Patterns of Anterior Inferior Tibiofibular Ligament Avulsion Fracture Accompanied by Ankle Fracture.

The anterior inferior tibiofibular ligament (AITFL) avulsion fracture accompanying an ankle fracture can compromise ankle stability, necessitating accurate evaluation and a clear understanding of its pathophysiology.. The aim of this study was to investigate the association between AITFL avulsion fracture and Lauge-Hansen, Wagstaffe classification. A retro-prospective study was conducted at a university-affiliated tertiary care medical center. We selected 128 patients who underwent surgery at our institution between January 2013 and July 2017 and analyzed the association between AITFL avulsion fracture and the foot position. According to the modified Wagstaffe classification system, there were 39 cases of type II, followed by 9 cases of type III and 8 cases of type IV. Of the7 pronation-abduction fractures, 3 were AITFL avulsion fracture (43%), while of the 21 pronation-external rotation fractures, 9 were AITFL avulsion fracture (43%). Of the 95 supination-external rotation fractures, there were 56 cases (59%) of AITFL avulsion fractures. Of the pronation fractures, 0% were fibular avulsion fractures and 43% were tibial avulsion fractures. Of the supination fractures, 44% were fibular avulsion fractures and 16% were tibial avulsion fracture. The difference in the ratio of fibular to tibial avulsion fractures between pronation and supination fractures was significant (p < .001). These results suggest that tibial avulsion fractures of type IV in the modified Wagstaffe classification and pronation fractures occur due to collision with the anterolateral corners of the distal bone when the talus externally rotates. Moreover, in cases of pronation fractures, a new type of AITFL avulsion fracture has been observed.

Calcaneal tuberosity avulsion fractures - A review.

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures.

The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.

Acute surgical treatment of peroneus longus avulsion fracture of the first metatarsal base.

Acute avulsion fracture of the base of the first metatarsal is a rare occurrence, caused by an eccentric contraction of the peroneus longus tendon insertion. A number of case reports have been published outlining various treatment strategies for treating this rare injury. Management plans range from conservative to operative options and include both acute and delayed operative treatments.We present our operative management strategy of an acute avulsion fracture of the base of the first metatarsal. It includes a step-by-step approach including intraoperative clinical photographs and intraoperative image intensifier images. We explain the rationale behind our operative approach and provide insight on the importance of recognising and treating this injury. Initially, this avulsion fracture might seem innocuous but if left untreated may result in disabling functional foot problems.

Ischiofemoral Impingement Due to an Undiagnosed Pelvic Avulsion Fracture.

ABSTRACT: Ischial tuberosity (IT) avulsion fractures are an uncommon cause of injuries in athletes. In this case, a 26-year-old female suffering from posterior right hip pain for over a decade presented with debility and a decrease in athletic function. Notable history included a hamstring strain while sprinting in elementary school. Clinical examination suggested hamstring tendinopathy and ischiofemoral impingement (IFI). Magnetic resonance imaging (MRI) revealed a chronic, fragmented, IT apophyseal avulsion fracture with ischial bursitis and edema within the fragmented bone, suggesting the development of heterotopic ossification (HO). Diagnostic ultrasound revealed signs of IFI, not evident on MRI. Ultrasound-guided corticosteroid injection in her ischial bursa and ischiofemoral space provided complete relief. The patient was able to resume her activities of daily living and sports-related activities without pain. Although interventional treatments may provide temporary pain relief, a multimodal approach is required for the treatment of HO.

Bilateral Tibial Tubercle Avulsion Fractures With an Associated Patellar Tendon Avulsion in an Adolescent Patient.

Tibial tubercle fractures in pediatric patients are increasing in frequency as more children participate in sports. These injuries are often seen in boys engaging in jumping activities before closure of their proximal tibial physis. Bilateral tibial tubercle fractures have been reported in the literature, but less frequent are associated patellar tendon ruptures with fracture of the tubercle. In this case report, we present an 11-year-old girl who sustained bilateral tibial tubercle fractures, including an associated patellar tendon rupture from the tubercle on the right lower extremity. We describe our technique for the management of both injuries, which included a primary patellar tendon repair for the right leg and Kirschner wire fixation of the displaced tubercle for the left leg. The patient ultimately had a successful outcome at the final follow-up with healed fractures and full range of motion of both knees. In this case report, we also present similar cases from the literature and the differing treatment strategies.

The degree of fracture reduction does not compromise the clinical efficacy of arthroscopic reduction and fixation of tibial posterior cruciate ligament avulsion fractures: A retrospective study.

