Chapter 29: Proximal Tibial Physeal Fractures

Eric W. Edmonds, Scott J. Mubarak

Chapter Outline

Introduction to Proximal Tibial Physeal Fractures

Fractures of the proximal tibia physis require a significant amount of force, and therefore these injuries account for less than 1% of all physeal separations.27,40 Contrasting the distal femur discussed in the previous chapter, the proximal tibial physis has intrinsic varus–valgus and side-to-side translational stability because of the collateral ligaments and the lateral fibular buttress.6 Although potentially problematic regarding an apophyseal fracture of the tibial tubercle, the metaphyseal overhang of the tubercle can provide anterior–posterior translational support. 
An avulsion fracture of the tibial tuberosity is uncommon, accounting for less than 1% of all epiphyseal injuries and approximately 3% of all proximal tibial fractures.4,27,40 Most fractures concerning the proximal tibial physis result in anterior, anterolateral, and anteromedial epiphysis displacement relative to the metaphysis caused by the anatomic stability mentioned above.46 In the rare fracture with posterior displacement, the epiphysis and tubercle apophysis are displaced as a single unit.34 Fractures of the proximal tibial metaphysis usually occur in children aged 3 to 6 years, and may be complete or greenstick. In contrast, the tibial tubercle fracture is most commonly sustained by adolescents.30 The most critical features of proximal tibial physeal fractures are proximity to the popliteal artery and possible development of compartment syndrome. 

Assessment of Proximal Tibial Physeal Fractures

Mechanisms of Injury of Proximal Tibial Physeal Fractures

As mentioned, these injuries require a significant amount of force to propagate a proximal tibial physis fracture, most often motor vehicle trauma, sports injuries, or other traumatic events such as lawn mower accidents. However, Salter–Harris type II fractures have been reported in child abuse cases and Salter–Harris I fractures have been reported in arthogrypotic children undergoing physical therapy stretching.12,49 
Physeal fractures are often seen after a hyperextension force resulting in the metaphyseal portion of the tibia displacing posteriorly toward the popliteal artery. Valgus stress can open the physis medially with the fibula acting as a lateral resistance force (Fig. 29-1).54 Rarely, a flexion force can cause a Salter–Harris type II or III fracture. This flexion fracture pattern has a mechanism similar to that of tibial tuberosity avulsion injuries. 
Figure 29-1
Jumping on the trampoline is a common mechanism for young children to sustain valgus and varus fractures of the proximal tibia.
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Tibial tubercle apophyseal fractures are more frequently the result of jumping activities, especially at the initiation of the jump during eccentric loading at maximal quadriceps force, but may also be seen during eccentric loading while landing (Fig. 29-2).4,7,8,19,29,30,34 Moreover, tibial tuberosity fractures are reported almost exclusively in boys who tend to have greater quadriceps strength and may overcome the stability of the apophysis with a violent contraction of the muscle.4,5,7,8,19,26,29,30,34 
Figure 29-2
The tibial tubercle is commonly fractured because of the maximum generated force of the quadriceps contracture during jumping—primarily in male adolescents.
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Associated Injuries with Proximal Tibial Physeal Fractures

Although the proximal tibial physis and the tibial tubercle apophysis are intimately associated with each other, fractures of the two locations have a unique set of associated injuries. The proximal physis fracture is at risk for ligamentous, vascular, and neurologic injury; whereas, the tubercle apophyseal fractures are also at risk for compartment syndrome. 
Ligamentous injuries and internal derangement of the knee joint may occur during Salter–Harris III and IV proximal tibial physeal injuries in 40% of patients.41 In contrast, the tibial tubercle fractures may rupture the patellar ligament, quadriceps tendon, collateral, and cruciate ligaments in a far greater frequency.4,28,29,35 Even an avulsion of the anterior tibialis muscle has also been reported.25,53 
Vascular compromise in proximal tibial physeal fractures can be devastating, but they are uncommon in isolated tubercle injuries.6,46,55 The popliteal artery is tethered by its major branches near the posterior surface of the proximal tibial epiphysis. The posterior tibial branch passes under the arching fibers of the soleus. The anterior tibial artery travels anteriorly over an aperture above the proximal border of the interosseous membrane. A hyperextension injury that results in posterior displacement of the proximal tibial metaphysis may stretch and tear the tethered popliteal artery (Fig. 29-3). Even a minimally displaced fracture at presentation may have had significant displacement at the time of injury, and should therefore be monitored for vascular injury.50 Diagnostic workup of these fractures does not mandate routine angiography as long as motor function, pulses, warmth, and color are monitored closely after reduction during the initial 48 to 72 hours. 
Figure 29-3
Tethering of the popliteal artery by the more distal tibial artery creates a situation wherein posterior metaphyseal tibia displacement can rupture the artery.
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Regarding vascular injuries, the tibial tubercle avulsion fractures are at risk for bleeding of the anterior tibial recurrent artery (which traverses the base of the tubercle) into the anterior compartment. Rather than resulting in direct ischemia, this vascular compromise is associated with indirect ischemia through the development of compartment syndrome.37 
A peroneal neuropathy may also be associated with a fracture of the proximal tibial physis, but it will often undergo spontaneous resolution of symptoms. 

Signs and Symptoms of Proximal Tibial Physeal Fractures

Physical examination of children with either a proximal physis or tubercle apophysis fracture may not be dissimilar. Pain, knee effusion, and a hemarthrosis will often be present in both. Limb deformity may or may not be present in either fracture type, and hamstring spasm may limit knee extension on examination. 
The physeal injuries will have pain over the tibial physis distal to the joint line, in contrast to the tubercle injuries that will hurt directly anteriorly. Sometimes, the tubercle fractures will have a freely movable osseous fragment palpated subcutaneously between the proximal tibia and the femoral condyles, and may result in skin tenting; whereas, in the physeal fractures, the proximal metaphysis of the tibia is displaced posteriorly creating a concavity that can be palpated anteriorly at the level of the tibial tubercle. A valgus deformity suggests medial displacement of the metaphysis. 
The associated injuries need to be identified at this time, as well. Ischemia caused by disruption of the popliteal artery or secondary to compartment syndrome should not be delayed. Poor perfusion, pallor, and distal pain should be recognized for potential signs of vascular compromise. Pulses should be ascertained and compartments should be assessed by palpation and assessment of sensation plus passive and active toe motion. 
When the proximal end of the metaphysis protrudes under the subcutaneous tissues on the medial aspect of the knee, a tear of the distal end of the medial collateral ligament should be suspected in association with a physeal fracture. The presence of patella alta may represent either severity of tubercle displacement or rupture of the patella tendon. With a small avulsion, the child may be able to extend the knee actively through intact retinacular tissue, but active extension is impaired with larger injuries. 

Imaging and Other Diagnostic Studies for Proximal Tibial Physeal Fractures

Plain radiographs are the mainstay of evaluation for fractures, but nondisplaced physeal fractures may not be visible. Associated hemarthrosis can sometimes be the only indication of fracture and is primarily recognized by identifying an increased separation of the patella from the distal femur on lateral views (Fig. 29-4). Occasionally, relatively nondisplaced physeal fractures may have small Thurston–Holland fragments that extending either into the epiphysis or into the metaphysis. Often, fracture lines may only be visible on oblique view radiographs. At other times the metaphyseal fragments can be quite large (Fig. 29-5). Stress views can often differentiate a proximal tibial physeal fracture from a ligament injury, but there is potential risk for physeal injury and increased pain in a clinical setting when performing these x-rays. Often MRI can be done if indicated, to distinguish these two injury patterns, and it is safe, accurate, and a more comfortable method for diagnosis of obscure fractures or ligamentous injuries than stress radiographs (Fig. 29-6).48 Moreover, CT scans can define the bony injury better than MRI or plain film and is often helpful to determine treatment for Salter–Harris III and IV injuries (Fig. 29-7). 
Figure 29-4
Often the only radiographic evidence of a physeal fracture may be a joint effusion, as seen in this lateral of a minimally displaced tibial tubercle fracture.
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Figure 29-5
Displaced fracture of the proximal tibial physis with a large posterior metaphyseal Thurston–Holland fragment, as well as an anterior conjoined tibial tubercle fragment.
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Figure 29-6
MRI images can assist in differentiating physeal injuries from ligament ruptures.
 
