FRACTURE

OF

ADULTS A

NAMITA

AND

CHILDREN OF

STEPHEN

the Chinese

31

68%

is the result

of greater

energy

perhaps

Fulkerson

1988)

childhood

equivalent in adults.

and

have

been

ofanterior Apart from

CASES

University

a different

eminence of the tibia 1 875 (Burstein, Viola

in

IN

KAI-MING

ofHong

CHAN

Kong

treated for avulsion fractures of the tibial spine. most were caused by road-traffic accidents, and around the knee. compared

with children,

indicates

that

considered

to

mechanism.

The

were and be

the

cruciate ligament (ACL) case reports of unusual

presentations and complications, little has been published about the fracture in adults (Fyfe and Jackson 1981; Gr#{246}nkvist, Hirsch and Johansson 1984; Hayes and Masear 1984 ; Crenshaw 1987) and it is generally accepted that it rarely occurs as an isolated associated with soft-tissue injuries having a poor prognosis (Liljedah!, fors

injury, around Lindvall

aetiology

fractures, features and

the

the

childhood

with the aim of describing of the latter and determining

prognostic

indicators

II

usually being the knee and and Wetter-

1965 ; Keys and Walters 1988). We have compared and contrasted

and adult characteristic

the injury

worse outcome in some adults was due fractures and tears of the medial collateral ligament. Arthroscopy is useful Early accurate diagnosis and the correct treatment produce a good outcome.

and

to other associated infra-articular in both diagnosis and treatment. Fractures of the intercondylar first described by Poncet

SPINE

Y. C. HSU,

We reviewed 19 adults and 12 children who had been injuries have not previously been reported at length; were associated with other injuries, of which 58% were The higher incidence of associated injuries in adults as

Adult

ruptures

TIBIAL

REVIEW

S. KENDALL,

From

THE

of poor

the their

outcome.

IV Fig.

N. S. Kendall,

FRCS Ed, Registrar ofOrthopaedics, Royal Berkshire Berkshire RG1 SAN, England.

Department Reading,

S. Y. C. Hsu, MCh(Orth), Surgeon Department of Orthopaedics Hospital, Kowboon, Hong

FRCS

© 1992 British 030l-620X/92/6447

J Bone

848

Joint

Ed, FRACS, and FRCS

and Wales

G,

Road, Diagram showing the modified Meyers and McKeever classification of fractures of the tibial spine. Type I is minimally displaced, type II shows anterior elevation, type III has complete separation of the fragment and in type IV the fragment is also rotated, with comminution.

Orthopaedic

Princess

should

be sent

to Mrs

Society

ofBone

1992;

74-B

FRCS

Ed,

FRCS

Traumatology, Chinese Hospital, Shatin, New

Editorial [Br]

Consultant

Traumatology,

$2.00

Surg

London

Margaret

Kong.

K.-M. Chan, MCh(Orth), Reader Department of Orthopaedics of Hong Kong, Prince of Hong Kong. Correspondence

Hospital,

:848-52.

N. S. Kendall. and

Joint

Surgery

1

Ed(Orth), University Territories,

PATIENTS We

reviewed

the

records

treated for avulsion 1984 at the Prince recording the patients’ the

clinical

AND

presentation THE

and

METHODS radiographs

of

patients

fractures of the tibia! spine since of Wales Hospital, Hong Kong, ages, the mechanisms of injury, and JOURNAL

the

fracture

OF BONE

AND

type JOINT

(Fig. SURGERY

1)

FRACTURE

using

Meyers

also

and

reviewed

McKeever’s

the

(1959)

treatment

outcome was and a!! clinical

formed

of the

authors

The

Stryker

by one

Ltd.

error.

Reading,

England)

values for the Cybex ranges as

the

thigh Pivot

tubercle.

