Proximal Tibial Fractures

Cite this article as:
Deirdre Glynn. Proximal Tibial Fractures, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20257

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.

Tibial plateau fractures

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 I or II 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.

Case courtesy of Dr Adam Tunis, Radiopaedia.org. From the case rID: 42621 Tibial spine avulsion (and associated Segond fracture)

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.

Case courtesy of Dr Hani Salam, Radiopaedia.org. From the case rID: 13614

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.

Osgood-Schlatter disease

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).

References

Mann DC et al. Distribution of physeal and nonphyseal fractures in 2,650 long bone fractures in children aged 0-16 years. Journal of Paediatric Orthopaedics (1990); 10:713.

Chapman J, Cohen J. Proximal tibial fractures in children. uptodate.com/contents/proximal-tibial-fractures-in-children

Little RM, Milewski MD. Physeal fractures about the knee. Current Reviews in Musculoskeletal Medicine. (2016); 9(4): 478–486

Coyle C et al. Tibial eminence fractures in the paediatric population: A systematic review. Journal of Children’s Orthopaedics. (2014); 8(2): 149–159

Van Rijn RR, Sieswerda – Hoogendoorn T. Imaging child abuse: the bare bones. European Journal of Paediatrics. (2012); 171(2): 215–224

Frey S et al. Tibial Tuberosity Fractures in Adolescents. Journal of Children’s Orthopaedics. (2008) 2:469–474

Watson-Jones R.  Fractures and joint injuries. Baltimore: Williams & Wilkins; 1955

Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. Journal of Bone and Joint Surgery Am. 1980;62(2):205–215

Pesl T; Havranek P. Acute tibial tubercle avulsion fractures in children: selective use of the closed reduction and internal fixation method. Journal of Children’s Orthopaedics. (2008) 2(5):353-6

Pretell –Mazzini J et al. Outcomes and Complications of Tibial Tubercle Fractures in Pediatric Patients: A Systematic Review of the Literature.  Journal of Paediatric Orthopaedics. (2016) 36(5): 440-46

De Lucena,G., Dos Santos Gomes,C. and Guerra,R.(2011) Prevalence and associated factors of Osgood-Schlatter syndrome in a population-based sample of Brazilian adolescents.American Journal of Sports Medicine. 2011; 39(2), 415-420

Kujala UM, Kvist M, Heinonen O. Osgood-Schlatter’s disease in adolescent athletes. Retrospective study of incidence and duration. American Journal of Sports Medicine. 1995; 13:236.

Gholve PA, Scher DM, Khakharia S, et al. Osgood Schlatter syndrome. Current Opinion in Pediatrics. 2007;19:44-50.

Weiler R. Osgood-Schlatter Disease. BMJ, 2011;343:d4534

Atanda A., Shah S. and O’Brien K.Osteochondrosis: common causes of pain in growing bones.American Family Physician. 2011; 83(1), 285-291.

Wall EJ. Osgood-Schlatter Disease: practical treatment for a self-limiting condition. The Physician and Sports medicine (1998) 26(3):29-34

Ankle x-rays

Cite this article as:
Tessa Davis. Ankle x-rays, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9992

The ankle joint consists of three bones – the tibia, the fibula, and the talus.

The ankle also consists of two joints – the ankle joint (where the tibia, fibula and talus meet) and the syndesmosis joint (the joint between the tibia and fibula which is held together by ligaments).

There are three main sets of ligaments:

  • Medial: deltoid ligament
  • Lateral: posterior talofibular, anterior talofibular and calcaneofibular ligaments
  • Syndesmotic ligament

Ankle views

An x-ray of the ankle will have three views – AP, mortise, and lateral. It should be noted though, that in some countries, including the UK, only the mortise and lateral are used. See the annotated images below from WikiFoundry, and thanks also to Radiopaedia:

In the AP view:

  • The distal fibula should be slightly superimposed on the tibia
  • The lateral and medial malleoli should be in profile
  • The tibiotalar space should be open (although the full mortise isn’t visible)

In the mortise view:

  • This aims to assess the articulation of the ankle joint
  • The lateral and medial malleoli should be in profile
  • The mortise should be uniformly visible
  • The base of the fifth metatarsal should be included in the view

In the lateral view

  • The following bones can be assessed: tibia, fibula, talus, cuboid, navicular, calcaneus, and fifth metatarsal
  • The distal fibula should be superimposed by the posterior part of the distal tibia
  • The talar domes should be superimposed
  • The joint space between the tibia and the talus should be uniform

N.B. Assess each bone individually, and if you see a break in one, then look for a second break.

1. Trace around the tibia and fibula in both views.

Be mindful that an ankle fracture can be unstable and therefore it’s important not to miss them.

2. Pay particular attention to the fibula on the lateral view for an oblique fracture.

Oblique fracture (from Radiology Key)

3. Look at the mortise and the talar dome.

Make sure the space is uniform, and that the talar dome surface is smooth.

Osteochondral fracture (from Radiopaedia)

4. Look at the interosseous ligament.

Measure the gap between the tibia and the fibula 1cm proximal to the tibial plafond. It should be less than 6mm, otherwise, consider a ligament rupture which could be associated with a fracture.

Image result for interosseous ligament rupture xray
Widened gap between tibia and fibula

5. On the lateral view trace the lateral and medial malleolus, the posterior tibia, the calcaneus, and the base of the 5th metatarsal.

