Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary?
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ORIGINAL ARTICLE • KNEE - PAEDIATRIC
Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary? P. Checa Betegón1 · C. Arvinius1 · M. I. Cabadas González1 · A. Martínez García1 · R. Del Pozo Martín1 · F. Marco Martínez1 Received: 3 December 2018 / Accepted: 29 January 2019 © Springer-Verlag France SAS, part of Springer Nature 2019
Abstract Fractures of the anterior tibial tubercle are infrequent lesions. They often occur in male adolescent athletes, usually in relation with sports involving powerful jumps. We present a retrospective study of 10 patients, with an average age of 15.1 years, all of them males, and a total of 11 acute avulsions of the anterior tibial tubercle. We analyzed the etiology of the lesion, the type of treatment used as well as non-weight bearing period, protected immobilization period, and time until sports reincorporation. We obtained 11 acute avulsions: one case of type I; three cases of type II; four cases of type III; and three cases of type IV. Five cases were treated conservatively, including the three cases of type IV, and surgery was only performed in six cases since an anatomical reduction was not obtained with closed reduction. The results were satisfactory in all cases, with 100% percentage of sport reincorporation in less de 25 weeks. We registered only one complication, intolerance of material, which did not require additional surgeries. These fractures, although rare, have an excellent prognosis. Even if they are often treated surgically, we have obtained good results with the conservative treatment in patterns previously reported as surgical. Keywords Anterior tibial tubercle avulsion · Anterior tibial tubercle fracture · ATT fracture · Proximal tibia fractures · Pediatric fractures of the tibia
Introduction The anterior tibial tuberosity (ATT) serves as the insertion to the leg’s extensor apparatus. Its ossification center appears in ages between 11 and 14 years and ossifies approximately at ages between 14 and 18 years [1, 4]. Acute avulsions at this level are rare, representing 0.4–2.7% of pediatric fractures and less than 1% of the physeal lesions [9]. It is a lesion typically seen in teenagers, with an average age, according to the literature of 14.6 years [1, 9]. It occurs more frequently in males, 97%, and usually in the left leg, given that it is usually the propulsive leg in right-handed patients. Watson and Jones described the original classification with three types of fractures, which was later completed by Ogden adding subtypes A and B. Then, finally, Ryu and Debenham added type IV pattern, consisting of an avulsion
of the ATT whose fracture line continues from the proximal anterior physis of the tibia posteriorly as if it were a type I or II epiphysiolysis of the Salter and Harris’ classification system [2, 6]. See Table 1. There are two proposed causal mechanisms, both related to sports that involve jumping. In the anglo-saxon literature, this lesion is often related to basketball [3, 14]. The first one of these mechanisms i
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