(NSK),

was

TIBIAL

laxity

used

to obtain

SPINE

We

rehabilitation

18 cm varus/valgus

also tested. Follow-up anteroposterior graphs were taken of both knees, affected knees.

in a long-leg were In one

849

CHILDREN

hinge

sation

brace.

and lateral radiowith a tunnel view of

II

immobiliafter the it from reduction

a

fixation.

remaining

in a plaster

removed follow-up

of the type

brace, converting and requiring open

type

II and

all type

and fixation patients had cast

followed

an initial range of movement which was increased weekly

tibia! were

Two

treated by closed reduction and of these there was a refracture

treated by arthrotomy After operation the

measured

above the instability

then

The

and Lachman tests, and goniometer to determine was

AND

and internal

(Stryker

quantitative

wasting

and

ADULTS

early removal of the hinge type II to a type III fracture

intra-

tester

IN

fractures sation.

a standard were per-

to eliminate

knee

Quadriceps

circumference shift and

and

obtained from examinations

the anterior drawer ED! 320 electronic

of movement.

THE

classification.

regime

programme. Subjective questionnaire,

observer

OF

at the end of 2.6 years

III fractures

were

by absorbable sutures. two weeks of immobiliby bracing.

This

allowed

of 0#{176} to 30#{176} for two weeks, by 30#{176} until the brace was

of the fifth week. At an average (4 months to 5.5 years) all the knees

were

asymptomatic

drawer

and Lachman). Follow-up radiographs

with

no instabilityon showed

testing union

(anterior

in

1 1 cases,

RESULTS Table

We treated a total were 1 2 children

of 31 patients from eight

from 1984 to 16 years

to 1991 ; there of age (mean

Case

12.5)and 19 adults from 19 to 56 yearsofage(mean 37). Children. There were 1 ! boys and one girl ; in nine the injuries were right-sided and in three, left-sided. Seven of the

fractures

were

sustained

(including

bicycle

accidents),

four

caused

by

the

were

presentation

associated

had

with

the

1 2 patients

test

(Table

been

I). Only

range

one

had

activites In all cases

a painful drawer

an associated

initially

in a plaster

Pre-operative unite.

VOL.

74-B,

(a, b) and

No.

cast at between

three-year

6, NOVEMBER

1992

review

Anterior drawer

Eight

tibial

spine

Associated

in children

Injuries

Crack fracture femoral condyle

8

I

-

-

2

F

10

II

-

+

None

3

M

10

I

-

-

None

4

M

11

III

+

+

Fracture clavicle pubic rami

5

M 13

III

+

+

None

6

M

I

+

+

None

7

M 13

II

-

-

None

8

M

14

II

+

+

None

9

M

14

I

-

+

None

10

M

14

II

-

-

Fracture

Il

M

15

IltolIl

+

+

None

12

M

16

I

+

+

None

of

lateral

and

or Lachman knee

injury,

a

type

I fractures was for a minimum

Lachman test

ofthe

M

crack fracture of the lateral femora! condyle. Eight of the fractures were diagnosed on initial radiographs; one was type I, five type II and two type III. The remaining four required arthroscopy for diagnosis, and all of these were I. Treatment for type all cases, by immobilisation

Se x/Ag e Type

ofavulsion

haemarthrosis

of movement.

anterior

of 1 2 cases

1

from a fall and

accidents.

