Type V Tibial Tubercle Avulsion Fracture with Suspected Complication of Anterior Cruciate Ligament Injury: A Case Report.

Background and Objectives: Type V tibial tubercle avulsion fractures are extremely rare; therefore, information on them remains limited. Furthermore, although these fractures are intra-articular, to the best of our knowledge, there are no reports on their assessment via magnetic resonance imaging (MRI) or arthroscopy. Accordingly, this is the first report to describe the case of a patient undergoing detailed evaluation via MRI and arthroscopy. Case Presentation: A 13-year-old male adolescent athlete jumped while playing basketball, experienced discomfort and pain at the front of his knee, and fell down. He was transported to the emergency room by ambulance after he was unable to walk. The radiographic examination revealed a Type Ⅴ tibial tubercle avulsion fracture that was displaced. In addition, an MRI scan revealed a fracture line extending to the attachment of the anterior cruciate ligament (ACL); moreover, high MRI intensity and swelling due to ACL were observed, suggesting an ACL injury. On day 4 of the injury, open reduction and internal fixation were performed. Furthermore, 4 months after surgery, bone fusion was confirmed, and metal removal was performed. Simultaneously, an MRI scan obtained at the time of injury revealed findings suggestive of ACL injury; therefore, an arthroscopy was performed. Notably, no parenchymal ACL injury was observed, and the meniscus was intact. The patient returned to sports 6 months postoperatively. Conclusion: Type V tibial tubercle avulsion fractures are known to be extremely rare. Based on our report, we suggest that MRI should be performed without hesitation if intra-articular injury is suspected.

Tibial tubercle avulsion fractures in children.

PURPOSE OF REVIEW: To summarize and discuss the fundamentals of pediatric tibial tubercle avulsion fractures (TTAFs) including preferred imaging modalities, systems for fracture classification, frequently associated injuries, treatment options, outcomes, and common complications. RECENT FINDINGS: Although TTAFs amount to fewer than 1% of all physeal injuries in children, the incidence is increasing, likely because of greater participation in high-level athletics. SUMMARY: TTAFs tend to occur in adolescents nearing skeletal maturity who engage in sports with repetitive jumping. The most popular classification system was proposed by Ogden, which defines five fracture types based on the fracture pattern and extent of fragment displacement. Treatment can be nonsurgical or surgical, and indications depend on fracture type. Most fractures are surgical candidates and can be repaired with open reduction and internal fixation (ORIF) or arthroscopy. Arthroscopic approaches can reveal associated soft tissue injuries, such as meniscal tears, and confirm articular reduction. The most common postoperative complication is irritation because of hardware. With proper treatment, both nonsurgical and surgical outcomes are excellent. TTAFs have high rates of union and patients typically return to sports.

[Avulsion of the extensor carpi radialis longus et brevis tendons with avulsion fracture at the base of the third metacarpal bone : A rare case]. / Avulsion der Sehnen der Mm. extensor carpi radialis longus et brevis mit Ausrissfraktur an der Basis des Os metacarpale III : Ein seltener Fall.

This article presents the case of a traumatic avulsion of the extensor carpi radialis longus et brevis tendons with avulsion fracture at the base of the third metacarpal bone. Surgery as soon as possible is recommended in order to avoid retraction of the tendon.

An Unusual Case Report of a Stage IV Osteochondral Defect Imitating a Medial Malleolar Avulsion Fracture.

Osteochondral lesions of the talar dome are severely debilitating injuries that frequently can be missed on initial radiographic evaluation. In this case, we present the case of a 17-year-old male who injured his right ankle while skateboarding. Initial radiographic findings showed what appeared to be an avulsion fracture of the medial malleolus, and the patient was subsequently treated with immobilization. It was not until more advanced imaging of computed tomography was performed that the patient was appropriately diagnosed with a displaced talar dome fragment that was positioned in the medial gutter, requiring surgical intervention. This case report serves to show the importance of a proper workup, including advanced imaging, when clinical suspicion of a talar dome lesion is suspected. To the best of our knowledge, this is the only case in literature where a talar defect presents in the medial gutter of the ankle, imitating an avulsion of the medial malleolus.

Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary?

Fractures of the anterior tibial tubercle are infrequent lesions. They often occur in male adolescent athletes, usually in relation with sports involving powerful jumps. We present a retrospective study of 10 patients, with an average age of 15.1 years, all of them males, and a total of 11 acute avulsions of the anterior tibial tubercle. We analyzed the etiology of the lesion, the type of treatment used as well as non-weight bearing period, protected immobilization period, and time until sports reincorporation. We obtained 11 acute avulsions: one case of type I; three cases of type II; four cases of type III; and three cases of type IV. Five cases were treated conservatively, including the three cases of type IV, and surgery was only performed in six cases since an anatomical reduction was not obtained with closed reduction. The results were satisfactory in all cases, with 100% percentage of sport reincorporation in less de 25 weeks. We registered only one complication, intolerance of material, which did not require additional surgeries. These fractures, although rare, have an excellent prognosis. Even if they are often treated surgically, we have obtained good results with the conservative treatment in patterns previously reported as surgical.

Diagnosis of isolated extensor carpi radialis longus (ECRL) tendon avulsion fracture using ultrasound: a paradigm shift.

Isolated avulsion fracture of the extensor carpi radialis longus (ECRL) tendon is a rare and poorly understood injury. We present a unique case of a 45-year-old male who fell on his flexed right hand. He presented with a subtle but extremely painful mass on the dorsum of his wrist. Ultrasound (U/S) imaging of the mass revealed an avulsed bone fragment attached to the ECRL tendon, confirming the clinical suspicion of an ECRL avulsion injury. Computed tomography and magnetic resonance imaging are well-documented imaging modalities to detect tendon avulsions. As demonstrated by this case report, U/S is an excellent diagnostic tool for ECRL rupture, a cost-effective alternative that provides real-time dynamic examination of hand injuries. To our knowledge, this is the first case of ECRL avulsion diagnosed by U/S. The purpose of this case report is to educate the reader on detection and diagnosis of ECRL tendon avulsion using U/S, a time-efficient and cost-effective imaging modality that is infrequently used for this purpose.

Femoral avulsion fracture of ACL proximal attachment in male scuba diver: case report and review of the literature.

Femoral ACL avulsion fractures were not well described in the literature, and there were only several reports describing mostly immature patients. A case of 50-year-old man with ACL femoral attachment avulsion fracture after pivoting knee injury during skiing was presented. The bony attachment was reduced and fixed arthroscopically with screws. Four months after surgery, patient was allowed to return to full sport activity with full range of motion. He was able to perform a one-leg-hop test without limitation, and the strength of quadriceps muscle was comparable to contralateral side. Lachman and pivot shift tests were normal. Level of evidence IV.

Consequences of Avulsion Fracture of the Proximal Phalanx Caused by a Technical Failure of Hallux Valgus Surgery.