This coronal image demonstrates a proximal tibial physeal fracture with evidence of entrapped medical collateral ligament (MCL) fibers (arrow) limiting reduction.
This coronal image demonstrates a proximal tibial physeal fracture with evidence of entrapped medical collateral ligament (MCL) fibers (arrow) limiting reduction.
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Figure 29-6
MRI images can assist in differentiating physeal injuries from ligament ruptures.
This coronal image demonstrates a proximal tibial physeal fracture with evidence of entrapped medical collateral ligament (MCL) fibers (arrow) limiting reduction.
This coronal image demonstrates a proximal tibial physeal fracture with evidence of entrapped medical collateral ligament (MCL) fibers (arrow) limiting reduction.
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Figure 29-7
Both 3D and standard CT images can help define fracture patterns that involve the joint surface to guide appropriate treatment.
 
This 3D reconstruction demonstrates a tibial tubercle fracture with mild comminution at the joint surface (arrow).
This 3D reconstruction demonstrates a tibial tubercle fracture with mild comminution at the joint surface (arrow).
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Figure 29-7
Both 3D and standard CT images can help define fracture patterns that involve the joint surface to guide appropriate treatment.
This 3D reconstruction demonstrates a tibial tubercle fracture with mild comminution at the joint surface (arrow).
This 3D reconstruction demonstrates a tibial tubercle fracture with mild comminution at the joint surface (arrow).
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The standard method of identifying tibial tubercle fractures is via the lateral plain radiograph; however, more severe injuries should warrant advanced diagnostic imaging to help identify articular disruption and internal derangement that is often seen in these fracture patterns. Although, most patients with tibial tubercle fractures are adolescents (with developed secondary ossification of the tibial tubercle), fractures may occur in the more immature child and be seen merely has a small fleck of bone on plain film (Fig. 29-8). In order to improve the utility of diagnostic plain film, the lateral projection view should be done with the tibia rotated slightly internal to bring the tubercle perpendicular to the x-ray cassette. 
Figure 29-8
Young children may only have evidence of a small fleck (arrow) to represent an otherwise larger cartilaginous fracture of the tibial tubercle.
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With regard to the tibial tubercle, it is important to remember that normal ossification may progress from more than one secondary center of ossification. Opposite leg films may be helpful to distinguish normal ossification versus minimally displaced fragments, but patella alta may be more reliable in that comparison. 

Classification of Proximal Tibial Physeal Fractures

Proximal tibial physeal fractures are most commonly described using the Salter–Harris classification scheme that denotes the direction of fracture propagation relative to the growth plate. A recent study in 2009, proposed the first specific classification for these pediatric proximal tibia fractures that was based on the direction of force and fracture pattern.30 This classification scheme utilized the following mechanism of injury: Valgus, varus, extension and flexion–avulsion (Fig. 29-9). The youngest children (aged 3 to 9 years) sustain valgus and varus mechanism injuries with resultant metaphyseal fractures from activities such as a trampoline. The slightly older age group of 10 to 12 was more prone to extension mechanism injuries that resulted in tibial spine fractures and the greater than 13-year-old group sustained predominately flexion–avulsion mechanism injuries that resulted in tibial tubercle fractures. Within this mechanism of injury classification, there was also evidence that fracture location was age dependent. The mean age for metaphyseal fractures (including the Cozen fracture) was just under 4 years. The mean age for tibial spine fractures was 10 years old, the mean age for Salter–Harris I and II was 12 years old and Salter–Harris III and IV injuries mean age was about 14 years old (Fig. 29-10). 
Figure 29-9
All proximal tibial physeal fractures can be classified based on the mechanism of injury: Varus/valgus, extension, and flexion avulsion injuries.
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Figure 29-10
Bar graph representing the change in fracture patterns seen with increasing age.
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Most separations of the proximal tibial epiphysis are Salter–Harris I and II injuries. The frequency of Salter–Harris III injuries in the past literature may be skewed by the inclusion or exclusion of displaced tibial tubercle fractures, but the incidence of Salter–Harris IV injuries depends on whether certain open injuries to the knee are included (i.e., lawnmower injuries).6,46 If the Salter–Harris classification is utilized, then some predictable findings can be expected. 
In Salter–Harris I injuries, 50% are nondisplaced and this may be secondary to the overhanging tubercle preventing anterior displacement and the fibula preventing lateral displacement of the metaphysis. In contrast, about two-thirds of Salter–Harris II fractures are displaced with medial gapping and lateral Thurston–Holland fragment resulting in a valgus deformity and often a proximal fibula fracture. Salter–Harris III fractures are predominately tibial tubercle fractures in children and have their own classification scheme. 
Shelton and Canale46 and Burkhart and Peterson6 included tubercle avulsions in their reviews of proximal tibial physeal fractures, but these injuries are often considered separately.34,46,51 Watson-Jones51 described three types of avulsion fractures of the tibial tubercle, with subsequent modifications by Ogden and associates34 who noted that the degree of displacement depends on the severity of injury to adjacent soft tissue attachments (Fig. 29-11). Ryu42 and Inoue24 proposed a type IV fracture in which the physeal separation occurs through the tibial tuberosity and extends posteriorly into the horizontal tibial physis. A study from San Diego was recently presented by the authors delineating a three-dimensional classification of tibial tubercle fractures, in order to highlight the risk for associated pathology.36 It is based on skeletal maturity and ossification of the secondary ossification center as it relates to increasing need for surgery and risk for compartment syndrome (Fig. 29-12). San Diego type A tibial tubercle fractures occur in the youngest population (mean age 12.7 years) with most of the physis and apophysis open resulting in a largely cartilaginous fracture that is seen as a fleck of bone at the distal tibial tubercle. These are at low risk for compartment syndrome, but potentially greatest risk for premature physeal closure because of age. They require only sagittal plain radiographs for appropriate diagnostics. The San Diego type B fracture is found in a slightly older population wherein the physeal and apophyseal cartilage is primarily open (Fig. 29-13A and B). These are basically the same has the Ryu variant wherein the apophysis and proximal physis fracture as a single unit, and they are at the greatest risk for compartment syndrome, vascular injury, and growth arrest. The San Diego type C fracture is found in even older patients with closing growth plates that are partially open following a predictable pattern of closure. These fractures always involve the articular surface and require either pre-operative three-dimensional imaging or intra-operative intra-articular evaluation (Fig. 29-14A and B). These fractures almost always require surgical intervention. Finally, the San Diego type D fractures are found in the oldest population and most of the proximal tibial physis and apophysis have closed leaving only the most distal aspect of the tubercle unfused and at risk for fracturing. They look similar to the type A injuries, but occur in more skeletally mature individuals. These have the lowest risk of complications of all the groups and can be treated with either casting or screw fixation (Fig. 29-15A and B). 
Figure 29-11
The Ogden classification of tibial tubercle fractures
 
(Adapted from Ogden JA. Skeletal Injury in the Child. 2nd ed. Philadelphia, PA: WB Saunders; 1990: 808).
(Adapted from 


Ogden JA
. Skeletal Injury in the Child. 2nd ed. Philadelphia, PA: WB Saunders; 1990: 808).
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Figure 29-11
The Ogden classification of tibial tubercle fractures
(Adapted from Ogden JA. Skeletal Injury in the Child. 2nd ed. Philadelphia, PA: WB Saunders; 1990: 808).
(Adapted from 


Ogden JA
. Skeletal Injury in the Child. 2nd ed. Philadelphia, PA: WB Saunders; 1990: 808).
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Figure 29-12
Closure of the proximal tibial growth centers follows a predictable pattern: Posterior to anterior direction and medial to lateral with simultaneous proximal to distal closure of the tubercle apophysis.
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Figure 29-13
San Diego type B tibial tubercle fracture.
 