with

a positive

sporting

one resulted

road-traffic

decreased had

during

I. Details

conservative in offour weeks,

0#{176} and 45#{176} of flexion,

(c, d) radiographs

of an eight-year-old

13

boy with

a conservatively

treated

type

II fracture

distal

which

radius

failed

to

850

N. 5. KENDALL,

Table II. Details of the I 2 adult avulsion of the tibial spine

cases

Case

Associated

Sex/Age

Type

Cause

with

associated

injuries

and

F

19

II

Bicycle

Partial

tearlateral

14

M

25

IV

RTA

Lateral avulsed

malleolus MCL

16

M

30

III

RTA

Femoral condyle

17

F

30

III

RTA

Intracerebral

18

M

31

II

RTA

Partial

19

F

33

III

RTA

Head

meniscus and

trochanter

fibular

and

tear,

head

the injury Road-traffic

neck,

was

II

RTA

Femoral

23

M

35

II

RTA

Fibular

24

M

37

III

RTA

Fibula

27

M 43

I

RTA

Medial bowel

28

M

II

Fall

Head injury, both and 5th metacarpals

condyle

and

humeral

injury

perforated

1 1 and left-sided responsible for

bicycle also

had

injuries seven medial

and had

small

malleoli 4th

4th

in eight. ! 1 of the

in two. Al! the showed anterior instability.

associated

injuries,

but

(Table II). The 3. The average

years (4 months to 5.5 years). I fractures were treated conservatively to drain the haemarthrosis and

injury.

extending the sisted reduction

navicular

medial and

patients

up was three All type arthroscopy

neck

malleolus,

in were

falls in six and had a haemarthrosis ; of these, four

menisca!

M 35

right-sided accidents

seven of these were of the knee classification is shown in Figure

injury

22

CHAN

Twelve

bleed

PCL

K.-M.

injuries, patients instability

injuries

13

46

S. Y. C. HSU,

One

type

II

fracture

was

only

fracture followafter exclude

reduced

knee ; one required arthroscopically ; the remaining three had an arthrotomy,

by as-

open reduction, and wire-loop fixation. Al! type III and IV fractures had open reduction and internal fixation using a variety ofmethods including Vicryl pins (Ethicon Ltd, Edinburgh, Scotland), sutures and a steel wire-loop (Fig. 4). A Vicryl pin was inserted arthroscopical!y for a type IV fracture.

metatarsal 31

F

IV

56

Fall

Lateral

tibial

plateau

#{149}roadtraffic accident

0

E

z Postoperative and

wire

Four also had a femora! II

classification Fig.

Number their

of fractures

in

3

children

and

related

adults

to

classification.

fracture two

showing

eminence. (Fig. with

There

2) but after no clinical

to normal

Adults.

a slight was

increase nonunion

in the

of one

three years the patient evidence of instability

sporting activities. Of the 19 adults, 12 were

height

of the

type

tibial

II fracture

was asymptomatic and had returned and

seven

patients

complained

tears of the media! condylar fracture

and one Radiographs

increase One knee the oldest plateau

male

of a 28-year-old

man

treated

by reduction

of instability.

Two

collateral ligament, and the fourth had

had

one had developed

reflex sympathetic dystrophy. This patient had only a 15#{176} to 900 range of movement, but in all the others movement was good, with an extension lag averaging 6#{176} (5#{176} to 8#{176}) in four cases, but not affecting function. Only two patients had significant quadriceps wasting of 30 and 35 mm respectively ; one of these also had a femora! condylar

Ill

Fracture

radiographs

fixation.

female;

Both

in the

had failed indicated height

to attend union

of the

for physiotherapy. in all cases with

tibial

spine

showed patient,

osteoarthritic a 56-year-old

fracture. subjectively

and

on examination,

JOURNAL

OF BONE

THE

change, woman

AND

an

of 3 to 5 mm. but this was in with a tibia! 14 of our JOINT

SURGERY

19

FRACTURE

patients had or demonstrable

OF

THE

a good outcome with no residual disability (Table III).

TIBIAL

SPINE

IN

ADULTS

AND

81

CHILDREN

symptoms

DISCUSSION Our

literature

children

review

revealed

a reported

to 40 adults for tibia! spine 1988). We found a reversed

Walters that adult believed.

ratio

of

60

fractures (Keys and ratio, and consider

fractures may be more common One report on ACL ruptures

than stated

previously that 1 3 of

Table

Case

III.

