Giles Armstrong reminds us that curiosity is needed for all of our young patients and that without it, we cannot truly care for them. We have to be the detectives and be prepared to ask the questions, not just to the routine questions, but to the unspoken ones. Giles presents us with some challenging, but very realistic scenarios, in which it is easy to miss the subtle clues if you don’t look for them.
This talk was recorded live at DFTB19 in London, England. With the theme of “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal.
Proximal tibial fractures are infrequent in children relative to tibial shaft and distal tibial fractures. The patterns of injury correspond to the age of the child and the type of force involved.
Tibial physeal fractures
A 13-year-old boy is brought into ED by ambulance following a motor vehicle accident. He was a front street restrained passenger in a car that was involved in a head-on collision with another car. His knee was hyperextended on impact and he presents with an acutely painful and swollen knee.
Proximal tibial physeal fractures occur in young adolescents (12-14 years), usually from high energy mechanisms such as sports injuries and road traffic accidents. Patients present unable to weight bear with a swollen, tender knee and a marked decrease in range of movement. It is really important to assess the limb’s neurovascular status as rarely posterior displacement of the fracture may injure the popliteal artery. These patients are also at risk of developing compartment syndrome so make sure you frequently reassess of the limb and the child’s pain in the acute setting.
Confirm diagnosis with AP and lateral radiographs of the lower leg including the knee and ankle. Proximal tibial physeal fractures are classified according to the Salter-Harris system.
The initial treatment of closed proximal tibial fractures that are neurovascularly intact is analgesia and immobilisation in an above knee back slab or splint. If the patient has vascular compromise then they need an urgent ortho review and reduction.
Further treatment depends on the severity of the fracture and the degree of displacement. Generally speaking non-displaced Salter Harris IorII fractures can be treated non-operatively with 4-6 weeks of non-weight bearing and leg immobilisation in slight flexion. Displaced fractures and all Salter-Harris III, IV or V fractures need prompt ortho review and likely operative repair.
Serious acute complications are rare. These include arterial injury, nerve injury and compartment syndrome. The most serious long-term complication is growth arrest and resultant leg length discrepancy, which happens in up to 25% of cases. Therefore all physeal fractures need ortho follow up.
Tibial spine fractures
A 12-year-old girl presents with knee pain, decreased range of movement and swelling following a fall from her bicycle. As she fell she recalls hyperextending and twisting her knee.
Fractures of the tibial spine or eminence are avulsion fractures at the insertion of the anterior cruciate ligament (ACL). They are uncommon and typically occur in adolescents between the 8-14 years of age. They are usually associated with a fall from a bicycle or pivoting on a planted foot while playing sport. It is equivalent to mid-substance rupture of the ACL in adults. With stress, the incompletely ossified tibial eminence in the child avulses before the ligament ruptures.
These patients usually presents with painful haemarthrosis and are unable to fully extend the knee. Stability may be difficult to assess due to pain and muscle spasm but the anterior drawer and Lachman’s test may be positive. AP and lateral x-rays of the knee should be obtained. Complicated fractures will likely need further evaluation with CT or MRI to fully characterise the injury.
Fractures are identified as type I, II, and III by the Meyers and McKeever classification. Type I fractures are non or minimally displaced. Type II fractures are displaced anteriorly with an intact posterior hinge. Type III fractures are completely displaced from the proximal tibia. This classification system had been modified by Zaricznyj to include type IV/Comminuted fractures. (Zaricznyj 1977).
Immediate treatment in ED should be with appropriate analgesia and splinting the knee in extension. Displaced fractures may need operative repair. All patients will need to be followed by in orthopaedic clinic.
Complications are not uncommon and include pain, malunion, non-union, severe laxity and arthrofibrosis.
Metaphyseal corner fractures
A 2-year-old boy is brought to the ED by his concerned aunt. She has noticed over the last few days that he is reluctant to weight bear on his left leg and appears to have a painful knee.
Metaphyseal corner fractures, or bucket handle fractures occur in children less than two years old. In a previously well infant with normal bones this fracture is almost pathognomonic for non-accidental injury (NAI). These fractures are Salter Harris II fractures of the long bones and are most frequently seen in the proximal or distal tibia, distal femur or proximal humerus. They result from shaking or twisting injuries. If there is no sign of neurovascular compromise management is conservative and should focus on pain control and a period of immobilisation in plaster. As the diagnosis is highly suggestive of non-accidental injury the child should be referred through regular safeguarding pathway.
Tibial tubercle avulsion fractures
A 15-year-old boy presents with acute onset severe knee pain following landing heavily while playing basketball. The joint is swollen, he is unable to actively extend the knee and he is exquisitely tender over the tibial tuberosity.
