation of the avulsion fracture of the tibial tuberosity combined with minimally invasive percutaneous plate osteosynthesis of the proximal tibial diaphyseal fractures. Flexion-type fractures of the proximal tibial physis: a report of five cases and review of the literature. 2019 Jan;122(1):6-16. doi: 10.1007/s00113-018-0590-8. The leg was splinted till the soft tissues were healed and swelling was resolved. Pedrazzini A, Maserati I, Cesaro G, Visigalli A, Casalini D, Bertoni N, Yewo SH, Pogliacomi F. Acta Biomed. The recovery time then depends on healing and how long it takes the athlete to regain knee strength and motion, but return to sports likely takes many months. It is imperative to continue to follow up these patients until they have reached skeletal maturity to ensure normal growth without any resultant osseous deformities as additional procedures, such as growth plate modulation, may be required. After surgery exercise should be restricted for 6 weeks. Conclusion: Three patients with type-I fractures and one with a type-IIB fracture were treated with closed reduction and cast immobilisation for 3 to 4 (mean, 3.8) weeks. 440446, 2016. In this case, suture anchors were placed along the anatomic insertion of the patellar tendon on the anterior tibial cortex. 45, no. 2020 Mar 16;2020:8650927. doi: 10.1155/2020/8650927. and transmitted securely. Patients with a fracture pattern of the latter form should be evaluated for concomitant patellar ligament disruption, meniscal injury, or compartment syndrome [11]. Postoperative anteroposterior and lateral film radiographs in 2 days after operation. M. A. 2005 Dec;91(8):758-67. doi: 10.1016/s0035-1040(05)84487-3. 35, no. 469474, 2008. Therefore, this technique may need to be performed under fluoroscopic guidance in order to minimize these risks. Tibial tubercle avulsion fracture during sport activities in adolescent: a case report. Results: Please enable scripts and reload this page. Tibial tubercle avulsion fractures occur in 0.42.7% of epiphyseal injuries and less than 1% of physeal injuries [1, 2]. 10. Nimityongskul P, Montague WL, Anderson LD. Fractures usually take about three to 12 weeks to heal completely. Anterior-posterior (a) and lateral (b) X-rays 2.5 weeks following operative management demonstrates well-positioned screws with callus formation beginning at the site of injury. 2019 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. International Journal of Surgery Case Reports, https://doi.org/10.1016/j.ijscr.2019.03.017. You might be sprinting, hitting, sliding or doing other sports activities that involve quick movements and sudden changes in direction. A piece of bone attached to a ligament or tendon breaks away from the main part of the bone. It might take up to 12 weeks for you to fully heal. An avulsion fracture in a finger. What is an avulsion fracture? Strong contraction of the quadriceps femoris muscle during leg extension causes failure of the physis at the patellar tendon insertion [5]. The authors have no funding and conflicts of interest to disclose. Epidemiology These fractures have an incidence 0.4% to 2.7%, and males are affected more-so than females. The site is secure. Eight patients injured the right side, 3 the left side, and one both sides. This report of a 45-year old male with a high energy open proximal tibial fracture associated with a displaced tibial tuberosity fracture that has been successfully managed with a planned open reduction and screw fixation of the tuberosity and a minimally invasive technique for the tibial diaphysial fracture. doi: 10.1136/wjps-2020-000169. He was discharged home later that day. Georgiou G, Dimitrakopoulou A, Siapkara A, et al. These injuries cause significant disruption to school and sport, but fortunately, complications are rare and functional recovery is usually complete. The tendon remained attached to the inferior pole of the patella. 2007 Feb;15(2):147-9. doi: 10.1007/s00167-006-0164-0. Ma CH, Wu CH, Yu SW, et al. It was believed that the impending compartment syndrome occurred due to damage to the surrounding bony and muscular tissue. Transverse petrous temporal bone fracture. Avulsion fractures of the tibial tuberosity in adolescent athletes treated by internal fixation and tension band wiring. In addition to the tubercle fracture, this patient suffered patellar tendon avulsion and subacute compartment syndrome. WebA tibial tubercle avulsion fracture is a complete or incom-plete break (fracture) of the growth plate of the leg just below the knee at the tibial tubercle, a prominence just below the kneecap. No neurovascular deficit was noted. Methods: Records of 12 patients aged 11 to 17 (mean, 14) His knee was in a state of flexion and internal rotation before the traffic accident occurred, and heavy items (such as woods or metal) directly hit him on the left proximal tibial. Purpose: China (YDH). Two patients presented symptoms of homolateral Osgood-Schlatter's disease before the lesion. 4, pp. Before MeSH 2022 Mar 10;92(S3):e2021571. World J Pediatr Surg. J. Pretell-Mazzini, D. M. Kelly, J. R. Sawyer et al., Outcomes and complications of tibial tubercle fractures in pediatric patients: a systematic review of the literature, Journal of Pediatric Orthopedics, vol. From the Department of Trauma Orthopedics, Tengzhou Central People's Hospital, Shandong (YPL, QHH, FL, MMW); and Department of Orthopedics, Huaian First People's Hospital, Jiangsu, P.R. 12. He was also encouraged to become full weight-bearing with the brace until its removal two months postoperatively. Intraoperative arthroscopic view of avulsed fascia and tibialis anterior muscle belly through the site of injury. The incision extended from Gerdy Tubercle to the tibial tuberosity. 2. The mean follow-up period was 39 (range, 23-59) months. Purpose of review: To summarize and discuss the fundamentals of pediatric tibial tubercle avulsion fractures (TTAFs) including preferred imaging modalities, systems for fracture classification, frequently associated injuries, treatment options, outcomes, and common complications. A tibial tubercle avulsion fracture is a complete or incomplete break (fracture) of the growth plate of the leg just below the knee at the tibial 9. Nikiforidis PA, Babis GC, Triantafillopoulos IK, Themistocleous GS, Nikolopoulos K. Knee Surg Sports Traumatol Arthrosc. Longitudinal petrous temporal bone fracture, Transverse petrous temporal bone fracture, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, Transverse vs longitudinal petrous temporal bone fracture, Transverse versus longitudinal petrous temporal bone fracture, Longitudinal versus transverse petrous temporal bone fracture, more common pattern of temporal bone fracture (70-90%), the fracture line is parallel to the long axis of the petrous temporal bone, less common pattern of temporal bone fracture (10-30%), the fracture line is perpendicular to the long axis of the petrous temporal bone, the otic capsule is often involved, resulting in, the ossicles and the tympanic membrane are usually spared, facial nerve involvement more common (~50%), fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. 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