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. 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 injury—exhibited only with fracture types that extend intra-articularly. 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. 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. 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. Due to concerns of compartment syndrome, a fascial release was performed along the anterolateral compartments. By five months postoperatively, the patient demonstrated near-normal function, no evidence of extensor lag, and nearly full range of motion. 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. 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.
Tibial tubercle avulsion fractures occur in 0.4–2.7% of epiphyseal injuries and less than 1% of physeal injuries [
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 [
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. 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. The injuries were managed with an open reduction internal fixation (ORIF) of the tibial tubercle and distal patellar tendon repair. Intraoperatively, it was noted that extensive bleeding accumulated subacutely within the anterior and lateral compartments. There was sufficient concern for impending compartment syndrome which led to fascial compartment release.
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. 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
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.
Upon presentation to the clinic the following day, he reported mild pain (3/10) and noted no normal function of his leg. A physical exam was performed but was limited due to pain. 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
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.
An 8-centimeter anterior incision was made at the superior aspect of the tibial tubercle and extended distally. 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. The tendon remained attached to the inferior pole of the patella. 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 50 mm fully threaded 3.5 mm cortical screw (Arthrex, Naples, FL).
The distal patellar tendon was completely avulsed through two-thirds of its length. To restore the native footprint of the patellar tendon, a 4.5 mm 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. The anatomic repair of the patellar tendon was completed with two mattress sutures and tied.
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
Intraoperative arthroscopic view of avulsed fascia and tibialis anterior muscle belly through the site of injury.
Three 3-centimeter incisions were made along the anterolateral aspect of the leg. 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. 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
Intraoperative arthroscopic view of Metzenbaum scissors releasing fascial tissue (a) and the site of injury following fascial tissue release (b).
On postoperative day number two, the patient’s Hemovac drain was removed by a family member. The patient was seen 1 week postoperatively and noted moderate pain (6/10) and 0% normal function. On physical examination, incisional sites were clean, dry, and intact and a small fracture blister was noted on the posterior aspect of the knee—which was cleaned and redressed. Radiographic imaging revealed well-positioned screws, no evidence of new fractures or foreign bodies, and early evidence of callus formation. Two and a half weeks after surgery, the patient presented to the clinic for evaluation. He reported that he had no pain (0/10) and had 5% of his normal function at this time. On physical examination, he noted no tenderness to palpation of the knee joint, and he had 40 degrees of knee flexion. Anterior-posterior and lateral X-rays were taken which showed evidence of callus formation in the bone (Figure
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.
Five months postoperatively, the patient reported no pain (0/10) and possessed 95% of his normal function at this time. On physical examination, he was nontender to palpation along the joint line. There was no laxity with varus or valgus stress. He demonstrated 5/5 quadriceps strength with no evidence of an extensor lag. He had an active range of motion from 0 to 130 degrees of flexion, and there was no lag with straight leg raise. Repeat anterior-posterior and lateral X-rays demonstrated a well-reduced tibial tubercle fracture as well as well-positioned and nondisplaced hardware (Figure
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.
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 [
Extensor mechanism deficit can occur concomitantly in patients with a tibial tubercle avulsion fracture due to patellar tendon rupture [
Isolated, noncomminuted tibial tubercle fractures (types IA, IB, and IIA) can be treated with closed reduction for 4–6 weeks, whereas tibial tubercle fractures that are comminuted or extend intraarticularly should be repaired via open reduction internal fixation [
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 [
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 [
Previous reports of tibial tubercle avulsion fractures noted patients who had concomitant tendon avulsion, meniscal damage, ligament injury, and vascular compromise. However, there were no such reports of patients suffering multiple injuries in addition to a tubercle avulsion fracture. 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. Due to the severity of compartment syndrome, each patient who undergoes ORIF should be evaluated at that time for compartment syndrome. In cases of tibial tubercle avulsion fracture, clinicians should have a high index of suspicion to evaluate for additional injuries that may be present.
This case report is limited in the duration of follow-up. As a 14-year old patient at the time of initial consultation, this patient was not skeletally mature at the time of follow-up. 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 [
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. In addition to the tubercle fracture, this patient suffered patellar tendon avulsion and subacute compartment syndrome. 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.
The authors declare that they have no conflicts of interest.