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in the younger child and have high risk for vascular injury.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in the younger child and have high risk for vascular injury.
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Figure 29-13
San Diego type B tibial tubercle fracture.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in the younger child and have high risk for vascular injury.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in the younger child and have high risk for vascular injury.
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Figure 29-14
San Diego type C tibial tubercle fracture.
 
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in young, but maturing children and have high risk for intra-articular pathology.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in young, but maturing children and have high risk for intra-articular pathology.
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Figure 29-14
San Diego type C tibial tubercle fracture.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in young, but maturing children and have high risk for intra-articular pathology.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in young, but maturing children and have high risk for intra-articular pathology.
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Figure 29-15
San Diego type D tibial tubercle fracture.
 
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in older children and have low associated risks.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in older children and have low associated risks.
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Figure 29-15
San Diego type D tibial tubercle fracture.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in older children and have low associated risks.
A: Upper line drawing indicating area of closed physis (red), lower line drawing demonstrating fracture pattern in three planes; (B) radiographic representation of the fracture. These occur in older children and have low associated risks.
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Outcome Measures for Proximal Tibial Physeal Fractures

There are no specific outcome scores or tools validated for proximal tibial physeal fractures; however, most studies have utilized plain radiographs to determine healing and a few have utilized return to sports for functional outcomes. 

Pathoanatomy and Applied Anatomy Relating to Proximal Tibial Physeal Fractures

Present at birth, the ossific nucleus of the proximal tibial epiphysis lies central in the cartilaginous anlage. Usually singular, it can occasionally have two ossification centers, not including the universal secondary center of ossification of the tubercle that appears between 9 and 14 years of age. Closure of the proximal tibial physis and union between the epiphysis and tubercle centers occurs commonly in girls between 10 and 15 years and in boys between 11 and 17 years of age. 
The development of the tibial tubercle has been further defined by Ehrenborg.15 After birth is the cartilaginous stage that exists prior to development of the secondary ossification center and persists until the age of 9 years in girls and age of 10 years in boys. This is followed by the apophyseal stage, in which the ossification center appears in the tongue of cartilage that drapes over the anterior tibial metaphysis. The epiphyseal stage is marked by the tubercle and epiphyseal bony union, and this is followed by the final bony stage, wherein the proximal tibia becomes fully ossified. There is evidence that closure of the physis follows a predictable pattern.3,13,18,33,36,45,47 In the sagittal plane, the proximal tibial physis has been shown to close in a posterior to anterior direction, with subsequent progression of closure toward the tubercle apophysis which is closing in a proximal to distal direction, simultaneously. In the coronal planes, the proximal tibial physis is closing in a medial to lateral direction; whereas, in the axial plane, the tibia is closing in a posteromedial to anterolateral direction. 
As previously discussed, the anatomy of the collateral ligaments provides some protection from epiphyseal disruption. The superficial portion of the medial collateral ligament extends distal to the physis inserting into the medial metaphysis, therefore acting as a medial buttress. The lateral collateral ligament inserts on the proximal pole of the fibula, and this entire lateral construct acts like a lateral buttress. Anteriorly, the patellar ligament attaches to the secondary ossification center of the tibial tuberosity that is draped over the metaphysis serving as a constraint to posterior displacement. Yet, this design of terminal insertion of the powerful quadriceps at the boundary between the secondary ossification centers of the tubercle and the proximal tibial epiphysis does place the tubercle at risk for isolated or combined avulsion fractures. This risk is minimal until adolescence when the quadriceps mechanism is matured because some fibers of the patella tendon extend distal to the apophysis into the anterior aspect of the upper tibial diaphysis. Therefore, it is important to recognize that these adolescent avulsions often have extensive soft tissue damage that extends down the anterior diaphysis. 
The distal portion of the popliteal artery lies close to the posterior aspect of the proximal tibia. Firm connective tissue septa hold the vessel against the knee capsule placing it at risk for injury during proximal tibia physeal fractures (Fig. 29-16). The lateral inferior geniculate artery crosses the surface of the popliteus muscle, anterior to the lateral head of the gastrocnemius, and turns forward underneath the lateral collateral ligament. The medial inferior geniculate artery passes along the proximal border of the popliteus muscle, anterior to the medial head of the gastrocnemius, and extends anterior along the medial aspect of the proximal tibia. The popliteal artery divides into the anterior tibial and posterior tibial branches beneath the arch of the soleus muscle. Much of the blood supply to the proximal tibial epiphysis is derived from an anastomosis between these geniculate arteries.10,20 The tibial tubercle receives its main blood supply from a plexus of arteries behind the patellar ligament at the level of the attachment to the tibial tubercle.10 This vascular anastomosis arises from the anterior tibial recurrent artery and may be torn with this fracture.37,53 Several small branches extend down into the secondary ossification center. A smaller part of the blood supply enters the superficial surface of the tubercle from adjacent periosteal vessels. 
Figure 29-16
Arteriogram after a proximal tibial physeal fracture.
 
Even with minimal displacement, note the construction of the popliteal artery (arrow).
Even with minimal displacement, note the construction of the popliteal artery (arrow).
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Figure 29-16
Arteriogram after a proximal tibial physeal fracture.
Even with minimal displacement, note the construction of the popliteal artery (arrow).
Even with minimal displacement, note the construction of the popliteal artery (arrow).
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Treatment Options for Proximal Tibial Physeal Fractures

Nonoperative Treatment of Proximal Tibial Physeal Fractures

Salter–Harris I and II fractures of the proximal tibial physis and San Diego type D tubercle fractures can often be treated with closed reduction (Table 29-1). Traction is important during reduction to minimize the risk of damage to the physis. Hyperextension fractures are reduced with traction in combination with gentle flexion. A fracture with valgus angulation can usually be reduced by adducting the leg into varus with the knee extended. This should be done with gentle manipulation to decrease the risk of injury to the peroneal nerve. After reduction, a long-leg cast with varus molding is applied with the knee in slight flexion. 
 
Table 29-1
Proximal Tibial Physeal Fractures
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Table 29-1
Proximal Tibial Physeal Fractures
Nonoperative Treatment
Indications Relative Contraindications
No associated pathology Joint involvement
No to minimal displacement Compartment syndrome
Stable fragment Open fracture
X
Regarding tubercle reductions, a persistant gap between the distal end of the tubercle and the adjacent metaphysis may indicate an interposed flap of periosteum.8,19 Minimally displaced, small avulsion fragments have been treated successfully with immobilization in a cylinder cast or long-leg cast.7,8,29,34 The leg is positioned with the knee extended, but even with a long-leg cast, a straight leg raise can place tension on the fracture. Molding above the proximal pole of the patella has been suggested to help maintain reduction. 

Indications/Contraindications (Table 29-1)

Techniques (Proximal Physis)

Closed reduction is paramount to nonoperative treatment, second only to immobilization. As mentioned, traction during the reduction maneuver will reduce the risk of physeal damage. The reduction should recreate the injury before applying a leveraging force in the opposite direction of displacement whilst maintaining traction on the limb. Prior to closed reduction, a tense knee effusion may be aspirated using sterile technique followed by an injection of 2 to 5 mL of either 0.5% bupivacaine, or 0.2% ropivacaine to relieve pain and augment the reduction attempt. However, many children will not tolerate this method of anesthesia and either moderate conscious sedation or general anesthesia should be employed. 
Patients with a nondisplaced (2 mm or less) and stable proximal tibial epiphyseal fracture can be simply placed in a long-leg cast with 20 to 30 degrees of knee flexion. Appropriate padding is important and thick (1/2 inch) foam may be placed either along the popliteal fossa or on the bony prominences to protect the skin. The cast should be either univalved or bivalved to permit swelling. Almost universally, the child is then admitted to the hospital for observation and gentle elevation to monitor for the high incidence of vascular injury and compartment syndrome. 
Radiographs should be obtained at the time of reduction and cast placement to confirm appropriate alignment of the fracture. Future films should include both the AP and lateral x-rays at 1 week post-reduction to confirm maintenance of reduction. The cast may be removed 4 to 6 weeks after injury if the fracture demonstrates radiographic and clinical union. Return to normal activities can be permitted about 4 weeks following cast removal. 