This study aimed to explore the postoperative outcomes of patients who underwent arthroscopic internal fixation with repositioning sutures for the treatment of posterior cruciate ligament (PCL) avulsion fractures with poorly reduced fracture fragments. It was hypothesized that improperly repositioned fracture fragments might not influence the postoperative clinical outcomes in patients with PCL avulsion fractures treated by arthroscopic sutures. From January 2020 to December 2021, patients admitted to our hospital with PCL avulsion fractures were evaluated. Our inclusion criteria were as follows: diagnosis of PCL avulsion fracture as Meyers & McKeever Type II or Type III; underwent arthroscopic double tunnel suture fixation; and age below 70. Of the patients meeting these criteria, data from 34 individuals were collected by a designated follow-up officer. Based on postoperative imaging, the patients were divided into 2 groups: well fracture reduction and poor fracture reduction groups. Prior to the surgery, the Lysholm score, knee mobility, and international knee documentation committee (IKDC score) were recorded for both groups. At the 3-month post-surgery mark, CT-3D reconstruction was performed. Statistical analysis was conducted on the collected data. For data that conformed to a normal distribution, the t test was applied. For data that didn't conform, we used a non-parametric test. Both groups achieved successful wound healing without encountering any adverse events, such as fracture nonunion infection. Fracture healing was observed in both groups at the 3-month postoperative mark. The average follow-up duration was 13.24 ± 6.18 months. There were no significant differences in Lysholm score, IKDC score, or knee mobility between the well- and poorly-reduced groups at the final follow-up (P > .05). Postoperatively, both groups demonstrated significant improvements in knee function compared to the preoperative scores, with statistically significant differences observed in Lysholm score, IKDC score, and knee mobility (P < .05). Arthroscopic fixation with double-tunnel sutures proved to be a highly effective treatment approach for PCL avulsion fractures, even in cases where the fractures were poorly reduced. Remarkably, there were no significant differences observed in postoperative knee function between the well- and poorly-reduced groups, indicating that both groups achieved favorable outcomes.

Inferior scapula avulsion fracture: an unusual presentation of winged scapula.

Inferior scapula avulsion fractures are rare injuries, with few cases reported and only a small number managed operatively discussed in the literature. We report the case of a man in his 40s who fell from a height and presented with right-sided scapular winging and point tenderness at the inferior pole of his right scapula with no neurological deficit. Radiographs and CT diagnosed avulsion fracture of the inferior scapula. The patient underwent surgical fixation and, following a course of physiotherapy, successfully recovered with no residual winging and full range of movement.

Posterior Cruciate Ligament Femoral Avulsion Fractures in Pediatric Patients: A Report of 2 Interesting Surgical Cases.

CASE: This report describes 2 cases of femoral-sided posterior cruciate ligament (PCL) avulsion injuries. A 10-year-old male patient presented with a chronic nonunion of a bony PCL femoral avulsion. In addition, a 4-year-old boy presented with an acute, displaced PCL femoral avulsion off the medial femoral condyle. Both injuries were repaired using arthroscopic techniques. CONCLUSION: Femoral-sided PCL avulsions are very rare in pediatric patients and have not been reported often. We hope to increase the awareness of PCL femoral avulsion injuries in pediatric patients by describing 2 unique cases.

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.

Hollow screw fixation of type II avulsion fractures of the calcaneal tuberosity using the finite element analysis.

We aimed to establish a model of type II avulsion fractures of the calcaneal tuberosity treated with 2 hollow screws implanted in different directions and to analyze the biomechanical properties of the model using the finite element method. The Dicom data of the calcaneal bone obtained after computed tomography scan were inputted into Mimics 21.0 software and Geomagic Studio software to generate a 3D finite element digital model of the calcaneal bone. The model was then imported into SOLIDWORKS 2020 software. Based on the Beavis theory, the calcaneal bone was cut to build a type II avulsion fracture model of the calcaneal tuberosity; the calcaneal fracture was then simulated by internal fixation using hollow screws. Two screws were used to fix the calcaneal bone from the calcaneal tuberosity in different ways, resulting in 3 different calcaneal models (Model 1 involved 2 screws for fixing the fracture vertically; Model 2 had 2 screws for fixing the fracture cross-wise; and Model 3 had 2 screws for fixing the fracture parallelly). Three internal fixation models were loaded under the same conditions, and lines finite element analysis was then performed to calculate the stress distribution of the generated internal fixation models. Under the same loading conditions, compared with Models 2 and 3, Model 1 exhibited smaller maximum displacement values of the heel bone, maximum equivalent force values of the screws, and more dispersed stresses. Avulsion fractures of the calcaneal tuberosity can be treated using 2 screws to fix the fracture vertically (Model 1), which is more biomechanically relevant.

