Tibial spine avulsion

Educational Objectives

The goal of this program is to improve the management of tibial spine avulsion fractures. After hearing and assimilating this program, the clinician will be better able to:

1. Provide an overview of tibial spine avulsion fractures.

Summary

Tibial spine fracture: avulsion fracture of tibial eminence at ACL insertion; presentation can vary; commonly anterior and under intermeniscal ligament; often involves tibial plateau; more common in children; incidence increasing in adults

Mechanism of injury: often related to skiing; 1) deceleration with valgus-external rotation; 2) boot-induced injury from landing heels-first; tibia levered forward violently and pops ACL; 3) skier falls backward between wedged ski; forced internal rotation against flexed knee pops ACL

Classification: (Meyers and McKeever; 1959) type I — minimally displaced; type II — tipped in anterior portion one-third to one-half; type III — completely displaced; type III+ — displaced and flipped; classification describes fracture in final position; damage sustained best represented by maximum displacement; classification describes bony position but provides no information about soft tissues; studies revealed high percentage of entrapped menisci and intermeniscal ligaments block reduction (address soft-tissue pathology); Hunter and Willis (2004) reported 60% of all avulsions demonstrated Stener-like lesion with intermeniscal ligament interposed; x-rays underestimate displacement; MRI better; consider stress x-ray for fracture classification

Treatment: extension casting/brace for types I and II; fixation for types III and III+; Meyers and McKeever (1970) reported poor results in 45% of patients treated closed; McLennan (1995) studied type III fractures treated by closed reduction {CR], arthroscopic reduction [AR], and arthroscopic reduction with fixation [ARIF]; arthroscopy follow-up showed all ARIF remained reduced; CR and AR groups lost reduction; indications for surgery — 1) instability documented by Lachman test and pivot shift; or 2) displaced eminence

Readings

Suggested Reading

Bonneux I, Vandekerckhove B: Arthroscopic partial lateral meniscectomy long-term results in athletes. Acta Orthop Belg, 2002 Oct;68(4):356-61; Chatain F et al: A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-year minimum follow-up. Arthroscopy, 2003 Oct;19(8):842-9; Covall DJ, Wasilewski SA: Roentgenographic changes after arthroscopic meniscectomy: five-year follow-up in patients more than 45 years old. Arthroscopy, 1992;8(2):242-6; Harrison MM et al: Influence of obesity on outcome after knee arthroscopy. Arthroscopy, 2004 Sep;20(7):691-5; Hunter RE, Willis JA: Arthroscopic fixation of avulsion fractures of the tibial eminence: technique and outcome. Arthroscopy, 2004 Feb;20(2):113-21; Lee SJ et al: Tibiofemoral contact mechanics after serial medial meniscectomies in the human cadaveric knee. Am J Sports Med, 2006 Aug;34(8):1334-44; McLennan JG: Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop, 1995 Jan-Feb;15(1):59-62; McNicholas MJ et al: Total meniscectomy in adolescence. A thirty-year follow-up. J Bone Joint Surg, 2000 Mar;82(2):217-21; Meredith DS et al: Factors predicting functional and radiographic outcomes after arthroscopic partial meniscectomy: a review of the literature. Arthroscopy, 2005 Feb;21(2):211-23; Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am, 1970 Dec;52(8):1677-84; Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am, 1959 Mar;41-A(2):209-22; Peña E et al: Why lateral meniscectomy is more dangerous than medial meniscectomy. A finite element study. J Orthop Res, 2006 May;24(5):1001-10; Reigel CA et al: Arthroscopic all-inside meniscus repair. Clin Sports Med, 1996 Jul;15(3):483-98; Rodner CM et al: Medial opening wedge tibial osteotomy and the sagittal plane: the effect of increasing tibial slope on tibiofemoral contact pressure. Am J Sports Med, 2006 Sep;34(9):1431-41; Rubman MH et al: Arthroscopic repair of meniscal tears that extend into the avascular zone. A review of 198 single and complex tears. Am J Sports Med, 1998 Jan-Feb;26(1):87-95; Spang JT et al: The effect of medial meniscectomy and meniscal allograft transplantation on knee and anterior cruciate ligament biomechanics. Arthroscopy, 2010 Feb;26(2):192-201; Tenuta JJ, Arciero RA: Arthroscopic evaluation of meniscal repairs. Factors that affect healing. Am J Sports Med, 1994 Nov-Dec;22(6):797-802.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Hunter is a consultant for Biomet and Smith & Nephew. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Hunter was recorded at Boston University School of Medicine’s Evaluation and Treatment of the Injured Athlete: Sports Medicine Update 2011, held July 25-29, 2011, on Martha’s Vineyard, MA. To learn about future Boston University School of Medicine orthopaedic meetings, go to bumc.bu.edu/cme. The Audio-Digest Foundation thanks the speaker and Boston University School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR350804

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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