Techniques (Tibial Tubercle)

Closed reduction can be performed for minimally displaced and extra-articular fractures of the tibial tubercle. Knee extension with a slight mold above the patella to minimize the pull of the quadriceps muscle is appropriate, but this technique may be safer to utilize in patients that can still achieve active knee extension against gravity. Similar to the closed reduction and immobilization of the physeal injuries described above, this fracture should be immobilized with either a cylinder or long-leg cast and they should be admitted to the hospital for observation regarding the possible development of compartment syndrome. 
Furthermore, treatment follows the basic outline described above for physeal fractures with regard to follow-up duration, length in cast, and return to activities. 

Outcomes

There have been no good outcome studies for nonoperative management of proximal tibial physeal fractures or tibial tubercle fractures. To date, no authors have attempted to utilize a patient-derived satisfaction questionnaire. However, there are a few case series that identify the complications associated with these injuries and their treatment. A discussion of complications is discussed in that section. 

Operative Treatment of Proximal Tibial Physeal Fractures

Indications/Contraindications

Salter–Harris type I and II fractures of the proximal tibial physis may be unstable. Those that are reducible via closed methods, but unstable, may be stabilized with crossing percutaneous smooth pins. Likewise, a percutaneous compression screw may be placed in the metaphyseal spike of an unstable Salter–Harris type II fractures as long as it reduces well and the implant does not cross the physis. Salter–Harris II fractures that cannot be anatomically reduced require open reduction for removal of soft tissue interposition (entrapped pes anserinus and periosteum have been reported).9,49,54 Another relative indication for open reduction and internal fixation of a Salter–Harris type I or II hyperextension injury is to facilitate wound management when a vascular repair is necessary. 
Open reduction is also indicated for all displaced Salter–Harris types III and IV injuries. Moreover, open reduction and internal fixation is recommended for displaced or intra-articular tibial tubercle avulsions.4,7,8,19,29,32,34 Residual displacement greater than 2 to 3 mm may lead to an extensor lag and quadriceps weakness. 

Surgical Procedure (Closed Reduction and Percutaneous Fixation)

Preoperative Planning
Depending on the physical location of the initial attempt of closed reduction, a conversion to this surgical procedure could follow a natural progression. If the reduction is performed in the emergency department but the fracture is deemed unstable, then a temporary splint should be placed and plans to move to the operating room should be made. However, if the initial attempt was undertaken in the operating room and the fracture was deemed unstable, then percutaneous pinning could be done immediately. Moreover, if the fracture cannot be adequately reduced, then the treating surgeon could move directly to open reduction followed by fixation. This procedure will be discussed in its dedicated section. 
Therefore, before entering to operating room, there should be an algorithm in place with preparations having been made for the predictable contingencies. First, identification of the fracture pattern must be understood. Is this a pure physeal injury? Is it a tubercle injury? Does the fracture extend into the joint? Based on the answers to these questions, then choices can be made regarding closed reduction attempts and methods of fixation that need to be prepared (Table 29-2). 
Table 29-2
Closed Reduction and Percutaneous Pinning of Proximal Tibial Physeal Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent, preferably without metallic side bars
  •  
    Position/positioning aids: Assistant for counter traction
  •  
    Fluoroscopy location: Opposite to surgeon and back table
  •  
    Equipment: C-arm, smooth pins, unopened trays for open reduction
  •  
    Tourniquet (nonsterile): May not need to inflate, unless surgery converted to open reduction
X
Positioning
The patient should be placed supine on the bed with leg centered within the width of the bed to limit obscuring radiographic views with metal side bars (if present). No bumps are usually needed, but if the child has excessive femoral retroversion or hip external rotation, then a pelvic bump to keep the patella pointing skyward can be helpful for imaging during the procedure. The C-arm and the back table should be positioned opposite to each other relative to the patient, with the surgeon on the same side as the back table and injured extremity. 
Surgical Approach
The closed reduction should be performed as described in that section, and the pinning is done by first determining the appropriate pin size. Pin placement is then determined by the fracture pattern and the method of cross-pinning is utilized to augment the construct. Therefore, one pin will be placed medial and the other will be placed lateral through the metaphysis. 
Technique
The process flow for closed reduction and percutaneous pinning starts with the operative room setup. Once the reduction is confirmed by fluoroscopy then pinning may begin. Pin size choice will depend on the size of the tibia, but usually range from a 0.062 inch pin to a 2.5 mm pin in bigger children. Often, four pins will be better than two large pins. 
For the proximal tibial physeal fractures that are Salter–Harris types I and II, the pinning should start in the metaphysis, and utilize fluoroscopy guidance. If the first pin starts on the medial metaphyseal cortex, then the surgeon should aim the pin toward the lateral epiphyseal cortex. The opposite is true for the lateral metaphyseal starting point. The pins usually aim from slightly anterior to slightly posterior. They should be bicortical and not cross at the fracture line (Fig. 29-17). Occasionally, for large Thurston–Holland fragments, a percutaneous compression screw may be placed to secure the fracture. Rather than using the crossing pin technique, or in conjunction with that technique, a small stab incision can be made directly over the fragment after reduction. Fluoroscopy guidance is then utilized to place the guide pin from a cannulated screw system, being sure not to violate the physis or the apophysis anteriorly. Length is measured, the proximal cortex drilled, and the screw is inserted and secured into place with fluoroscopy. If a bicortical purchase can be achieved, then that is optimal. Yet, cancellous screws can be utilized if the width of the tibial metaphysis exceeds the screw options (Fig. 29-18). 
Figure 29-17
San Diego type B tibial tubercle, or Salter–Harris type 2 (with posterior metaphyseal fragment and tibial tubercle fracture).
 
A: AP radiograph demonstrating cross-pin technique; (B) lateral radiograph demonstrating anatomic reduction with fixation.
A: AP radiograph demonstrating cross-pin technique; (B) lateral radiograph demonstrating anatomic reduction with fixation.
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Figure 29-17
San Diego type B tibial tubercle, or Salter–Harris type 2 (with posterior metaphyseal fragment and tibial tubercle fracture).
A: AP radiograph demonstrating cross-pin technique; (B) lateral radiograph demonstrating anatomic reduction with fixation.
A: AP radiograph demonstrating cross-pin technique; (B) lateral radiograph demonstrating anatomic reduction with fixation.
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Figure 29-18
Salter–Harris type 2 proximal tibial physis fracture with two cannulated, partially threaded cancellous screws in the Thurston–Holland fragment.
A: AP radiograph; (B) lateral radiograph.
A: AP radiograph; (B) lateral radiograph.
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For the extra-articular tibial tubercle fragments (San Diego type A and D), a choice between the smooth pin (Fig. 29-19) and the compression screw (Fig. 29-20) can be made but the technique is the same. These fractures will often have soft tissue interposition and conversion to open reduction is not uncommon. 
Figure 29-19
Intra-operative lateral fluoroscopy image demonstrating multiple smooth pin fixation of a tubercle fracture.
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Figure 29-20
Post-operative lateral radiograph with single compression screw and washer fixation of an extra-articular tibial tubercle fracture.
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With fluoroscopy confirmation that the reduction is anatomic and the pin placement is appropriate, the skin should be cleaned, the pins should be bent perpendicular at the skin and then cut leaving only about an inch of exposed skin on the surface (Table 29-3). 
Table 29-3
Closed Reduction and Percutaneous Pinning of Proximal Tibial Physeal Fractures
Surgical Steps
  •  
    Closed reduction of the fracture with C-arm guidance
  •  
    Option 1: Smooth cross-pinning pin placement (SH type 1 and 2)
  •  
    Option 2: Guide pin placement that does not cross physis in the metaphyseal fragment (SH type 2)
    •  
      Drill proximal cortex with cannulated system
      •  
        Compression screw placement
  •  
    Option 3: Smooth pin placement that does not cross physis, but crosses apophysis in tibial tubercle fragment
    •  
      Can use this smooth pin as a guide pin for compression screw placement, if desired
  •  
    For smooth pin placement, bend and cut pins to be pulled at 4 weeks post-op
  •  
    For cannulated screws, close stab incisions with suture
  •  
    Place dressing and apply long-leg cast in 30 degrees of knee flexion
X