Final

Sex/Age

results

in all patients

Range of movement (degrees)

Quadriceps wasting (mm)

Lachman sign (mm)

I

M

8

OtoI26

No

0

2

M

10

Otol42

No

0

3

F

10

Otol3O

No

0

4

M

II

1to127

No

I

5

M

13

0to145

No

1

6

M

13

0to145

No

0.5

7

M

13

0to148

No

0

8

M

14

ltol4O

No

0

9

M

14

Otol42

No

I

find an association with meniscal injuries, seeing only one case, but did show a high incidence of local bony injury. These were both fibular neck fractures and intra-articular fractures, the

10

M

14

Otol4S

No

2

II

Ml5

ltol40

No

I

12

M

5

1

latter

13

F

19

2tol24

5

1

14

M

25

OtoIl9

No

2

15

M

28

8to132

20

1

16

M30

ltoll8

No

0

17

F

30

5to129

No

0.5

18

M

31

1to135

5

0.5

19

F

33

ltol3O

5

2

20

M

34

2tol42

No

0

21

M

34

2tol25

5

1

22

M

35

ltoll3

30

1

23

M

35

5to145

10

0

24

M 37

0to136

No

0

25

F

38

OtoI3l

35

0.5

26

F

42

ltoI38

27

M43

28

M

46

29

F

52

30

M

31

F

48 acute injuries were associated with avulsion fractures (Liljedahl et al 1965). In our centre, 219 cases of acute and chronic rupture ofthe ACL have been treated during the period of our study. Avulsions therefore appear to

represent

I 4#{176}/a of ACL

Our

injuries. in children agree

results

including

the

rarity

outcome McNair, higher

(Liljedahl Marshall incidence

et a! 1965; and Matheson of adult injuries

reports

other Liljedahl

knee injuries et al 1965),

of

1959;

collateral

ligament.

having All

We did

a strong

cases

and this evaluation

with

of associated

reports,

and

the

good

Gr#{246}nkvist et a! 1984; 1990). We report a and agree with earlier (Meyers particularly

and

McKeever the medial

not

bearing

presented

previous

injuries

on prognosis.

with

a painful

haemarthrosis

injury should lead to careful radiographic in all age groups, not only children. Tunnel

and oblique views may be required The distribution of fracture types

to make the diagnosis. in Table III suggests

that

injury,

adults

sustain

a more

severe

there

type IV fractures in children. Zaricznyj however, an incidence of 60% of type children. Arthroscopy several

reasons.

cartilaginous

radiographic classification of

is useful

intra-articular articular. In two of our II fractures, arthroscopy

cartilage

Arthroscopy throsis,

arthroscopic adults and absorbable and

the

only

removal surgery

children, pins and

the associated Conservative

effective.

haemarthrosis

injuries, both soft-tissue cases initially diagnosed revealed comminution

fragments not

but

acute

no

for

It is diagnostic, particularly where the areas of the skeleton in children make diagnosis difficult, and it allows precise of type. It also allows an accurate diagnosis

other

loose

in

being

(1977) reported, IV fractures in

not

allowed ofboose will have allowing avoiding

visible drainage

In adults,

radiographically. of the haemar-

fragments. a greater the insertion the need for

longer rehabilitation treatment for all

and as type with

In the future, role in both of strong arthrotomy

period. type I injuries

is

type II, III and IV injuries require arthroscopy for lavage and accurate classification, to allow the selection of the best treatment. If satisfactory closed reduction cannot be obtained, open or arthroscopic reduction and fixation should be performed. All type III VOL.