Tibial tubercle fractures are uncommon and usually occur in boys between the ages of 13 and 16 years. The mechanism is usually forced flexion of the knee during active quadriceps contraction e.g. landing a jump while playing basketball.
Acute tibial tubercle apophyseal fractures are different from tibial tubercle apophysitis (Osgood Schlatter disease – see below) which has gradual onset.
Patients presents with acute onset pain with swelling and tenderness over the tibial tubercle with limited knee extension, proximal displacement of the patella and shortening and spasm of the quadriceps muscle.
Diagnosis is confirmed on lateral knee x-ray, which demonstrates a fracture through the base of the tubercle. The fracture fragment is proximally displaced and remains attached to the patellar tendon.
There are several classification systems described. Watson-Jones classified the fracture in to three types .
Type 1: The fracture is within the most distal portion of the tibial tuberosity with resultant avulsion of the most distal part.
Type 2: The fracture line extends through the cartilage bridge to the proximal end of the tibia but doesn’t involve the articular surface.
Type 3: The fracture line extends to the articular surface of the proximal tibia.
Ogden modified this classification system to include subtypes A and B to indicate if the fracture is comminuted or not.
Initial management of a tibial avulsion fracture without neurovascular compromise, is pain control, immobilisation of the fracture, and reduction of swelling. Type IA injuries are treated conservatively with knee immobilisation in full extension. Patients should remain non-weight-bearing. Type IB, type II, and type III injuries are generally treated with open reduction and internal fixation (ORIF). All patients need a variable period of immobilisation (average four weeks). Progressive rehab of the quads will be needed afterwards. Return to play can be expected approximately two to three months after type I and II injuries and at three to six months after type III injuries.
Acute compartment syndrome, the most serious complication associated with tibial tubercle fracture, is rare. Due to its potential catastrophic consequences it is important to repeatedly assess the neurovascular status of the limb in the acute phase with onward urgent orthopaedic referral if needed. More common complications include bursitis, ongoing tenderness or prominence of the tibial tuberosity, mal or non-union and re-fracture.
A 12-year-old keen footballer, presents with her father complaining of several months of anterior knee pain that is worse during and after exercise. Recently she has noticed a prominent bump to the front of her knee.
Osgood-Schlatter disease, also known as osteochondritis or apophysitis of the tibial tubercle, is a common cause of anterior knee pain in adolescents. It is an overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification centre (apophysis) of the tibial tubercle at the insertion point of the patellar tendon. It is more common in boys and affects up to 10% of athletic adolescents. It occurs in children aged 9 -14 years who have undergone a rapid growth spurt. It’s typically unilateral but can be bilateral in 20-30% of cases.
It occurs more frequently in children who play sports that place stress on the tibial tubercle through repetitive quadriceps contraction e.g. football, basketball, sprinters, gymnastics and dance. The patient generally presents with a history of non-traumatic gradual onset anterior knee pain associated with tenderness and swelling over the tibial tubercle. Symptoms are exacerbated by exercise and kneeling and relieved by rest.
Exam findings include tenderness and soft tissue or boney prominence of the tibial tubercle. Pain is reproducible with resisted knee extension. Straight leg raise is usually painless and range of motion of the knee is not affected.
Osgood-Schlatter disease is a clinical diagnosis. Imaging is not necessary to confirm the diagnosis in cases where the presentation is characteristic. If knee x-ray is done it may be normal or show anterior soft tissue swelling or fragmentation of the tibial tubercle, Occasionally a persistent bony ossicle may be visible after fusion of the tibial epiphysis. Imaging may be needed as part of the work up in patients with atypical symptoms and signs.
Consider other diagnoses, investigation, and onward referral in the presence of trauma, knee erythema, systemic symptoms, bone or joint pain elsewhere, night pain, rest pain or painful examination of the hip or knee joint.
Osgood-Schlatter disease is usually a benign and self limiting condition. Symptoms generally resolve once the growth plate is ossified. Conservative measures are the mainstay of treatment and include:
Continued sports participation is recommended providing pain is tolerable and resolves within 24 hours. Otherwise a graded reduction in activity may be sufficient to control the pain.
Simple analgesia and application of ice for pain control.
Physiotherapy that includes stretching and strengthening of the quadriceps and hamstrings.
Corticosteroids, crutches and knee immobilisers are not recommended.
Specialist referral is indicated for severe cases or where symptoms remain intolerable into adulthood.
Complications of Osgood-Schlatter disease include persistent prominence of the tibial tubercle, persistent pain and rarely genu recurvatum (hyperextension of the knee).
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With millions upon millions of journal articles being published every year it is impossible to keep up. Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.