Working Diagnosis:
Type III tibial tubercle avulsion fracture with extension through the proximal tibial epiphysis into the intra-articular space

Treatment:
Tibial tubercle fracture reduced via open reduction technique and fixed with two screws. Case Photo #4 . Case Photo #5

During arthroscopy, a contusion of the anterior fat pad and ACL was noted, but the ACL was intact with good tension. The menisci were without tears. A small ripple in the tibial plateau cartilage was noted but no cartilaginous defect or step-offs were apparent after reduction.

Outcome:
The patient was placed in a hinged-knee brace post-op and locked in full extension. He was placed on non-weight-bearing (NWB) status for 2 weeks. X-rays one week post-op revealed stable alignment.

NWB ROM was initiated at 2 weeks post-op. Then, partial WB in the locked brace was allowed at 2-4 weeks.
The patient was progressed to gradual WB ROM at 4-6 weeks, and excellent healing was noted at 4 ½ months post-op.

Return to activity was allowed at 4 ½ months with recommendation to avoid contact sports or high-impact activities for another 6 weeks.

Author's Comments:
- Fortunately, his injury was not complicated by compartment syndrome, which occurs nearly 20% of the time in one case series.
- Progressive fusing of the tibial physis is associated with this particular type of fracture, similar to a Tillaux fracture in the ankle.
- This should not affect his goals to join the military if he regains full function, which is likely.
- Did his previous knee injury put him at risk for this one?

Editor's Comments:
Tibial tubercle avulsion fractures typically occur in adolescent males. Forceful contraction of the quadriceps leads to avulsion at the tibial tubercle physis. Surgical management is often necessary. It is important to maintain reduction against the pull of the quadriceps by placing the affected leg in extension post-op and gradually increasing ROM and activity.

References:
- Lau K, Ramachandran M. Tibial Tubercle Fracture. eMedicine 3 Nov 2009. Available at http://emedicine.medscape.com/article/250197-overview#showall, Accessed April 17, 2011.
- Buck buck. Wikipedia. 5 March 2011. Available at
http://en.wikipedia.org/wiki/Buck_buck, Accessed April 17, 2011.

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