Surgical Procedure (Open Reduction and Internal Fixation)

Preoperative Planning
The preoperative plan for open reduction and internal fixation of these fractures follows the course outlined in the closed reduction and percutaneous pinning section with two exceptions. For the Salter–Harris III and IV physeal injuries including the San Diego type C tubercle fractures, there should be no attempt at closed reduction and percutaneous pinning. An arthrotomy (or arthroscopy) should be performed to assess the articular reduction and associated intra-articular pathologies. Furthermore, even the San Diego type B tubercle fractures are usually extra-articular, open reduction should be performed since the entire proximal tibial physis and apophysis are disrupted (Table 29-4). 
 
Table 29-4
ORIF of Proximal Tibial Physeal Fractures
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Table 29-4
ORIF of Proximal Tibial Physeal Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent, preferably without metallic side bars
  •  
    Position/positioning aids: Assistant for counter traction
  •  
    Fluoroscopy location: Opposite to operative limb, surgeon and back table
  •  
    Equipment: C-arm, smooth pins, trays for open reduction including a cannulated compression screw system (4.0 to 6.5 mm sizes available)
  •  
    Tourniquet (nonsterile): May need to deflate during reduction of tubercle fragments
  •  
    Confirm vascular status prior to surgery, and have sterile Doppler available
X
Positioning
This is no different than positioning for a closed reduction percutaneous pinning procedure. The patient should be placed supine on the bed with the leg centered within the width of the bed to limit obscuring radiographic views with metal side bars (if present). No bumps are usually needed, but if the child has excessive femoral retroversion or hip external rotation, then a pelvic bump to keep the patella pointing skyward can be helpful for imaging during the procedure. The C-arm and the back table should be positioned opposite to each other relative to the patient, with the surgeon on the same side has the back table and injured extremity. 
Surgical Approach
A midline anterior longitudinal incision is required from the inferior pole of the patella to below the tibia tubercle. Care should be taken not to score or further damage the physis at the perichondral ring of LaCroix during the approach. The incision should be performed adjacent to the tibial tubercle (rather than directly over it) to minimize the potential for scar discomfort over the prominent bone. This full length incision is often required to fully expose the fracture bed, the soft tissue damage, and to perform an adequate arthrotomy to evaluate the articular surface (Fig. 29-21). 
Figure 29-21
Intra-operative photograph of a San Diego type C fracture.
 
The patella is to the upper right and foot the lower left, with the physis (curved arrow) and fracture bed (double-headed arrow). There is evidence of a large periosteal avulsion attached to the tubercle fragment (arrowhead).
The patella is to the upper right and foot the lower left, with the physis (curved arrow) and fracture bed (double-headed arrow). There is evidence of a large periosteal avulsion attached to the tubercle fragment (arrowhead).
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Figure 29-21
Intra-operative photograph of a San Diego type C fracture.
The patella is to the upper right and foot the lower left, with the physis (curved arrow) and fracture bed (double-headed arrow). There is evidence of a large periosteal avulsion attached to the tubercle fragment (arrowhead).
The patella is to the upper right and foot the lower left, with the physis (curved arrow) and fracture bed (double-headed arrow). There is evidence of a large periosteal avulsion attached to the tubercle fragment (arrowhead).
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There are no vascular or neurologic structures at risk during this approach. 
Technique
A tourniquet can be used high on the thigh, but may need to be released if it is hindering reduction of a displaced fracture caused by constriction of the quadriceps muscle. After creating the anterior approach, the fracture bed is carefully cleared of debris such as fracture hematoma and an assessment is taken of the entire fracture personality. For example, a periosteal flap (from the diaphysis) is frequently entrapped in the fracture blocking an anatomic reduction.8,19 After extracting the soft tissue, the nonviable portions may be debrided. 
At this point, the fracture can often be reduced utilizing the same maneuvers discussed in the closed reduction section utilizing axial traction and leverage in the direction appropriate to reduce displacement. Depending on the fracture pattern, there are a multitude of fixation methods that can be employed. For Salter–Harris type I physeal fractures and San Diego type B tubercle fractures, smooth cross-pins can be utilized. For Salter–Harris II, III, and IV, as well as the other tubercle fractures, either pins or screw fixation can be used (Fig. 29-22). The orientation of the fixation in this latter group is the placement parallel to the tibial physis (but, this will often violate the growth of the apophysis). 
Figure 29-22
Lateral radiograph demonstrating multiple compression screw fixation of a Salter–Harris type IV proximal tibial physeal fracture.
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Screw fixation is used when the tuberosity fragment, or metaphyseal fragment, is large enough to support this type of fixation. The screw is inserted from anterior to posterior over a guidewire. They should be bicortical, but often the tibial width is greater than the screw lengths and in those situations the screws do not need to engage the posterior cortex, but cancellous lag screws may be used. When there are three or more years of growth remaining or when the fragment is too small for screw fixation, transfixing pins can be used instead of screw fixation. Alternatively for tibial tubercle fractures, a tension band can be passed around the fragment or through the patellar ligament and fixed through a drill hole across the anterior tibia distal to the attachment of the tuberosity. Tension band wiring has even been reported as a first-line method to facilitate rapid rehabilitation in athletes.32 The wire is driven around the proximal pole of the patella or through a drill hole in the distal pole and then looped distally through a cannulated cortical screw that is inserted across the anterior tibia distal to the patellar tendon insertion. This method may also be useful when the fracture fragments are comminuted or too small for secure fixation to the tibial metaphysis. 
A variation of these fractures that are similar to patella sleeve avulsion fractures, but originating at the tuberosity can be fixed using this tension band method as well. Davidson and Letts11 recommended fixation of these injuries with small cancellous screws and heavy nonabsorbable sutures to repair the torn retinaculum and periosteum (Table 29-5). 
 
Table 29-5
ORIF of Proximal Tibial Physeal Fractures
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Table 29-5
ORIF of Proximal Tibial Physeal Fractures
Surgical Steps
  •  
    Anterior midline exposure of proximal tibia (no vascular compromise)
    •  
      If vascular issue, then consider medial approach to combine fracture reduction and vascular repair through a single incision
  •  
    Hematoma debridement and identification of all fracture components (fragment, fracture bed, physis, soft tissue injury, joint injury)
  •  
    Apply tibial traction and leverage to reduce proximal physeal fractures (key in metaphyseal or epiphyseal fragments for SH II to IV injuries, including tubercle fractures)
  •  
    Utilize C-arm fluoroscopy and place tentative smooth wire fixation
    •  
      If planning to use cannulated screws, place smooth wires has guide pins (avoid violating physis)
  •  
    Option 1: Smooth cross-pinning pin placement (SH type 1 and 2)
  •  
    Option 2: Guide pin placement that does not cross physis in metaphyseal fragment (SH type 2)
    •  
      Drill proximal cortex with cannulated system
      •  
        Compression screw placement
  •  
    Option 3: Smooth pin placement that does not cross physis, but crosses apophysis in tibial tubercle fragment
    •  
      Can use this smooth pin as a guide pin for compression screw placement, if desired
  •  
    If there is a large periosteal flap and retinacular tear, then place 1 to 2 suture anchors distal in tibia
    •  
      Suture soft tissue back into position
  •  
    Closure of incision
  •  
    Cast application (long-leg or cylinder) in near full extension
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Author's Preferred Treatment for Proximal Tibial Physeal Fractures