Fractura avulsión tipo sleeve de la patela / Patella sleeve avulsion fracture

Introducción: la fractura avulsión tipo sleeve o en manguito es una lesión rara que puede afectar a la patela durante la etapa de crecimiento infantil. Su diagnóstico precoz es clave para obtener un buen resultado clínico y funcional y evitar secuelas derivadas de la lesión. El diagnóstico diferencial se realiza con el síndrome de Sinding-Larsen-Johansson y la fractura del polo inferior de la rótula. Caso clínico: presentamos el caso de un varón de 12 años, sin antecedentes de interés, que acude a urgencias refiriendo gonalgia derecha tras mal movimiento mientras corría. El paciente es dado de alta orientándose como una tendinitis rotuliana. Dos semanas más tarde acude con dolor e impotencia funcional completa para la extensión de rodilla derecha tras caída de nuevo en ámbito deportivo. En la imagen de la radiografía convencional se observa una avulsión osteocondral desplazada del polo inferior de la patela, tipo sleeve. Dada la limitación funcional, se decide intervención quirúrgica mediante reinserción del polo inferior patelar mediante sutura tipo Krackow y puntos transóseos. Conclusiones: la fractura tipo sleeve es poco frecuente y puede pasar desapercibida. El mecanismo lesivo (indirecto por tracción), los antecedentes de dolor previo y las imágenes de radiología convencional deben aportar un alto nivel de sospecha y disminuir el infradiagnóstico de esta entidad para así evitar las secuelas derivadas como la patela alta, el dolor anterior de rodilla persistente o la pérdida de fuerza del cuádriceps (AU)

Introduction: the patella sleeve fracture is a rare injury that can affect the patella during the infant growth stage. Its early diagnosis is important to obtain a good clinical and functional result and to avoid sequelae derived from the injury. Differential diagnosis is made with Sinding-Larsen-Johansson syndrome and the fracture of the lower pole of the patella.Clinical Case: we present the case of a 12-year-old male, with no history of interest, who came to the emergency room reporting right knee pain after making a bad movement while running. The patient is discharged oriented as patellar tendonitis. Two weeks later, he returned with pain and complete functional impotence to extend his right knee after falling again doing sport. In the conventional X-ray image, a displaced osteochondral avulsion of the lower pole of the patella, 'sleeve' type, is observed. Because of the functional limitation, surgical intervention was decided doing reinsertion of the lower patellar pole using Krakow suture and transosseous stitches.Conclusions: patella sleeve type fracture is rare and may go unnoticed. The lesion mechanism (indirect by traction), the history of previous pain and conventional radiology images should provide a high level of suspicion and reduce underdiagnosis of this entity and thus avoid derived sequelae such as patella alta, anterior knee pain or loss of quadriceps strength. (AU)

Does Skeletal Maturity Predict the Pattern of Tibial Tubercle Avulsion Fracture?

BACKGROUND: Proximal tibial physeal development and closure is thought to relate to tibial tubercle avulsion fracture (TTAF) patterns. Prior work has yet to formally evaluate the relationship between skeletal maturity and fracture pattern.  Using 2 knee radiograph-derived skeletal maturity assessments [growth remaining percentage (GRP) and epiphyseal union stage], we examined their association with TTAF injury patterns using the Ogden and Pandya fracture classifications. We hypothesized that different TTAF injuries would occur during unique periods of skeletal development. METHODS: Pediatric patients sustaining TTAFs treated at a single institution (2008-2022) were identified using diagnostic and procedural coding. Demographics and injury characteristics were collected. Radiographs were reviewed to assign epiphyseal union stage, Ogden and Pandya classifications and for measurements to calculate GRP. Univariate analyses examined the relationship between injury subgroups, patient demographics, and skeletal maturity assessments. RESULTS: Inclusion criteria identified 173 patients with a mean age of 14.76 (SD: 1.78) and 2.95% (SD: 4.46%) of growth remaining. The majority of injuries were classified Ogden III/Pandya C. Most (54.9%) were the result of the axial loading mechanism. Ogden groups showed no significant differences across all patient characteristics studied including age and GRP. With the exception of Pandya A fractures, we did not identify a direct relationship between GRP, age, and Pandya groups. Epiphyseal union stage differed for Pandya A and D groups. CONCLUSIONS: A predictable pattern in TTAF characteristics across skeletal (GRP), epiphyseal union, or chronologic age was not identified in this study. Distal apophyseal avulsions (Ogden I/II and Pandya A/D) occurred across a broad chronologic and skeletal age range. No differences were identified in epiphyseal or posterior extension (Ogden III/IV and Pandya B/C) injuries. Although differences in age and GRP were identified among Pandya As, this is thought to be due to the degree of skeletal immaturity that is a prerequisite for differentiation from Pandya Ds. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Outcomes of U-shaped internal fixation in the treatment of avulsion fracture of calcaneal tubercle.

