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Case Report Tibial Tuberosity Avulsion Fracture and Patellar Tendon Avulsion: A Case Report :Tai Diane Hei Yan * , Lee Kin Bong, Wong Kwok Fai Department of Orthopaedics and Traumatology, Block F, 3/F, Queen Elizabeth Hospital, Jordan, Hong Kong article info Article history: Received 21 September 2015 Received in revised form 2 November 2015 Accepted 14 December 2015 Keywords: patellar tendon avulsion tibial tuberosity fracture fracture xation abstract A case with simultaneous tibial tuberosity fracture and patellar tendon avulsion in a 16-year-old boy is presented. Surgery was performed for open reduction, screw xation and patellar tendon repair, and protected with a wire loop to restore the extensor mechanism. The wire loop was removed at 2 months postoperatively. The fracture healed at 5 months after surgery and the patient regained the full range of movement of the knee at 5 months. :16,,,髕骨 圈在25,人也Introduction Tibial tuberosity avulsion fracture is not common. Incidence varies from 0.4% to 2.7%. 1 The mechanism of injury is when the knee is exed against the contracting quadriceps muscle. It occurs in adolescent patients when the physis is undergoing physiological changes that make it more vulnerable to loading. Watson-Jones 2 classied this fracture into three different types. Ogden et al 3 further modied it into A and B subtypes. In contrast, patellar tendon rupture is not uncommon and 80% of cases are reported in patients less than 40 years of age. 4 There are only a few cases of simultaneous tibial tuberosity avulsion fracture and patellar tendon rupture in the literature. Case Report A 16-year-old boy with a history of global developmental delay, tyrosine hydroxylase deciency (THD), and bilateral clubfoot with posterolateral release at 1 year of age presented with right knee pain after jumping during a handball game. He was unable to elevate his right lower limb. Physical examination showed that there was local tenderness along the right tibial tuberosity and a palpable gap, and associated joint effusion. The extensor mechanism of his right knee was absent. Radiographs revealed that there was fracture of the tibial tuberosity, Ogden Type IB, with 180 rotation of the fragment. The patella was high riding (Figures 1 and 2). Surgery was performed. Intraoperatively, the patellar tendon was found to avulse from its tibial insertion. The tibial tuberosity fracture was rotated 180 and remained as a free fragment. The free fragment was xed with one 6.5-mm Asnis screw with a washer, beneath the patellar tendon. The patellar tendon was then repaired in Krachow fashion using a FiberWire (Arthrex FiberWire braided polyblend suture), with a bone tunnel created at the proximal tibia. Another two 5.0-mm Asnis screws were inserted on top of the patellar tendon with a spike washer. A protective wire loop was inserted using a percutaneous method with a bone tunnel created in the proximal tibia (Figures 3e5). Postoperatively, he was given a long leg cast with a bone window created for wound inspection. Radiographs showed that there was no patella baja (Figures 6 and 7). Touch-down walking exercise was commenced. The protective wire loop and the cast were removed at 2 months postoperatively. Physiotherapy was started immediately after removal of the wire loop for a vigorous active range of motion exercises and quadriceps strengthening exercises. The fracture * Corresponding author. E-mail: [email protected]. Contents lists available at ScienceDirect Journal of Orthopaedics, Trauma and Rehabilitation Journal homepages: www.e-jotr.com & www.ejotr.org http://dx.doi.org/10.1016/j.jotr.2015.12.002 2210-4917/Copyright © 2016, Hong Kong Orthopaedic Association and the Hong Kong College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Journal of Orthopaedics, Trauma and Rehabilitation 21 (2016) 44e47

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Journal of Orthopaedics, Trauma and Rehabilitation 21 (2016) 44e47

Contents lists availab

Journal of Orthopaedics, Trauma and Rehabilitation

Journal homepages: www.e- jotr .com & www.ejotr .org

Case Report

Tibial Tuberosity Avulsion Fracture and Patellar Tendon Avulsion:A Case Report脛骨粗隆撕脫骨折及髕腱撕脫:病例報告

Tai Diane Hei Yan*, Lee Kin Bong, Wong Kwok FaiDepartment of Orthopaedics and Traumatology, Block F, 3/F, Queen Elizabeth Hospital, Jordan, Hong Kong

a r t i c l e i n f o

Article history:Received 21 September 2015Received in revised form2 November 2015Accepted 14 December 2015

Keywords:patellar tendon avulsiontibial tuberosity fracturefracture fixation

* Corresponding author. E-mail: dianetai510@yahoo

http://dx.doi.org/10.1016/j.jotr.2015.12.0022210-4917/Copyright©2016,HongKongOrthopaedicAssociaCC BY-NC-ND license (http://creativecommons.org/licenses/by

a b s t r a c t

A case with simultaneous tibial tuberosity fracture and patellar tendon avulsion in a 16-year-old boy ispresented. Surgery was performed for open reduction, screw fixation and patellar tendon repair, andprotected with a wire loop to restore the extensor mechanism. The wire loop was removed at 2 monthspostoperatively. The fracture healed at 5 months after surgery and the patient regained the full range ofmovement of the knee at 5 months.

