Classifying Ischial Tuberosity Avulsion Fractures by Ossification Stage and Tendon Attachment.

BACKGROUND: We propose a new classification system for ischial tuberosity fractures in adolescents that is based on the ossification pattern of the apophysis. METHODS: We performed a retrospective review of patients who were diagnosed with ischial tuberosity avulsion fractures at a single institution from 2008 to 2018. Skeletal maturity and fracture location, size, and displacement were recorded based on initial injury radiographs. The fractures were classified by location as being lateral (type 1) or complete (type 2). Pelvic computed tomography (CT) review demonstrated 5 stages of ossification. We then reviewed pelvic CT and magnetic resonance imaging scans to assess the tendinous insertions at the ischial tuberosity apophysis. Reliability analysis was performed. RESULTS: We identified 45 ischial tuberosity fractures. The mean patient age was 14.4 years (range, 10.3 to 18.0 years). Boys accounted for 82% of the cohort. Forty-seven percent of the fractures were classified as type 1, and 53% were classified as type 2. Type-1 fractures were associated with younger age (p = 0.001), lower Risser score (p = 0.002), lower modified Oxford score (p = 0.002), less displacement (p = 0.001), and smaller size (p < 0.001) when compared with type-2 fractures. Of the 45 patients, 18 had follow-up of >6 months, with 56% going on to nonunion. Nonunion was associated with greater displacement (p = 0.016) and size (p = 0.027). When comparing union rates by fracture type, 33% of type-1 fractures progressed to nonunion, while 78% percent of type-2 fractures progressed to nonunion; however, this difference was not significant (p = 0.153). A review of the advanced imaging indicated that type-1 fractures involved the semimembranosus and conjoined tendons, whereas type-2 fractures also involved the adductor magnus tendon. CONCLUSIONS: We propose a new classification system based on the ossification pattern of the ischial tuberosity apophysis that reflects the skeletal maturity of the patient, the size and location of the fracture, and the amount of displacement, and likely predicts the probability of subsequent nonunion. The ischial tuberosity ossifies in a pattern similar to the iliac crest as described by Risser, and this pattern of ossification dictates the size of the ischial tuberosity avulsion fracture fragments and the involved tendons.

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.

Tibial tubercle avulsion fracture according to different mechanisms of injury in adolescents: Tibial tubercle avulsion fracture.

Tibial tubercle avulsion fracture caused by knee extensor is very rare; furthermore, non-traumatic fractures during running or bilateral fractures have been reported. The purpose of this study was to evaluate any differences according to the mechanisms of injury in adolescents with tibial tubercle avulsion fracture.Thirty patients with tibial tubercle avulsion fractures were reviewed and the average age was 13 years 1 month. Seven patients (low-stress group) had a spontaneous fracture during running without definite trauma. Twenty-three patients (high-stress group) experienced pain during jumping and landing, or definite trauma. The mechanisms of injury, age, height, weight, body mass index (BMI), BMI percentile, fracture type, as well as any complication, such as limitation of motion and deformity related to the physeal arrest, were compared between groups.There was no definite difference in age, fracture type, and surgical outcomes between groups. There was no patient with significant early physeal arrest in both groups. The weight (P = .02), BMI (P = .03) and BMI percentile (P = .01) in low-stress group were higher than those in high-stress group. In low-stress group, 6 patients' BMIs were in the 97th percentile, and 1 patient's BMI was in the 5th percentile.Extreme BMI may be a risk factor for tibial tubercle avulsion fractures in adolescents during running without definite trauma. However, there was no difference in the final outcome according to injury mechanisms.

Avulsion Fractures of Posterior Calcaneal Tuberosity: Identification of Prognostic Factors and Classification.

Avulsion fractures of the posterior calcaneal tuberosity are rare injuries, and little is known about the underlying factors, outcomes, and prognosis. Furthermore, classifications described previously focus on fracture morphology, with uncertain clinical utility. We present the results of a retrospective study of 21 patients treated for this pathology from January 2002 to December 2015. Features analyzed were age; sex; mechanism of injury; medical comorbidities; type of fracture, as proposed by Beavis; fracture displacement; fragment size; type of treatment; complications; need for secondary surgery; and the American Orthopaedic Foot and Ankle Society score after treatment and follow-up care. Mean age was 56.95years. A total of 61.9% were females, and 71.4% were secondary to low-energy trauma. In addition, 19% were diabetic. Mean follow-up was 57.24 months. Surgery was performed in 81%. Complications rate was 61.9%, and secondary surgery was needed in 38.1%. Mean fracture displacement was significantly higher when complications occurred (25.91mm versus 7.61 mm) (p = .03) and when soft tissues complications appeared (30.65mm versus 14.68 mm) (p = .02). Female gender was associated with the secondary loss of reduction (p = .04). The Beavis classification was not related significantly with any outcome variable. When fracture displacement was ≥2cm, complication rate increased from 30% to 90.9% (p = .008) and soft tissue compromise increased from 0% to 45.45% (p = .035). A new classification system with prognostic value is described, based on fracture displacement. We present 1 of the largest series published to date; fracture displacement is a major variable that influences the outcomes of these injuries, and a new classification attending to a prognostic factor is developed.

Arthroscopic Management of Tibial Spine Avulsion Fractures: Principles and Techniques.

Tibial spine fractures are uncommon injuries affecting the insertion of the anterior cruciate ligament on the tibia. They typically occur in skeletally immature patients aged 8 to 14 years and result from hyperextension of the knee with a valgus or rotational force. Diagnosis is based on history, physical examination, and standard radiographs. The use of MRI can identify entrapped soft tissue that may prevent reduction. Open or arthroscopic repair is indicated in patients with partially displaced fractures (>5 mm) with one third to one half of the avulsed fragment elevated, in patients who have undergone unsuccessful nonsurgical reduction and long leg casting or bracing, and in patients with completely displaced fractures. Arthroscopy offers reduced invasiveness and decreased morbidity. Suture fixation and screw fixation have produced successful results. Suture fixation can eliminate the risk of fracture fragment comminution during screw insertion, the risk of neurovascular injury, and the need for hardware removal. Suture fixation is ideal in cases in which existing comminution prevents screw fixation.

Calcaneal fractures: radiological and CT evaluation and classification systems.

BACKGROUND AND AIM OF THE WORK: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. The articular involvement has been associated with a poor functional outcome. The aim of this work is to describe the radiologic evaluation, the classification systems, the morphological preoperative diagnostic imaging features of calcaneal fractures, highlighting the correlation with the choice of treatment and predictive capacity for the fracture surgical outcome. METHODS: A PubMed search was performed for the terms Imaging calcaneus fracture, selecting articles in English language, published in the last two years, where preoperatively diagnostic imaging of fractures of the calcaneus are described.  Case reports have not been included. RESULTS: We have collected a number of data that provide important help in preoperative evaluation of calcaneal fractures, such as the new classification system created by Harnroongroj et al, the association of calcaneal fractures with fractures of other bone structures or soft tissue impairment, the use of calcaneotalar ratio in assessing the length of heel. CONCLUSIONS: These data suggest an approach geared to the specific choice of treatment and to improving patient outcomes.