Abstract: Background: Tibial tubercle fractures (TTFs) are uncommon injuries, comprising <3% of all proximal tibial fractures. These fractures occasionally occur in conjunction with a patellar tendon injury (PTI). We aimed to identify risk factors associated with combined TTF and PTI.
Methods: A retrospective review was performed of patients presenting to a single, tertiary children's hospital with TTF between 2012 and 2023. Demographic data, operative details, radiographs, and injury patterns were analyzed. Radiographs were assessed for the epiphyseal union stage (EUS), Ogden classification, and fracture patterns. Multiple logistic regression models were used to assess the impact of body mass index, comminution, fracture fragment rotation, EUS, bilateral injury, and Ogden classification on injury type.
Results: We identified 262 fractures in 252 patients (mean age, 13.9 ± 1.31 years). Of the patients, 6% were female and 48% were Black. Of the 262 fractures, 228 (87%) were isolated TTFs and 34 (13%) were TTFs with PTI. Multivariable analysis demonstrated fragment rotation on lateral radiographs (p < 0.0001) and Ogden Type-I classification (p < 0.0001) to be the most predictive risk factors for a combined injury. Rotation was associated with a substantial increase in the odds of a combined injury, with an odds ratio of 22.1 (95% confidence interval [CI], 6.1 to 80.1). Ogden Type-I fracture was another significant risk factor, with an odds ratio of 10.2 (95% CI, 3.4 to 30.4).
Conclusions: The Ogden classification and fragment rotation are the most useful features for distinguishing between isolated TTF and combined TTF with PTI. This is the first study to identify risk factors for TTF combined with PTI. Surgeons may use this information to aid in preoperative planning.
Level of Evidence: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I213 ).
(Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)
References: Cole WWI, Brown SM, Vopat B, Heard WMR, Mulcahey MK. Epidemiology, diagnosis, and management of tibial tubercle avulsion fractures in adolescents. JBJS Rev. 2020 Apr;8(4):e0186.
Bolesta MJ, Fitch RD. Tibial tubercle avulsions. J Pediatr Orthop. 1986 Mar-Apr;6(2):186-92.
McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fractures. Orthop Clin North Am. 2003 Jul;34(3):397-403.
Lima AS, Cabral J, Boavida J, Balacó I, Sá Cardoso P, Tarquini O, Ling TP, Alves C. Tibial tubercle avulsion fractures in adolescents: impact on function and quality of life. J Pediatr Orthop B. 2022 Mar 1;31(2):e135-40.
Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am. 1980;62(2):205.
Fields MW, Kaushal NK, Patel NM, McCormick SK, Eberson CP, Schmitz ML, Swarup I, Blanco JS, Crawford LM, Edobor-Osula OF. Variability in evaluation and treatment of tibial tubercle fractures among pediatric orthopedic surgeons. J Pediatr Orthop B. 2022 Mar 1;31(2):e141-6.
Mayba II. Avulsion fracture of the tibial tubercle apophysis with avulsion of patellar ligament. J Pediatr Orthop. 1982 Aug;2(3):303-5.
Yousef MAA. Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in pediatric population: case series and review of literature. Eur J Orthop Surg Traumatol. 2018 Feb;28(2):317-23.
Frankl U, Wasilewski SA, Healy WL. Avulsion fracture of the tibial tubercle with avulsion of the patellar ligament. Report of two cases. J Bone Joint Surg Am. 1990;72(9):1411-3.
Bárcena Tricio VM, Hidalgo Bilbao R. Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in adolescents: a case report. Eur J Orthop Surg Traumatol. 2019 Aug;29(6):1359-63.
Agarwalla A, Puzzitiello R, Stone AV, Forsythe B. Tibial tubercle avulsion fracture with multiple concomitant injuries in an adolescent male athlete. Case Rep Orthop. 2018 Aug 2;2018:1070628.
Behery OA, Feder OI, Beutel BG, Godfried DH. Combined tibial tubercle fracture and patellar tendon avulsion: surgical technique and case report. J Orthop Case Rep. 2018 May-Jun;8(3):18-22.
Mayer C, Nolte-Boenigk L, Stanjek M, Klingler A, Jäger M. Acute traumatic patellar tendon rupture and simultaneous fracture of the tibial tubercle avulsion in a premature soccer player. Trauma Case Rep. 2023 Jun 8;47:100876.
Schiedts D, Mukisi M, Bastaraud H. [Fractures of the tibial tuberosity associated with avulsion of the patellar ligament in adolescents]. Rev Chir Orthop Reparatrice Appar Mot. 1995;81(7):635-8. French.
Kramer DE, Chang TL, Miller NH, Sponseller PD. Tibial tubercle fragmentation: a clue to simultaneous patellar ligament avulsion in pediatric tibial tubercle fractures. Orthopedics. 2008 May;31(5):501.
Sullivan L, Lee CB, Simonian PT. Simultaneous avulsion fracture of the tibial tubercle with avulsion of the patellar ligament. Am J Knee Surg. 2000 Summer;13(3):156-8.
Yang D, Kell D, Syed A, Huang K, Sarkar S, Goodbody CM, Williams BA. Does skeletal maturity predict the pattern of tibial tubercle avulsion fracture? J Pediatr Orthop. 2023 Aug 1;43(7):e561-6.
Shin YW, Kim DW, Park KB. Tibial tubercle avulsion fracture according to different mechanisms of injury in adolescents: tibial tubercle avulsion fracture. Medicine (Baltimore). 2019 Aug;98(32):e16700.
Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018 Jan;32(Suppl 1):S1-10.
McKern TW, Stewart TD. Skeletal age changes in young American males: analysis from the standpoint of age identification. American Anthropologist. 1957;60(5):982.
O’Connor JE, Bogue C, Spence LD, Last J. A method to establish the relationship between chronological age and stage of union from radiographic assessment of epiphyseal fusion at the knee: an Irish population study. J Anat. 2008 Feb;212(2):198-209.
Pretell-Mazzini J, Kelly DM, Sawyer JR, Esteban EM, Spence DD, Warner WC Jr, Beaty JH. Outcomes and complications of tibial tubercle fractures in pediatric patients: a systematic review of the literature. J Pediatr Orthop. 2016 Jul-Aug;36(5):440-6.
Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop. 2004 Mar-Apr;24(2):181-4.
Ali Yousef MA, Rosenfeld S. Acute traumatic rupture of the patellar tendon in pediatric population: case series and review of the literature. Injury. 2017 Nov;48(11):2515-21.
Reyes CD, Wu W, Pandya NK. Adolescent tibial tubercle fracture: review of outcomes and complications. Curr Rev Musculoskelet Med. 2023 Sep;16(9):392-7.
Processing Request
No Comments.