Part 6: Distal Detachment from Tibia with bony avulsion - case example

A closing word from the course convenor - Professor Adrian Wilson

Distal Detachment from Tibia - with bony avulsion

This is a common type of injury seen in children, and is in fact the most common way in which rupture presents in the skeletally immature.

We have a classification - the McKiever classification - based on the amount of displacement, small, moderate or severe amount of displacement.

Patient: 'O'

This seven year old girl was referred to Professor Wilson from another hospital and presented with a nasty injury to her right knee.

She had twisted the knee whilst playing football and rather than rupture the ligament she pulled off the attachment of the ligament where it inserts onto the tibia. This can be seen on both of the X-rays shown below. 

X-rays

The arrow marks out the site on the lateral view on the left the bone fragment which is sitting up and represents really quite a large part of the central aspect of the upper part of the tibia. We can see the bone fragment again on The AP or straight view, which is on the right.

The lateral view of the knee

The A-P (antero-posterior) view of the knee

Fracture reduction & fixation

The technique used for fixing this fragment down was to create two small drill holes from the front, and come up and pass sutures over the top of that bone fragment which he reduced via keyhole surgery, and effectively lashed that piece of bone back down into position.

Normally we would then take patients very slowly through their rehabilitation, but in this case Prof Wilson also drilled up through the middle and across the ACL to an attachment point on the femur. He then created a tunnel through to the outer aspect of the femur and ran some FibreTape - the so-called internal brace - which he fixed with a button on the side of the femur and with a little screw on the front of the shin bone...without any immobilisation or need for a brace.

Arthroscopic findings

The video on the right shows the arthroscopy at three months when the surgeon did a second look, and removed the hardware. The video might be a little confusing, as starts off by showing the patellofemoral joint (0:08) and then the camera moves to the rounded end of the femur (0:13), and continues down into the medial side of the joint. where we can see the ACL nicely reduced (0:17).

Follow-up at 4 months

Olivia was then followed up at four months, where you can see that she was comfortable with a stable knee. The anterior drawer at 90 degrees was beautifully stable with an excellent range of motion. 

Follow-up at one year

At one year follow-up, you can see that she has full range-of-motion.

The one-year X-rays show how nicely that bone fragment has been reduced and held in position.

Of course, Olivia is being followed up long term until skeletal maturity to make sure there is no growth disturbance but the risk of this is really minimal. She is now back to full activity with no limitations.

This is an excellent way of treating this injury. The historical techniques of just allowing these bony avulsion injuries to heal in a long-leg plaster is really totally inadequate. We should go for anatomic reduction, strong good fixation and early mobilisation - a mantra for any injury within the joint.

End of Course

That brings us to the END of this mini course. We trust that you have found something of value here. Thank you for joining us. If you enjoyed this course, please share so that others can benefit ...

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