74B

No

6. NOVEMBER

1992

16

Otol4O

Otol35 l5to

89

5

0

No

0

5

0.5

2tol4O

5

0

53

5to130

No

0

56

ltol29

10

0

N. 5. KENDALL,

852

and IV fractures variety of methods

require internal are available.

residual

instability,

pain

and

tional

intra-articular collateral ligament.

fixation, A poor

was

5. Y. C. HSU,

for which a outcome, with

associated

with

fractures or damage to the We recommend immobilisation

addimedial for

four weeks in children under 12 years of age but a minimum of six weeks for older patients. Protected limited motion may be started at four weeks. We found a low association with menisca! injuries

in

comparison with (Meyers and McKeever different mechanism

commonly rotation,

valgus The

occurs and

of

excessive

mechanism

ofavulsion

(Roth

ofthe a direct

or forceful

ACL rupture be due to the ACL rupture

of deceleration,

hyperextension,

rotation

to be either femur

reported for !959); this may injury. Isolated

as a result

and internal

is thought part ofthe

that

or deceleration, 1977).

tibia! spine blow on the

in children lowermost

with

rotation

into hyperextension the rotatory element

injuries, may be The

relative energy causing the hyperextension was also much greater in adults than in children ; this, with the lack of rotation, may be responsible for the differences between the two groups in our series. Our results suggest that tibia! spine fractures are

more are

common more

usually

in adults

than associated

was previously thought, but with other injuries than in

In 35%

ofour

series,

they

were

isolated

injuries

outcome. No benefits commercial article.

in any party

form have been related directly

received or will be received or indirectly to the subject

from a of this

REFERENCES

Burstein

DB, Viola A, Fulkerson JP. Entrapment ofthe medial meniscus in a fracture of the tibial eminence. Arthroscopv 1988 ; 4 :47-SO. CrenshawAH. Campbe//’soperativeorthopaedics. Vol. 3, 7th ed. Missouri: CV Fyfe

Mosby

Co.

1987 :23S3-7.

IS, Jackson JP. Tibial intercondylar fractures in children : a review of the classification and the treatment of malunion. Injury 1981: 13:165-9.

Grfinkvist spine

H,

Hirsch

in children.

G,

Johansson

J Pediatr

L.

Fracture

Orthop

1984;

Hayes

JM, Masear VR. Avulsion fracture associated with severe medial ligamentous a case report and literature review. Am 330-3.

Keys

GW, Walters J. Nonunion the tibia. J Trauma 1988;

S-O, Lindvall N, Wetterfors of acute ruptures of the anterior arthrographic study of forty-eight 1965; 47-A:l503-13.

McNair

PJ, Marshall RN, Matheson with acute anterior cruciate 103 :S37-9.

Meyers

MH, the tibia.

Rockwood CA, Lippincott Roth

J. Early cruciate cases.

PB. Fracture 10:09-18.

B. Avulsion open reduction A :1111-4.

of the

Zaricznyj

and

eds. spine

Fractures of the

eminence

JOURNAL

tibial

in adu/ts.

OF BONE

of

features associated NZ Med J 1990;

of the intercondylar 1959; 41-A :209-22.

tibia.

fracture

diagnosis and treatment ligament : a clinical and J Bone Joint Surg [Am]

eminence

Philadelphia,

J Bone

fracture of the tibial eminence pinning. J Bone Joint Surg

THE

anterior

of the tibial eminence injury in an adolescent: J Sports Med 1984; 12:

JA. Important ligament injury.

McKeever FM. Fracture J Bone Joint Surg [Am] Green DP, Co. 1984.

of the 4:465-8.

of intercondylar 28:870-1.

Liljedahl

by the impact. in ACL ruptures,

which causes the high association with meniscal is not present in avulsion fractures ; these produced only by deceleration and hyperextension.

CHAN

and should be considered in the differential diagnosis of acute traumatic haemarthrosis. Early accurate diagnosis and the correct treatment are essential for a good

internal

(Rockwood and Green 1984). In our series most adults sustained the injury in road-traffic accidents, in a seated position with the leg stretched out. In this situation, the knee tends to be near full extension at the time of injury and may be forced Thus it may be that

children.

1928 ; Zaricznyj

hyperextension

K.-M.

AND

Joint

etc : JB Surg

: treatment [Am] 1977

JOINT

of

1928;

by ; 59-

SURGERY