Closed reduction of these fractures is considered when they are extra-articular and minimally displaced. Epiphyseal separation (whether a Salter–Harris type I, or a tibial tubercle San Diego type B) results in a higher risk for vascular injury. Therefore, the first step in the management of these fractures is assessing and then documenting the neurologic and vascular examination. If perfusion is poor, then the child is brought urgently to the operating room for reduction under general anesthesia. If not logistically possible, then a closed reduction is done with conscious sedation in the emergency department. Regardless of the direction of fracture displacement, all physeal fracture closed reductions utilize the technique mentioned above of traction followed by leverage force to minimize a shearing injury to the physis. 
This is done with the patient in a supine position with the hip and knee flexed to about 45 degrees. It is important to have an assistant placing counter traction at the thigh. The surgeon grasps the proximal leg and applies traction while leveraging the metaphysis back into anatomic position. Reduction is then confirmed by fluoroscopy. If deemed stable via gentle knee range of motion, then the leg is placed into a univalved cast. However, if the reduction is not stable, then percutaneous smooth pin fixation is undertaken. The long-leg cast is then applied after reduction in about 30 degrees of flexion, and the child is admitted for observation. 
Percutaneous smooth-pin fixation with 2 to 2.5 mm diameter Kirschner wires is reserved for unstable fractures following a closed reduction maneuver. For Salter–Harris types I and II fractures, they are inserted in a crossing fashion through the tibial metaphysis and across the physis to stabilize the epiphysis, as described above. The leg is then immobilized in a univalved cast with the knee in 30 degrees of flexion. Four weeks after reduction and fixation, the pins are removed in clinic, but the child is placed back into a long-leg cast for up to 4 more weeks depending on the radiographic findings at the time of pin removal. Children are released to full activities out about 4 weeks following cast removal. 
Open reduction with surgical stabilization is performed when the closed reduction fails to achieve anatomic alignment, or when the fractures extend to the joint surface (Salter–Harris types III and IV physeal fractures and San Diego type B and C tibial tubercle fractures). We will often use a combination of smooth Kirschner wires and cannulated screws to stabilize the fractures, but we prefer cannulated screws inserted parallel to the physis. After internal fixation, the knee may be carefully stressed into valgus to assess the competency of the medial collateral ligament. If an arthrotomy was not performed as part of the reduction, then a gentle Lachman test should be performed to assess anterior cruciate ligament (tibial eminence) integrity. Concerning the large periosteal and retinacular injuries that often accompany these injuries, we often utilize suture anchors to repair the soft tissues back in place to augment the fixation (Fig. 29-23). 
Figure 29-23
Intra-operative photograph demonstrating placement of suture anchors (circles) in the meta-diaphyseal tibia to repair the extensive soft tissue injury of a tibial tubercle avulsion.
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During an open reduction, the anterior compartment fascia is released to reduce the risk of compartment syndrome and a drain is placed in the anterior compartment. 
Following wound closure, a long-leg or cylinder cast is applied in full knee extension and the patient is observed overnight in the hospital. 
Arteriography for isolated injuries but may be helpful when the circulation is questionable. It is usually recommended that fracture fixation be performed prior to vascular repair caused by the manipulation that often accompanies reduction. An extended medial approach will often allow open reduction of the fracture and vessel management for the vascular surgeon through the same incision. However, the posterior approach provides easier access to the popliteal space and can be used with percutaneous fixation of the fracture (Fig. 29-24). 
Figure 29-24
Author's preferred treatment algorithm for proximal tibial physeal fractures.
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Postoperative Care for Proximal Tibial Physeal Fractures

The cast should be either univalved or bivalved to permit swelling. Almost universally, the child is then admitted to the hospital for observation and gentle elevation to monitor for the high incidence of vascular injury and compartment syndrome. 
Shorter periods of immobilization may be used in younger adolescents if fixation is secure. For larger fragments that are securely fixed with two or more screws, a knee immobilizer can be substituted for cast immobilization. Range of motion and quadriceps strengthening are initiated 6 weeks following injury for these patients. 
Radiographs should be obtained at the time of reduction and cast placement to confirm appropriate alignment of the fracture. Future films should include both the AP and lateral x-rays at 1 week post-reduction to confirm maintenance of reduction. The cast may be removed 4 to 6 weeks after injury if the fracture demonstrates radiographic and clinical union. Return to normal activities can be permitted about 4 weeks following cast removal. Physis checks should be done between 4 and 6 months post-operatively via plain radiographs. 

Potential Pitfalls and Preventative Measures for Proximal Tibial Physeal Fractures

With open physes, children with knee trauma, or those with polytrauma should have their radiographs scrutinized for nondisplaced proximal tibial fractures.17,44 Overnight observation in the hospital is recommended for all fractures of the proximal tibia because of the risk of vascular injury or development of compartment syndrome. All casts should be at least univalved during early immobilization, and repeated compartment assessments need to be performed and documented (Fig. 29-25). Arterial injuries can go unrecognized, especially in “minimally” displaced fractures, since the full displacement at time of injury is not known. Nondisplaced fractures can be misdiagnosed as medial collateral ligament injuries.52 Stress radiographs, or preferably an MRI can assist in correct diagnosis. Be cognoscente of the Cozen fracture and the proximal tibial growth disturbance that can occur following metaphyseal fractures.23,31 Recurvatum is the most common deformity following a physeal injury and should be carefully followed radiographically, with comparisons of the contralateral side. Osteotomies may be necessary for correction.38 An intra-articular placement of the smooth pins may result in a septic joint and should be avoided. There is an association of anterior cruciate ligament injuries with these proximal fractures that may result in late instability if untreated. 
Figure 29-25
Physical examination findings in the setting of compartment syndrome.
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Tibial tubercle fractures have an increased risk of compartment syndrome caused by bleeding of the recurrent anterior tibial artery into the anterior compartment. Utilization of a tourniquet may bind the quadriceps and hinder reduction of a displaced fracture (Table 29-6). 
 
Table 29-6
Proximal Tibial Physeal Fractures
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Table 29-6
Proximal Tibial Physeal Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Pitfall #1: Unrecognized physeal or apophyseal fracture Scrutinize radiographs for signs of nondisplaced fractures
Obtain stress radiographs or MRI to confirm diagnosis
Caution the diagnosis of MCL injury in the very young
Pitfall #2: Unrecognized arterial injury Understand that maximal displacement at the time of injury can be far greater than that seen at the time of presentation
Thorough physical examination particularly concerning the circulatory system
Repeat examination during in-hospital observation
Pitfall #3: Compartment syndrome Vigilance during the first 24 hours to assess compartment status
Be aware that a neurologic injury may confound physical examination results
Univalve or bivalve cast to allow for swelling post-reduction
Pitfall #4: Growth disruption of the affected physis Metaphyseal fractures (Cozen injuries) may auto-correct the valgus deformity and observation is warranted
Recurvatum is the most common (especially following tubercle injuries) and may require surgical intervention
Pitfall #5: Intra-articular pin placement May result in septic arthritis and should be avoided
Pitfall #6: Tourniquet utilization in tubercle fractures can hinder reduction Releasing the tourniquet, and thereby the quadriceps muscle, will assist in the reduction of tubercle fractures
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Treatment-Specific Outcomes for Proximal Tibial Physeal Fractures

Treatment outcomes do not currently exist in the English literature regarding comparisons between methods of treatment for these fractures. However, there is a limited number of case series that discuss the treatment of these fractures. A recent study involving 18 adolescents involved in sports activities who sustained tibial tubercle fractures underwent surgery utilizing a technique of open reduction and fixation with two parallel screws, one proximal and one distal to the physis. No adverse complications were noted and they were all able to resume their previous sports activities. The only other outcome measure was noting that eight children had the screws subsequently removed because of local discomfort.1 
Other studies, primarily regarding tibial tuberosity fractures, will often have a mixed employment of fixation in the study during their discussion of outcomes.14,16,21,22,39,54 They suggest that there are few complications after closed management of nondisplaced extra-articular fractures, or reduction and surgical stabilization of displaced fractures. Usually, the primary adverse outcome, as recounted above, is prominent and painful implants. 