BACKGROUND: The purpose of this study was to analyze the efficacy of U-shaped internal fixation for calcaneal tubercle fracture after nearly 3 years of case follow-up and data collection. METHOD: We retrospectively analyzed the collected data from 16 patients with avulsion fracture of calcaneal tubercle between December 2018 and February 2021 at our institute. All patients were required to conform to regular follow up postoperatively. X-ray film was applied to all cases. The American Orthopaedic Foot and Ankle Association (AOFAS) score, Cedell score and the visual analog scale (VAS) were used to evaluate functional results. RESULTS: All patients achieved bone union. The preoperative AOFAS score was 26.34 ± 3.34, which was significantly different from 91.38 ± 6.15 half a year after operation (p = 0.003). The preoperative Cedell score was 31.05 ± 4.18 and the score half a year after operation was 92.17 ± 5.39(p = 0.011). The VAS score was 8.91 ± 1.51 before operation and decreased to 0.58 ± 1.31 half a year after operation (p = 0.014). CONCLUSIONS: In the treatments of calcaneal tubercle fracture, U-shaped internal fixation is a new attempt. Through the short-term follow-up study, we found that its therapeutic effect is excellent, which is a recommended treatment in clinic.

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.

A New Arthroscopic Tightrope Suture-Button Fixation Procedure for Tibial Eminence Avulsion Fracture.

This case-series outcome study presents a new arthroscopic technique for tibial eminence avulsion fracture (TEAF) with double-tunnel using two tightrope suture buttons. From May 2017 to July 2020, we performed a new arthroscopic technique for TEAF with double tunnels, using two tightrope suture buttons on 13 patients. Clinical assessments included anterior drawer, Lachman, and pivot shift tests, the International Knee Documentation Committee (IKDC), Lysholm knee scores, visual analog scale (VAS) scores, and range of motion (ROM). An independent observer noted conditions before surgery and during the last follow-up. The patients had an average follow-up of 26.2 months, ranging from 15 to 37 months. During the last postsurgical follow-up, the anterior drawer, Lachman, and pivot shift tests were negative in all the cases. According to the IKDC, Lysholm, and VAS final scores, all patients presented a significant knee function improvement at last follow-ups compared with preoperatively. The study shows that satisfactory results about an anatomic reduction of the fragment, knee stability, function, and strength can be achieved with the new arthroscopic technique for TEAF with double tunnels using two tightrope suture buttons. This study is a therapeutic case series and its level of evidence is IV.

Delayed Repair of a Lesser Tuberosity Avulsion Fracture in an Adolescent 3 Years After Initial Injury.

This case study examines an adolescent athlete who had an avulsion fracture of the lesser tuberosity of the humerus. This is a relatively rare injury, although a collection of case studies have identified an increase in this type of injury in the past 15 years. Uniquely, the patient experienced a delay in appropriate diagnosis for approximately 3 years from the time of his initial injury. This is one of the most significant delays in diagnosis and treatment in the current body of literature regarding lesser tuberosity fractures. The authors include a detailed series of imaging studies, including preoperative plain radiographs, preoperative computed tomography, intraoperative arthroscopic images, and postoperative plain radiographs. In addition, a thorough description of the patient's surgery is presented. The degree of scarring to the axillary nerve present in this patient required conversion to a full open reduction. The authors' aim is that this case can be used as a reference for future surgical decision making, particularly in pediatric patients whose injuries are highly chronic or who are actively involved in athletic physical training programs. [Orthopedics. 2023;46(3):e189-e192.].

Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis.

The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Sinding-Larsen-Johansson syndrome with minimally displaced patellar sleeve avulsion fracture: a case report with multimodality approach and literature review.

Sinding-Larsen-Johansson syndrome is an osteochondrosis affecting the inferior pole of the patella. Most cases can be easily diagnosed with adequate clinical history, physical examination, and proper imaging, including conventional radiography, ultrasound, and magnetic resonance imaging. Differentiating this condition from patellar sleeve avulsion fractures is important, since treatment is frequently surgical in the latter. Overlap between these two conditions can also occur. We present a case of an 11-year-old boy, with Sinding-Larsen-Johansson syndrome on both knees and a minimally displaced acute patellar avulsion sleeve fracture of the left knee, which was treated conservatively.