中 文 摘 要

摘要:我們報告一個16歲男孩,同時患有脛骨粗隆撕脫骨折及髕腱撕脫。病人接受了開放性復位,螺釘固定,髕骨

肌腱修復以及用套圈加以保護伸肌機制。套圈在術後2個月拆除。骨折在術後5個月癒合,病人也在同一時間完

全恢復膝蓋的運動。

Introduction

Tibial tuberosity avulsion fracture is not common. Incidencevaries from 0.4% to 2.7%.1 The mechanism of injury is when theknee is flexed against the contracting quadriceps muscle. It occursin adolescent patients when the physis is undergoing physiologicalchanges that make it more vulnerable to loading. Watson-Jones2

classified this fracture into three different types. Ogden et al3

further modified it into A and B subtypes. In contrast, patellartendon rupture is not uncommon and 80% of cases are reported inpatients less than 40 years of age.4 There are only a few cases ofsimultaneous tibial tuberosity avulsion fracture and patellar tendonrupture in the literature.

Case Report

A 16-year-old boy with a history of global developmental delay,tyrosine hydroxylase deficiency (THD), and bilateral clubfoot withposterolateral release at 1 year of age presentedwith right knee painafter jumping during a handball game. He was unable to elevate hisright lower limb. Physical examination showed that there was local

.com.

tionand theHongKong College ofOrthop-nc-nd/4.0/).

tenderness along the right tibial tuberosity and a palpable gap, andassociated joint effusion. The extensor mechanism of his right kneewas absent. Radiographs revealed that there was fracture of thetibial tuberosity, Ogden Type IB, with 180� rotation of the fragment.The patella was high riding (Figures 1 and 2).

Surgery was performed. Intraoperatively, the patellar tendonwas found to avulse from its tibial insertion. The tibial tuberosityfracture was rotated 180� and remained as a free fragment. The freefragment was fixed with one 6.5-mm Asnis screw with a washer,beneath the patellar tendon. The patellar tendonwas then repairedin Krachow fashion using a FiberWire (Arthrex FiberWire braidedpolyblend suture), with a bone tunnel created at the proximal tibia.Another two 5.0-mm Asnis screws were inserted on top of thepatellar tendon with a spike washer. A protective wire loop wasinserted using a percutaneous method with a bone tunnel createdin the proximal tibia (Figures 3e5).

Postoperatively, hewas given a long leg castwith a bonewindowcreated for wound inspection. Radiographs showed that there wasno patella baja (Figures 6 and 7). Touch-downwalking exercise wascommenced. The protectivewire loop and the cast were removed at2 months postoperatively. Physiotherapy was started immediatelyafter removal of the wire loop for a vigorous active range of motionexercises and quadriceps strengthening exercises. The fracture

aedic Surgeons. Publishedby Elsevier (Singapore) Pte Ltd. This is an openaccess articleunder the

Figure 1. Injury film AP view.

Figure 2. Injury film lateral view.

Figure 3. Patellar tendon repaired and bone tunnel created with drill.

D.H.Y. Tai et al. / Journal of Orthopaedics, Trauma and Rehabilitation 21 (2016) 44e47 45

healed and the patient regained his full range of movement of theknee at 5 months after the operation (Figures 8 and 9).

Discussion

Simultaneous avulsion fracture of tibial tuberosity and patellartendon avulsion is rare. A review conducted by Kaneko et al5 in2000 found that there were six reported cases in the literature. Allcases were reported to occur during sports activity. It was specu-lated that the avulsed bone fragment from tibial tuberosity wasproximally displaced, resulting in avulsion of the patellar tendon

Figure 4. Patellar tendon sutured and tension adjusted.

Figure 5. Fracture fixed and protective wire loop inserted.

Figure 7. Postop film lateral view.

D.H.Y. Tai et al. / Journal of Orthopaedics, Trauma and Rehabilitation 21 (2016) 44e4746

from its tibial insertion. All cases were treated by anatomicalreduction of the bone fragment, internal fixation and repair of thepatellar tendon. In 2004, Mosier et al6 reported a series of 19 tibialtubercle avulsion fractures, of which, three were associated withpatellar tendon ruptures. Swan et al7 reported two similar cases in2007.

Figure 6. Postop film AP view. Figure 8. Postop film at 5 months AP view.

Figure 9. Postop film at 5 months lateral view.