Several cases of avulsion fracture of the proximal phalanx of the big toe during the lateral capsular release procedure were observed. However, these fractures have not been reported as a complication of hallux valgus surgery. The purpose of the present study was to report the proximal phalanx base fracture as an unrecognized complication and to evaluate the clinical and radiographic consequences of this complication. We retrospectively reviewed 225 feet that had undergone hallux valgus surgery involving proximal chevron osteotomy and distal soft tissue release from May 2009 to December 2012. Of these 225 feet (198 patients), 12 (5.3%) developed proximal phalanx base fracture postoperatively. These patients were assigned to the fracture group. The remaining patients were assigned to the nonfracture group. Patients were followed to observe whether the fractures united and whether degenerative changes developed at the first metatarsophalangeal joint because of this fracture. The mean follow-up period was 36 (range 12 to 72) months. All the subjects in the fracture and nonfracture groups underwent weightbearing anteroposterior and lateral radiographs of the foot at the initial presentation and final follow-up point. The 2 groups were compared with respect to the hallux valgus angle, intermetatarsal angle, range of motion, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes. No significant differences were found in age, follow-up period, hallux valgus angle, intermetatarsal angle, range of motion of the first metatarsophalangeal joint, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes between the 2 groups. Ten (83.3%) of the 12 fractures healed, 2 (16.7% of the fractures, 0.89% of the operated feet) progressed to asymptomatic nonunion, and 3 (1.33%) developed first metatarsophalangeal joint degeneration. Avulsion fracture of the proximal phalanx of the big toe is an uncommon complication of hallux valgus surgery. It seems to be caused by excessive tension placed on the lateral soft tissues that attach to the base of the proximal phalanx at the time of plantarlateral soft tissue release. However, this fracture does not seem to cause significant clinical problems.

Popliteus Avulsion Fracture After Unicompartmental Arthroplasty: A Case Report.

CASE: An active 64-year-old patient presented with new-onset lateral knee pain 42 days after an uncomplicated medial unicompartmental knee arthroplasty (UKA). Magnetic resonance imaging and diagnostic injection of local anesthetic identified an avulsion fracture of the popliteus tendon as the source of discomfort. Repair of the tendon to its native footprint was performed with suture anchor fixation. The patient was pain-free and returned to work without restrictions at 12 weeks. CONCLUSION: We identify a unique cause of knee pain after UKA-avulsion of the popliteus tendon. Successful management of this condition included anatomic repair of the tendon with suture anchor fixation.

Bilateral anterior superior iliac spine apophysis avulsion fractures in a skeletally mature patient: case report and literature review.

We present a case of bilateral anterior superior iliac spine avulsion fractures in an adult patient who was involved in a road traffic collision. Her injuries were managed conservatively and she has had an uncomplicated recovery with a good outcome. This is, to our knowledge, the only reported case of bilateral simultaneous anterior superior iliac spine apophyseal avulsion fractures in an adult.

Hyperflexion Knee Injury with Anterior Cruciate Ligament Rupture and Avulsion Fractures of Both Posterior Meniscal Attachments: A Case Report.

CASE: A 54-year-old patient presented with low-velocity hyperflexion knee trauma while falling at a ski lift with anterior cruciate ligament (ACL) rupture and avulsion fractures of both posterior meniscal attachments. Meniscal avulsions were treated arthroscopically using transtibial sutures; a partial medial collateral ligament tear was treated conservatively. Six weeks later, reconstruction of the ACL was performed, and both meniscal attachments were stable. CONCLUSION: Hyperflexion of the knee puts direct shear and compressive force on the posterior tibia. This can result in ligament injuries combined with avulsion fractures of both posterior meniscal attachments. Arthroscopic treatment is a practicable technique for this type of injury.

Bilateral Anterior Inferior Iliac Spine Avulsion Fractures in an Adolescent with Type I Osteogenesis Imperfecta: A Case Report.

CASE: A 13-year-old boy with known type I osteogenesis imperfecta (OI) presented with bilateral asynchronous anterior inferior iliac spine (AIIS) apophyseal avulsion fractures 6 weeks apart. Each happened while running. These were successfully treated nonoperatively, and he went on to heal. CONCLUSION: Apophyseal avulsion fractures in patients with OI have been reported in the literature around the elbow and knee; however, to the author's knowledge, this is the first report of an AIIS avulsion fracture in a patient with type I OI. The fractures were treated successfully nonoperatively with activity modification and healed well.

A surgical reduction technique for posterior cruciate ligament avulsion fracture in total knee arthroplasty: a comparison study.