Management of Expected Adverse Outcomes and Unexpected Complications for Proximal Tibial Physeal Fractures

Closed reduction of proximal tibial physeal injuries may be unstable. Often, reductions can be lost if percutaneous pinning or screw placement was not performed in conjunction with the reduction. Being a correctable adverse outcome of the initial treatment, the patients should obtain x-rays at about 1 week after casting to verify the position and alignment of the fracture. A repeat manipulation may be performed at this point, if necessary—keeping in mind that a delay could increase the risk of injuring the physis during reduction maneuvers. 
Moreover, these injuries—defined has growth plate injuries—are subject to limb shortening or angulation from subsequent growth arrest (Fig. 29-26). Any of the fracture patterns mentioned above can result in this particular complication; and, as with any physeal (or apophyseal) fracture, an anatomic reduction with fixation reduces the risk of growth disturbance.43 If a partial or complete growth arrest is diagnosed, there is limited recourse. Surgery can be done to limit deformity progression via epiphysiodesis or excision of an epiphyseal bar depending on estimations of remaining growth and location of the arrest within the physis (Fig. 29-27). Therefore, frequent radiographic follow-up is important to achieve early recognition of the growth arrest and thereby limit the extent of disturbance through early intervention. As a reminder, the proximal tibia grows longitudinally at a mean rate of 6 mm per year. And the mean age of physeal closure at the proximal tibia is 14 years old in girls and 16 years old in boys. If angular growth disturbances are identified late, then an osteotomy can be done to correct the deformity. Even recurvatum following a tibial tubercle fracture can be corrected with an osteotomy.38 
Figure 29-26
Sagittal CT scan at 1 year post-reduction and smooth wire fixation of a 12-year-old tibial tubercle fracture (San Diego type A) with subsequent physeal bar formation (arrow) and developing genu recurvatum.
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Figure 29-27
Same child as the one seen in Figure 29-26, status post physeal bar excision and fat graft placement to correct deformity.
 
A: Initial post-corrective surgery lateral; (B) 3 years post-corrective surgery with 7 degrees persistent recurvatum compared to contra-lateral limb, but over 2.5 cm of uninhibited longitudinal growth; (C) contra-lateral limb at 3 years post-corrective surgery for comparison.
A: Initial post-corrective surgery lateral; (B) 3 years post-corrective surgery with 7 degrees persistent recurvatum compared to contra-lateral limb, but over 2.5 cm of uninhibited longitudinal growth; (C) contra-lateral limb at 3 years post-corrective surgery for comparison.
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A: Initial post-corrective surgery lateral; (B) 3 years post-corrective surgery with 7 degrees persistent recurvatum compared to contra-lateral limb, but over 2.5 cm of uninhibited longitudinal growth; (C) contra-lateral limb at 3 years post-corrective surgery for comparison.
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Figure 29-27
Same child as the one seen in Figure 29-26, status post physeal bar excision and fat graft placement to correct deformity.
A: Initial post-corrective surgery lateral; (B) 3 years post-corrective surgery with 7 degrees persistent recurvatum compared to contra-lateral limb, but over 2.5 cm of uninhibited longitudinal growth; (C) contra-lateral limb at 3 years post-corrective surgery for comparison.
A: Initial post-corrective surgery lateral; (B) 3 years post-corrective surgery with 7 degrees persistent recurvatum compared to contra-lateral limb, but over 2.5 cm of uninhibited longitudinal growth; (C) contra-lateral limb at 3 years post-corrective surgery for comparison.
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A: Initial post-corrective surgery lateral; (B) 3 years post-corrective surgery with 7 degrees persistent recurvatum compared to contra-lateral limb, but over 2.5 cm of uninhibited longitudinal growth; (C) contra-lateral limb at 3 years post-corrective surgery for comparison.
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Compartment syndrome may occur following any proximal tibial physeal fracture caused by either a mechanical blockage of the vascular structures by a displaced fracture, damage to the popliteal artery, or tearing of the anterior tibial recurrent vessels that bleed into the anterior compartment.37,53 It is important to recognize that even a minimally displaced fracture at the time of presentation, may have injured one of these vessels at the moment of fracturing. Furthermore, even minimal posterior displacement of the metaphysis can obstruct popliteal blood flow since that vessel is tethered against the bone by soft tissues and the distal anterior tibial artery.6 Vigilant monitoring is recommended for all patients with proximal tibial physis or displaced tibial tuberosity avulsion fractures. Prophylactic anterior compartment fasciotomy should be considered at the time of open reduction because of the high risk associated with these fractures.4 
Bursitis over prominent implants is not uncommon, especially for tibial tubercle fractures.53 Countersinking the screw heads may not always be impossible without risking fracture of a tuberosity fragment. Fixation with small screws or use of a tension band construct may be good alternatives, but fixation of these fractures should not be sacrificed for a potential risk of bursitis since the pull of the quadriceps muscle can displace fixed fractures. Families should be consulted that approximately 50% of patients may require a secondary procedure for implant removal after successful union of the fracture. 
Less frequently, there have been reports of symptomatic knee instability, primarily in children sustaining Salter–Harris types III and IV proximal tibial injuries.2,41 Refracture has also been reported for tibial tubercle fractures.4,53 This was seen in two children, one after a rapid return to sports (4 weeks after injury) and one wherein a transverse proximal tibial fracture occurred 7 months postoperatively at the level of the retained screws. There is one report of arthrofibrosis and persistent loss of motion of 25 degrees in a Salter–Harris type III fracture at almost 2 years post-injury.8 Finally, even a thrombophlebitis has been reported in the literature (Table 29-7).34 
 
Table 29-7
Proximal Tibial Physeal Fractures
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Table 29-7
Proximal Tibial Physeal Fractures
Common Adverse Outcomes and Complications
Compartment syndrome and vascular injury
Growth disturbance and leg-length discrepancy
Loss of reduction
Prominent and painful implants
Knee instability
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Summary of Proximal Tibial Physeal Fractures

Fractures of the proximal tibial physis may be relatively uncommon, but they can result in deleterious consequences for the patient if poorly managed. Unrecognized compartment syndrome or arterial injury would be devastating to a young limb. The treatment of these injuries (beyond surgeon diligence to avoid catastrophe) is generalized based on current concepts in the treatment of any physeal injury. 

