Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Tibial Spine Avulsion Fracture

SYMPTOMS

This injury is caused by a sprain and prevents continuation of sport in a young growing athlete usually below or just above 15 years of age. The symptoms are immediate haemarthrosis, which is caused by bleeding from the bone, and pain. This is an injury that is not uncommon in contact sports such as football or rugby and other high-intensity sports such as downhill skiing.

AETIOLOGY

The typical athlete suffers a hyperextension or valgus rotation sprain during sport. In some cases however it is a non-contact injury where the player loses their balance and twists the knee. The ACL avulses its insertion at the tibia spine since the bone is weaker than the ligament. Grade I injuries are not displaced; Grade II are but with the fragment still attached; Grade III is a displaced loose bony fragment. This injury is often associated with other injuries to cartilage, menisci, capsule or other ligaments.

CLINICAL FINDINGS

There is haemarthrosis in most cases. If there is a capsule rupture, blood can penetrate from the joint and cause bruising. The Lachman test is positive in Grade III injuries but can be falsely negative in Grade I and II injuries. Since there are often associated injuries, examin ation must also include tests for collateral ligaments, menisci and cartilage. The compression rotation test is often positive due to the loose bony fragment.

INVESTIGATIONS

Clinical examination is the most important tool for diagnosis and should include tests for all ligaments and other structures in the knee. X-ray is essential in growing athletes with a suspected ACL injury, to rule out this type of fracture. MRI or CT scans can be useful in unclear cases.

TREATMENT

An athlete with haemarthrosis and suspected ACL tear should be seen by an orthopaedic surgeon to consider arthroscopy. This procedure can verify the diagnosis and deal with associated injuries that are often missed. In Grade III and in some Grade II injuries, the bone fragment can be re-fixated with a screw. Grade I injuries can be treated without surgery by being kept braced in extension for four to six weeks, followed by progressive rehabilitation.

REFERRALS

Refer to Dr Kevin Yip (+65 9724 1219) senior consultant orthopaedic surgeon for further investigations to verify the extent of the injury. Physiotherapists will be involved in close collaboration with the surgeon.

EXERCISE PRESCRIPTION

Cycling and water exercises are good alternatives to keep up general fitness. Rehabilitation back to full sport usually takes around six months.

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. Different functional knee scores for different sports are available to measure when the knee allows a return to full sport.

DIFFERENTIAL DIAGNOSES

ACL rupture.

PROGNOSIS

Surgery will allow a return to sport within around six months. The risk of re-rupture is low. Note! If the bony Grade II-III injury is missed, it will lead to chronic increased laxity and most often to the inability to perform pivoting sports due to functional instability.

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