BACKGROUND: Posterior cruciate ligament (PCL) avulsion fracture of the tibia is an uncommon but serious complication during primary cruciate-retaining total knee arthroplasty (TKA). The first objective of this report was to conduct a retrospective cohort study to investigate the incidence and potential risk factors of PCL avulsion fracture in primary cruciate-retaining TKA. The second objective was to assess the functional outcomes of the knee after reduction of PCL avulsion fracture. METHODS: From January 2014 to January 2016, 56 patients who experienced PCL avulsion fracture of the tibia in primary cruciate-retaining TKA were included in the study group. Patients in this group underwent reduction of avulsion fracture. In this period, we selected 224 patients (control group) for comparison. Patients in this group also underwent the same TKA, but no PCL avulsion fracture occurred. The range of motion of the knee and Knee Society Scores were assessed. The Forgotten Joint Score was used to analyze the ability to forget the joint. Differences were considered statistically significant at p < 0.05. RESULTS: In our series, the incidence of PCL avulsion fracture was 4.6%. There were no significant differences (p > 0.05) with regard to the preoperative or postoperative range of motion of the knee, final 4-year mean clinical score in the study and control groups 92.4 ± 2.7 and 93.6 ± 1.9, respectively, and mean functional scores of 85.1 ± 1.8 and 87.1 ± 1.2, respectively. CONCLUSIONS: The incidence of PCL avulsion fracture of the tibia is relatively high. Older age and female gender were the two risk factors of fracture in primary cruciate-retaining TKA. Reduction of PCL avulsion fracture with a high-strength line can achieve good stability and function of the knee.

Repair of Chronic Concomitant Avulsion Fractures of the Extensor Carpi Radialis Longus and Brevis.

Combined simultaneous radial wrist extensor injuries, namely ipsilateral extensor carpi radialis longus (ECRL) and brevis (ECRB) avulsion fractures, are rare. While non-operative management with cast immobilization has been described, most recommend operative intervention in the acute setting. Surgical repair of chronic injuries, however, has received little attention in the literature. This case describes a 50-year-old male who sustained combined ipsilateral ECRL and ECRB avulsion fractures from the bases of the index and middle metacarpals. Five months after the initial trauma, he underwent surgical repair with lengthening of the tendons using a novel technique and suture anchor fixation. This case demonstrates that successful repair of this rare injury can be achieved with retracted extensor tendons in the chronic setting.

Ipsilateral open anterior hip dislocation and avulsion fracture of the greater trochanter: An unusual case report.

Approximately 3% of all joint dislocations involve the hip joint, and only 8-10% of these will be anterior. Traumatic anterior open dislocation of the hip is rare in children and prone to be associated with injuries, extensive soft tissue damage, and avascular necrosis of the femoral head. We present a case of a 13-year-old boy who had an open anterior dislocation of the hip with ipsilateral avulsion of the greater trochanter after a tractor wheel crush in an agricultural accident. Additional lesions included a diaphyseal closed fracture of the contralateral femur. We report this case because of the rarity and seriousness of this injury due to its progressive complications and difficulties related to its management.

Complete Avulsion of Quadriceps Tendon in a Child with Juvenile Idiopathic Arthritis: A Case Report.

CASE: We report a rare case of complete avulsion of the quadriceps tendon in an 8-year-old child with juvenile idiopathic arthritis (JIA). Our patient presented with acute onset of pain and effusion with a history of feeling a "pop" in the knee after a fall while playing kickball. Although knee radiographs showed a cortical irregularity involving the superior patellar pole, it was assumed that the symptoms were a result of a JIA flare rather than an acute injury. Complete quadriceps disruption was later diagnosed by magnetic resonance imaging, and surgical repair was performed. CONCLUSIONS: Complete rupture of the quadriceps tendon is an unusual, disabling injury in children that necessitates prompt diagnosis and early surgical repair. High index of suspicion and thorough physical evaluation are essential for the diagnosis of such injuries, especially in children with complex medical conditions.