6. Assess the Bohler’s angle

  • Draw two lines at tangents to the anterior and posterior aspects of the calcaneus
  • The angle should be 20-40°
  • If it’s less than 20° then consider a calcaneus fracture
Calcaneus fracture (from Radiopaedia)

7. Do a final check around the bones to make sure you haven’t missed anything the first time around.

8. Remember about accessory ossicles – they aren’t fractures!

  • There are three common accessory ossicles in the ankle: os trigunum (usually forms at 7-13 years old); os subtibiale (when the medial malleolus epiphysis fails to fuse with the tibia in the later teenage years); os subfibulare (can also be an unfused ossification centre or an avulsion fracture).

Common fractures and their management

The level of the fracture directs the treatment – fractures can be classified according to the Salter-Harris classification.

Salter-Harris classification of fractures

Lateral malleolus fracture

In children, a fibula fracture usually requires a short leg cast and six weeks of non-weight bearing. Salter-Harris I distal fibula fractures can be diagnosed if there is tenderness directly on the lateral malleolus (rather than the ligaments) and many recommend treating it as a fracture even if no radiographic fracture is noted.

However, a study in JAMA carried out MRI scans on 135 children with presumed SH1 distal fibula fractures. All children were treated with a removable leg brace and advised to continue regular activities as tolerated. 4 of the children had an SH1 on MRI, 38 had an avulsion fracture, and the rest showed ligamentous injury or bony contusion. By 1 month, 72.1% had full weight-bearing activity and by 3 months 96.9% had returned to normal activities (it didn’t matter which type of injury they had on MRI). Therefore, a removable brace may be appropriate for a Salter-Harris I, if your department stocks them. (See a full summary of this article on ALiEM).

Medial malleolus fracture

An undisplaced distal tibia (Salter-Harris I or II) can be managed with a long leg cast and non-weight bearing. SH3 or 4 needs discussion with ortho. All will have a fracture clinic follow up in a week or so.

Salter-Harris I distal tibia fractures can be diagnosed if there is tenderness directly on the medial malleolus (rather than the ligaments) and many recommend treating it as a fracture even if no radiographic fracture is noted.

The most common distal tibial epiphysis injury is a Salter-Harris II

The high occurrence of Salter-Harris III and IV fractures is because the lateral and deltoid ligaments insert here and they are stronger than the physis itself.

A Tillaux fracture is a Salter-Harris III but with avulsion of the anterolateral corner of the distal tibial epiphysis. If there is <2mm displacement then the patient can have a long leg cast, and be non-weight bearing, with ortho discussion and follow-up. If there is >2mm displacement then an ortho review will be required as typically this need operative management.

Pilon fracture

A pilon fracture is where there is an axial load on the tibia and the talus is pushed into the tibia plafond.

If the fracture is non-displaced or very distal, it is unlikely to require surgery. It would usually be treated with a short leg cast, and weight-bearing would be avoided for six weeks.

If it is displaced or the ankle is unstable, then surgery may be required to avoid non-union, so speak to the ortho team.

Posterior malleolus fracture

Posterior malleolus fracture (from Wikiradiography)

Usually, when this has happened, there is also a lateral malleolus fracture (because they share ligament attachments). The ankle can be unstable if a large piece is broken and therefore surgery may be indicated – so speak to the ortho team.

An untreated posterior malleolus fracture can lead to arthritis because of the disruption to the cartilage surface.

If the fracture is not displaced then it would usually be treated with a short leg cast, and weight-bearing would be avoided for six weeks.

Talar neck fracture

Talar neck fracture

This fracture carries a high risk of avascular necrosis.

If the fracture is non-displaced then it can be managed with a short leg cast or a boot. If it is displaced then surgery will be required.

Bimalleolar fracture

Bimalleolar fracture (from Radiopaedia)

If two parts of the malleoli are broken then the ankle is not stable and surgery is usually needed.

Trimalleolar fracture

Trimalleolar fracture (from Radiopaedia)

If all three malleoli are broken then there can be associated dislocation. The ankle will be unstable and will require ortho input.

Maisonneuve fracture

This fracture is uncommon in children but can occur. It is where there is a spiral fracture of the proximal fibula along with ankle instability. On x-ray, there can be syndesmotic widening.

mason1
From Wheeles Online

In adults, this can be managed with a long leg cast, but in children, it will require operative fixation.

Syndesmotic injury

Overlap between the tibia and fibula in a syndestomic injury (thanks to Bone School)

The joint between the tibia and fibula are held together by ligaments. If this ligament is sprained then this is a syndesmotic injury.

As mentioned above, there can be a widening of the clear space between the medial border of the fibula and the lateral border of the posterior tibia (>5mm). You can also get an overlap of the fibula and the anterior tibial tubercle (>6mm on the AP views, >1mm on the mort

When do I need an orthopaedic review immediately?

  • Open fracture
  • Salter-Harris III or IV
  • Neurovascular injury
  • Compartment syndrome
  • Unable to reduce the fracture

Ref: RCH

Should we be worried about growth plates?

Growth arrest doesn’t occur immediately after the injury, and can even occur in seemingly benign fractures. It can be delayed for up to 6 months and so it is important to follow up ankle fractures post-injury.

Selected References

Wheeless Online

Radiopaedia

Royal Children’s Hospital, Melbourne

Radiology Masterclass

(Ed: Thanks to Eyston Vaughan-Huxley for his input too).