References

Ares O, Seijas R, Cugat R, et al. Treatment of fractures of the tibial tuberosity in adolescent soccer players. Acta Orthop Belg. 2011; 77(1):78–82.
Bertin KC, Goble EM. Ligament injuries associated with physeal fractures about the knee. Clin Orthop Relat Res. 1983; 177:188–195.
Blanks RH, Lester DK, Shaw BA. Flexion-type Salter II fracture of the proximal tibia. Proposed mechanism of injury and two case studies. Clin Orthop Relat Res. 1994;(301):256–259.
Bolesta MJ, Fitch RD. Tibial tubercle avulsions. J Pediatr Orthop. 1986; 6(2):186–192.
Bright RW, Burstein AH, Elmore SM. Epiphyseal-plate cartilage. A biomechanical and histological analysis of failure modes. J Bone Joint Surg Am. 1974; 56(4):688–703.
Burkhart SS, Peterson HA. Fractures of the proximal tibial epiphysis. J Bone Joint Surg Am. 1979; 61(7):996–1002.
Chow SP, Lam JJ, Leong JC. Fracture of the tibial tubercle in the adolescent. J Bone Joint Surg Br. 1990; 72(2):231–234.
Christie MJ, Dvonch VM. Tibial tuberosity avulsion fracture in adolescents. J Pediatr Orthop. 1981; 1(4):391–394.
Ciszewski WA, Buschmann WR, Rudolph CN. Irreducible fracture of the proximal tibial physis in an adolescent. Orthop Rev. 1989; 18(8):891–893.
Crock H. In: Dunitz M, ed. An Atlas of Vascular Anatomy of the Skeleton and Spinal Cord. London: Martin Dunitz; 1996.
Davidson D, Letts M. Partial sleeve fractures of the tibia in children: An unusual fracture pattern. J Pediatr Orthop. 2002; 22(1):36–40.
Diamond LS, Alegado R. Perinatal fractures in arthrogryposis multiplex congenita. J Pediatr Orthop. 1981; 1(2):189–192.
Dvonch VM, Bunch WH. Pattern of closure of the proximal femoral and tibial epiphyses in man. J Pediatr Orthop. 1983; 3(4):498–501.
Egol KA, Karunakar M, Phieffer L, et al. Early versus late reduction of a physeal fracture in an animal model. J Pediatr Orthop. 2002; 22(2):208–211.
Ehrenborg G. The Osgood-Schlatter lesion. A clinical and experimental study. Acta Chir Scand Suppl. 1962;(suppl 288):1–36.
Gonzalez-Reimers E, Perez-Ramirez A, Santolaria-Fernandez F, et al. Association of Harris lines and shorter stature with ethanol consumption during growth. Alcohol. 2007; 41(7):511–515.
Gupta SP, Agarwal A. Concomitant double epiphyseal injuries of the tibia with vascular compromise: A case report. J Orthop Sci. 2004; 9(5):526–528.
Haines RW, Mohiuddin A, Okpa FI, et al. The sites of early epiphysial union in the limb girdles and major long bones of man. J Anat. 1967; 101(Pt 4):823–831.
Hand WL, Hand CR, Dunn AW. Avulsion fractures of the tibial tubercle. J Bone Joint Surg Am. 1971; 53(8):1579–1583.
Hannouche D, Duparc F, Beaufils P. The arterial vascularization of the lateral tibial condyle: Anatomy and surgical applications. Surg Radiol Anat. 2006; 28(1):38–45.
Harris HA. The growth of the long bones in childhood with special reference to certain bony striations of the metaphysis and to the role of vitamins. Arch Int Med. 1926; 38:785–806.
Herring JA. General principles for managing orthopedic injuries. Tachdjian's Pediatric Orthopaedics. Philadelphia, PA: Saunders Elsevier; 2002.
Hresko MT, Kasser JR. Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am. 1989; 71(5):698–703.
Inoue G, Kuboyama K, Shido T. Avulsion fractures of the proximal tibial epiphysis. Br J Sports Med. 1991; 25(1):52–56.
Kaneko K, Matsuda T, Mogami A, et al. Type III fracture of the tibial tubercle with avulsion of the tibialis anterior muscle in the adolescent male athlete. Injury. 2004; 35(9):919–921.
Maffulli N, Grewal R. Avulsion of the tibial tuberosity: Muscles too strong for a growth plate. Clin J Sport Med. 1997; 7(2):129–132; discussion 132–133.
Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0–16 years. J Pediatr Orthop. 1990; 10(6):713–716.
McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fractures. Orthop Clin North Am. 2003; 34(3):397–403.
Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop. 2004; 24(2):181–184.
Mubarak SJ, Kim JR, Edmonds EW, et al. Classification of proximal tibial fractures in children. J Child Orthop. 2009; 3(3):191–197.
Navascues JA, Gonzalez-Lopez JL, Lopez-Valverde S, et al. Premature physeal closure after tibial diaphyseal fractures in adolescents. J Pediatr Orthop. 2000; 20(2):193–196.
Nikiforidis PA, Babis GC, Triantafillopoulos IK, et al. Avulsion fractures of the tibial tuberosity in adolescent athletes treated by internal fixation and tension band wiring. Knee Surg Sports Traumatol Arthrosc. 2004; 12(4):271–276.
Ogden JA, Southwick WO. Osgood-Schlatter's disease and tibial tuberosity development. Clin Orthop Relat Res. 1976;(116):180–189.
Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am. 1980; 62(2):205–215.
Ozer H, Turanli S, Baltaci G, et al. Avulsion of the tibial tuberosity with a lateral plateau rim fracture: Case report. Knee Surg Sports Traumatol Arthrosc. 2002; 10(5):310–312.
Pandya N, Edmonds E, Roocroft J, et al. Contemporary imaging for tibial tubercle fracture patterns in adolescents: Need for intra-articular assessment. Annual Meeting of the Association of Bone and Joint Surgeons Charleston, SC 2012.
Pape JM, Goulet JA, Hensinger RN. Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop Relat Res. 1993;(295):201–204.
Pappas AM, Anas P, Toczylowski HM Jr. Asymmetrical arrest of the proximal tibial physis and genu recurvatum deformity. J Bone Joint Surg Am. 1984; 66(4):575–581.
Park EA. The Imprinting of Nutritional Disturbances on the Growing Bone. Pediatrics. 1964; 33(suppl):815–862.
Peterson HA, Madhok R, Benson JT, et al. Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979–1988. J Pediatr Orthop. 1994; 14(4):423–430.
Poulsen TD, Skak SV, Jensen TT. Epiphyseal fractures of the proximal tibia. Injury. 1989; 20(2):111–113.
Ryu RK, Debenham JO. An unusual avulsion fracture of the proximal tibial epiphysis. Case report and proposed addition to the Watson-Jones classification. Clin Orthop Relat Res. 1985;(194):181–184.
Salter RHW. Injuries involving the epiphysial plate. J Bone Joint Surg Am. 1963;(45):587.
Sferopoulos NK, Rafailidis D, Traios S, et al. Avulsion fractures of the lateral tibial condyle in children. Injury. 2006; 37(1):57–60.
Shapiro F. Developmental Bone Biology. Pediatric Orthopedic Deformities: Basic Science, Diagnosis, and Treatment. San Diego, CA: Academic Press; 2001.
Shelton WR, Canale ST. Fractures of the tibia through the proximal tibial epiphyseal cartilage. J Bone Joint Surg Am. 1979; 61(2):167–173.
Smith JW. The structure and stress relations of fibrous epiphysial plates. J Anat. 1962; 96:209–225.
Stanitski CL. Stress view radiographs of the skeletally immature knee: A different view. J Pediatr Orthop. 2004; 24(3):342.
Thompson GH, Gesler JW. Proximal tibial epiphyseal fracture in an infant. J Pediatr Orthop. 1984; 4(1):114–117.
Tjoumakaris FP, Wells L. Popliteal artery transection complicating a non-displaced proximal tibial epiphysis fracture. Orthopedics. 2007; 30(10):876–877.
Watson-Jones R. In: Wilson JN, ed. Fractures and Joint Injuries. 5th ed. New York: Churchill Livingstone; 1976:1047–1050.
Welch P, Wynne G Jr. Proximal tibial epiphyseal fracture separation. J Bone Joint Surg Am. 1963; 45(4):782–784.
Wiss DA, Schilz JL, Zionts L. Type III fractures of the tibial tubercle in adolescents. J Orthop Trauma. 1991; 5(4):475–479.
Wood KB, Bradley JP, Ward WT. Pes anserinus interposition in a proximal tibial physeal fracture. A case report. Clin Orthop Relat Res. 1991;(264):239–242.
Wozasek GE, Moser KD, Haller H, et al. Trauma involving the proximal tibial epiphysis. Arch Orthop Trauma Surg. 1991; 110(6):301–306.