Tibial Spine Fractures in Children: Evaluation, Management, and Future Directions

Adams, Alexander J.; Talathi, Nakul S.; Gandhi, Jigar S.; Patel, Neeraj M.; Ganley, Theodore J.

doi:10.1055/s-0038-1636544

Cited by 31 publications

(28 citation statements)

References 103 publications

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“…The management of TSA still raises controversies. To date, it is widely accepted that undisplaced fractures (type I) are better managed conservatively, while major displacement (type III and IV) should require surgical repair [ 31 ]. The main concern remains the treatment of mild to moderate displacement in type II TSA fractures…”

Section: Discussionmentioning

confidence: 99%

Good Subjective Outcomes, Stable Knee and High Return to Sport after Tibial Eminence Avulsion Fracture in Children

et al. 2020

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Avulsion fracture of the tibial spine (TSA) is uncommon in children, although its incidence is increasing with the earlier practice of competitive sport activities. This study aims to report mid to long term outcomes in children who sustained a TSA, with a special focus on a return to sport activities. Skeletally immature patients with a TSA, treated in two orthopedic hospitals, were evaluated for range of motion and knee laxity using KT1000, KiRA and Rolimeter. The pediatric International Knee Documentation Committee score (Pedi-IKDC) and the Hospital for Special Surgery pediatric Functional Activity Brief Scale (Pedi-FABS) questionnaires were recorded during the latest visit. Forty-two children were included. Twenty-six were treated nonoperatively and 16 underwent surgery. At a mean follow-up of 6.9 ± 3.6 years, 36 patients completed the questionnaires and 23 patients were tested with arthrometers. Among them, 96% had normal knee laxity. The Pedi-IKDC score averaged 96.4 ± 5.7 points, while the mean Pedi-FABS was 22.2 ± 5.9 points, without statistically significant differences between groups. Twenty-eight patients (78%) returned to their previous level of sport activity (eight amateur, 13 competitive, seven elite athletes). Eight patients (22%) quit sport, mostly because of re-injury fear. If properly treated, pediatric TSAs achieve a high rate of successful healing, with complete restoration of knee stability and an early return to sport activities.

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Section: Discussionmentioning

confidence: 99%

Good Subjective Outcomes, Stable Knee and High Return to Sport after Tibial Eminence Avulsion Fracture in Children

et al. 2020

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“…20 Recent literature acknowledges that MRI is an important pretreatment evaluation method for tibial spine fractures; yet, there is a paucity of studies on the effect of pretreatment MRI in identifying concomitant injury and patient outcomes in pediatric patients. 1 The primary aim of this study was to evaluate and compare rates of identified concomitant injury in patients with and those without pretreatment MRI. We hypothesized that patients with pretreatment MRI would have a higher rate of identified concomitant injuries than those without.…”

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confidence: 99%

Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study

et al. 2020

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Background: There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI). Purpose: To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI. Study Design: Cross-sectional study; level of evidence, 3. Methods: We performed an institutional review board–approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups. Results: There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury ( P < .001). There was a higher rate of lateral meniscal tears ( P < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed ( P = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment. Conclusion: Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.

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“…5,32 The few TSF studies discussing this topic generally noted a higher incidence of arthrofibrosis with high-energy injury mechanisms and concomitant ligamentous or meniscal injuries without reporting it as a specific risk factor. 1 We found that traumatic injuries not resulting from athletics increased the risk of arthrofibrosis development nearly 3-fold in multivariate analysis. Grouping injury activity as sports related or not (trauma related) and creating a traumatic injury activity grouping (motor vehicle crash, bicycle accident, fall from height, or horseplay/fighting) both reached significance in analysis.…”

Section: Discussionmentioning

confidence: 72%

Four Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study

et al. 2020

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Background: Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development. Purpose: To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs. Study Design: Case-control study; Level of evidence, 3. Methods: This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions. Results: A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age <10 years (OR, 2.2; P = .049), and cast immobilization (OR, 2.4; P = .047) remained significant predictors of arthrofibrosis. Concomitant ACL injury (OR, 7.5; P = .030) was additionally predictive of a required return to the operating room for MUA. Conclusion: Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.

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Tibial Spine Fractures in Children: Evaluation, Management, and Future Directions

Cited by 31 publications

References 103 publications

Good Subjective Outcomes, Stable Knee and High Return to Sport after Tibial Eminence Avulsion Fracture in Children

Good Subjective Outcomes, Stable Knee and High Return to Sport after Tibial Eminence Avulsion Fracture in Children

Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study

Four Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study

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