- Tibial spine fractures are ACL equivalent injuries, and should be operatively managed if displaced
- The meniscus and intermeniscal ligament can be barriers to reduction
- Although ACL laxity can commonly occur due to ligamentous stretch during injury, this laxity is rarely clinically significant if the fracture is properly treated
Description:Tibial spine fractures are relatively uncommon injuries that typically occur at the base of the tibial spine. While these injuries can occur in adults, they are more common in skeletally immature patients between ages 8-14. These injuries can occur during sporting endeavors. They have classically been associated with a hyperextension injury to the knee as a result of a bike accident. The injury creates traction forces along the anterior cruciate ligament (ACL) and causes avulsion of the tibial spine. The immature tibial spine is weaker than the ACL. Prompt recognition and management of these injuries can decrease morbidity and minimize long term complications.
The term tibial eminence refers to the area between the medial and lateral tibia plateaus on the proximal tibia, and consists of the medial and lateral tibial spines. The ACL inserts on the medial tibial spine. Tibial spine fractures occur through the subchondral bone at the base of the medial tibial spine and are ACL equivalent injuries. The fracture may extend into the medial and lateral tibial articular surfaces. (Meyers 1970)
Clinical Findings:Patients who sustain these injuries typically present with a painful hemarthrosis and the inability to fully extend their knee.
ClassificationFractures are identified as type I, II, and III by the Meyers and McKeever classification. (Meyers 1959) Type I fractures are nondisplaced or minimally displaced. Type II fractures are displaced anteriorly with an intact posterior hinge. Type III fractures are completely displaced from the proximal tibia. This classification system had been modified by Zaricznyj to include type IV or comminuted fractures. (Zaricznyj 1977)
Imaging Studies:Plain radiographs, particularly the lateral radiograph identify the injury, and guide treatment. MRI can be useful to identify associated meniscal tears and chondral injuries as well as barriers to reduction including the meniscus and intermeniscal ligament (Mitchell 2015). MRI may identify an injury to the fibers of the ACL in addition to the tibial spine fracture. Usually this injury is a stretch injury to the fibers of the ACL rather than a midsubstance disruption.
Treatment:Treatment is based on the magnitude of displacement of the fracture and the presence of additional intraarticular injury. Goals of surgery include an anatomic reduction of the fracture and the preservation of motion. Nondisplaced or minimally displaced fractures can often be treated non operatively with either casting or bracing in full extension or slight flexion for approximately 6 weeks. (Meyers 1970, Meyers 1959,Lubowitz 2005) Type II fractures can be managed with immobilization of the knee in extension +/- arthrocentesis if a near anatomic reduction (< 3-5 mm) can be achieved. Fractures treated without surgery should be followed closely for loss of reduction. Type III and IV fractures should be treated operatively with either arthroscopic or open reduction. Surgical treatment allows for removal of the barriers to reduction and anatomic fixation of the fracture. (Figure 1) Similar results have been achieved with either arthroscopic or open techniques. (Edmonds 2015) Fixation of the fracture can be accomplished with either screw or suture fixation with similar results. (Edmonds 2015) An entrapped meniscus, the intermeniscal ligament, or an attached meniscus (lateral) can be a barrier to reduction. (Kocher 2003)
Video on POSNAcademy of Tibial Eminence ORIF
Complications:Complications associated with these fractures are not infrequent, and include laxity, nonunion, malunion with resultant extension block, growth plate disturbance, and arthrofibrosis. These complications can occur in fractures treated either nonsurgically or surgically, and with both open and arthroscopic surgical techniques. The degree of secondary laxity after recovery from these fractures rarely results in functional deficits. Growth plate disturbance can generally be avoided by not crossing the proximal tibia physis with fixation. Arthrofibrosis may be prevented with early mobilization and weight bearing. (Patel 2012) Management of arthrofibrosis can be accomplished with manipulation under anesthesia or an arthroscopic lysis of adhesions. Manipulation under anesthesia in children with open growth plates has been associated with distal femur physeal fractures. (Vanderhave 2010)
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- Edmonds EW, Fornari ED, Dashe J, Roocroft JH: Results of displaced pediatric tibial spine fractures: A comparison between open, arthroscopic and closed management. J Pediatr Orthop 35(7):651-656, 2015.
- Kocher MS, Micheli LJ, Gerbino P, Hresko MT: Tibial eminence fractures in children: Prevalence of meniscal entrapment. Am J Sports Med 31(3): 404-407, 2003.
- LaFrance, Russell M.; Giordano, Brian; Goldblatt, John; Voloshin, Ilya; Maloney, Michael Less: Pediatric Tibial Eminence Fractures: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 18(7):395-405, July 2010.
- Lubowitz JH, Elson WS, Guttmann D: Part II: Arthroscopic treatment of the tibia plateau fractures. Intercondylar eminence avulsion fractures. Arthroscopy 21(1): 86-92, 2005.
- Meyers MH, McKeever Fm: Fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Am 41:209-222, 1959.
- Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 52:1677-1684,1970.
- Mitchell, Jj, Sjostrom R, Mansour AA, Irion B: Incidence of meniscus injury and chondral pathology in anterior tibial spine fractures of children. J Pediatr Orthop 35(2): 130-135, 2015.
- Patel NM, Park MJ, Sampson NR, Ganley TJ: Tibial eminence fractures in children: Earlier posttreatment mobilization results in improved outcomes. J Pediatr Orthop 32(2): 139-144, 2012.
- Vander Have KL, Ganley TJ, Kocher MS, Price CT: Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents. Am J Sports Med 38(2):298-301, 2010.
- Zaricznyj B: Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am 59: 1111-1114, 1977.