D.H.Y. Tai et al. / Journal of Orthopaedics, Trauma and Rehabilitation 21 (2016) 44e47 47

Our patient had a history of THD, which is believed to be one ofthe risk factors for developing this kind of rare injury. THD is due tomutations of the tyrosine hydroxylase (TH) gene with autosomalrecessive trait inheritance. The TH gene contains instructions forencoding TH, which converts the amino acid tyrosine into dopa-mine. THD results in a deficiency of dopamine, norepinephrine, andepinephrine. Dopamine is a neurotransmitter and is critical for theproper function of the brain to control limb movement. THD rep-resents a spectrum of diseases with mild to severe forms. Patientsmay present with abnormal gait, spasticity, dystonia, and invol-untary movements of the affected limbs. Our patient suffered froma mild form of THD and he was still able to play handball. However,his symptoms may have worsened after prolonged exercise or fa-tigue, therefore predisposing development of this kind of injurywhile flexing the knee against the contracting quadriceps.8,9

It is important to look for associated injuries in tibial avulsionfractures, including patellar tendon avulsion, quadriceps tendonavulsion, meniscal injury and cruciate ligament injury.10 Franklet al11 recommended radiographs in extension and flexion views.The distance between the lower pole of the patella and the end ofthe avulsed fragment increases in flexion in cases of avulsedpatellar tendon.

Intraoperatively, care must be taken to avoid patella baja. In ourpatient, radiographs were taken intraoperatively for comparisonwith the other knee, so as to achieve a similar patellar height. TheInsalleSalvati ratio could be measured. In our patient, the preop-erative Insall ratio was 1.6, while the immediate postoperativeInsall ratio was 1.0. The Insall ratio after removal of the protective

wire loop was 1.2. Classically, Insall ratio <0.8 suggests patellar bajawhile >1.2 suggests patellar alta.

In isolated traumatic tendon rupture, early mobilization hasbeen advocated without cast immobilization after primary repair.Bhargava et al12 reported excellent results with early active quad-riceps exercises and full weight-bearing walking. The wire wasremoved at 10 weeks. For tibial avulsion fracture, patients areusually immobilized with a cast for 4e6 weeks, after which,physiotherapy is commenced. However, in our patient withsimultaneous tibial avulsion fracture and patellar tendon avulsion,we adopted a more conservative protocol with insertion of a pro-tective wire loop and a long leg cast for immobilization for 2months. Touch-down walking was commenced immediately post-operatively. In all the above-mentioned cases of simultaneous tibialavulsion fracture and patellar tendon avulsion in the literature, aprotective wire loop was not used, and a cast was retained for 4e6weeks. Most of the patients regained the full range of motion from6 weeks to 3 months. Complications from this fracture are rare.3

Although our patient did achieve the full range of movement at 5months, with mobilization exercise started 2 months after theinitial operation, the authors recommend that the rehabilitationperiod is shortened by adopting a less conservative protocol. Thatis, without the use of a wire loop so that the cast can be removed at4e6 weeks postoperatively; or, if a protective wire loop is used,immediate postoperative range of movement exercise and earlyremoval of the wire loop at 4e6 weeks.

In conclusion, simultaneous tibial tuberosity avulsion andpatellar tendon avulsion is a rare injury. Suspicion should be raisedespecially in patients with particular illnesses. Diagnosis can bedifficult. Open reduction, internal fixation and repair of the patellartendon are necessary to restore the extensor mechanism. Patellabaja should be avoided during surgery. Postoperatively, range ofmovement exercise should be commenced as early as possible aftercasting for 4e6 weeks.

Conflicts of interest

The authors have no conflicts of interest to declare.

References

1. Bolesta MJ, Fitch RD. Tibial tubercle avulsions. J Pediatr Orthop 1986;6:186e92.2. Watson-Jones R. Fractures and joint injuries. 5th ed. Volume 2. Baltimore:

Williams & Wilkins; 1976. p. 1048e50.3. Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents.

J Bone Jt Surg [Am] 1980;62:205e15.4. Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone

Joint Surg [Br] 1981;63-A:932e7.5. Kaneko K, Miyazaki H, Yamaguchi T. Avulsion fracture of tibial tubercle with

avulsion of the patellar ligament in an adolescent female athlete. J Sport Med2000;10:144e5.

6. Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop2004;24:2.

7. Swan Jr K, Rizio L. Combined avulsion fracture of the tibial tubercle and avul-sion of the patellar ligament. Orthopedics 2007;30:571e2.

8. Nikhar NK, Mani H. Dopamine-responsive dystonia. http://emedicine.medscape.com/article/1181084 (accessed 27 Feb 2012).

9. Willemsen M. Tyrosine hydroxylase deficiency. National Organization for RareDisorders. https://rarediseases.org/rare-diseases/tyrosine-hydroxylase-deficiency/2011.

10. Zrig M, Annabi H, Ammari T, et al. Acute tibial tubercle avulsion fractures in thesporting adolescent. Arch Orthop Trauma Surg 2008;128:1437e42.

11. Frankl U, Wasilewsik SA, Healy WL. Avulsion fracture of the tibial tubercle withavulsion of the patellar ligament. J Bone Joint Surg 1990;72-A:1411e3.

12. Bhargava SP, Hynes MC, Dowell JK. Traumatic patella tendon rupture: earlymobilisation following surgical repair. Injury Int J Care Injured 2004;35:76e9.