Surgical Reduction and Fixation of Tibial Spine Fractures in Children
Eric Wall, MD
Katrina Lewis, BA, BS
Dr. Wall or an immediate family member serves as a paid consultant to or is an employee of OrthoPediatrics and serves as a board member, owner, officer, or committee member of the Cincinnati Children’s Physician-Hospital Organization, PRISM, and the ROCK Group. Neither Mr. Lewis nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.
PATIENT SELECTION
Indications
Tibial spine fractures that are displaced 3 mm or more circumferentially may require surgical reduction and fixation. Mildly displaced fractures, especially those that are hinged posteriorly, may be manipulated into an acceptable position of less than 3 mm anterior elevation.1 In the emergency department or the office, the knee effusion is aspirated and the joint is injected with approximately 10 mL of local anesthetic. A radiograph is taken with the knee in full extension with the ankle on a bolster to document that the displaced fracture has reduced into acceptable position of less than 3 mm of displacement. Then the knee is casted in near full extension. It is likely that the notch impinges on the fragment and pushes it into position.1 Fractures with minimal displacement can be casted directly. Nonsurgical treatment of nondisplaced tibial spine fractures can have excellent results. Loss of full knee extension, arthrofibrosis, joint laxity, nonunion, meniscal entrapment, meniscal tears, and ACL insufficiency requiring ACL reconstruction can complicate the nonsurgical care of these fractures.1 Minimally displaced type I Meyers and McKeever fractures respond well to nonsurgical treatment, but type II (displaced with posterior hinge) and III (completely displaced) fractures have better outcomes with fixation.2
Open reduction and internal fixation of tibial spine fractures, despite good long-term outcomes,3 has been largely supplanted by arthroscopic reduction and fixation with similarly good outcomes. Two systematic reviews concluded that there was insufficient evidence on the superiority of suture verses screw fixation.4,5 Another systematic review found higher rates of instability and the ultimate need for ACL reconstruction in nonsurgically versus operatively treated patients.6 Patients treated with screw fixation had equivalent patient-reported instability and ACL reconstruction rates as suture fixation, but had a higher rate of measured instability and increased rate of hardware removal.6
Contraindications
Although controversial, because of the risk of arthrofibrosis,7 I recommend that surgical treatment be delayed until the hemarthrosis has resolved and the patient has regained most knee motion (>90° arc of motion). This is similar to most anterior cruciate ligament (ACL) reconstruction preoperative protocols (“prehab”). During this waiting period, the patient may be fully weight bearing and should wean out of a brace/immobilizer and undergo physical therapy before surgery. Surgical delay of 2 to 3 weeks improves arthroscopic visualization because the hemarthrosis will have largely resolved. The fracture does not heal during this waiting period because of its intra-articular location.
PREOPERATIVE IMAGING
Plain radiographs, especially the lateral view, should be scrutinized to assess fracture displacement and fracture comminution, which is less suitable for screw fixation (Figure 1). Meniscal entrapment and meniscal tears can complicate 40% of tibial spine fractures and can be identified preoperatively on MRI to help plan the procedure and more accurately estimate the surgical time.8 A CT scan or MRI can show true fracture displacement, the fracture size, and the condition and thickness of the epiphyseal bed into which the fracture will be fixed. The lateral radiograph (Figure 2, A) does not show the significant epiphyseal comminution that is apparent on an MRI (Figure 2, B). In this case, screw purchase restricted to the tibial epiphysis would be tenuous. Screw purchase across the epiphyseal plate into the metaphysis would be preferred.
PROCEDURE
Room Setup/Patient Positioning
It is essential to position the patient’s knee on the table so that a clear intraoperative lateral radiograph can be obtained. For suture fixation, the knee can be positioned in about 20° of flexion on top of the table by elevating
the knee holder under the thigh. Cannulated screw fixation is facilitated with the knee at 60° to 90° of flexion, usually off the end of the table. A “paint roller” placed at the end of the operating room table (Figure 3) can also be used to flex the knee >60°. In this situation a bump should be placed under the ipsilateral hip to keep the knee from flopping outward.
the knee holder under the thigh. Cannulated screw fixation is facilitated with the knee at 60° to 90° of flexion, usually off the end of the table. A “paint roller” placed at the end of the operating room table (Figure 3) can also be used to flex the knee >60°. In this situation a bump should be placed under the ipsilateral hip to keep the knee from flopping outward.
 FIGURE 1 AP (A) and lateral (B) radiographs of a displaced type III tibial spine fracture. The lateral view usually most clearly demonstrates tibial spine fracture displacement and fragment size. |
Special Instruments/Equipment/Implants
For suture fixation, the following instruments and equipment should be on hand: No. 2 reinforced braided nonabsorbable suture, a 45° or 90° suture passer, an ACL tibial drill guide and guide pin, a microfracture pick/awl, an arthroscopic curet, a Hewson suture passer, a standard fracture set with 3.5-mm drill guide, 30° and 70° arthroscopes, and an arthroscopy shaver.
Screw fixation will require a 4.0- or 4.5-mm cannulated screw/washer, a curet, an arthroscopy shaver, a microfracture pick/awl, a Kirschner wire (K-wire) set, and nonabsorbable high-strength suture to tag the washer.
 FIGURE 2 Images show a displaced type III tibial spine fracture in a 13-year-old boy; this fracture is amenable to screw fixation. A, Lateral radiograph. B, MRI shows that the displaced tibial spine fragment is large enough to fix with a screw and washer, but the rest of the tibial epiphysis has multiple fracture lines. In this case, epiphyseal screw fixation would be tenuous, and metaphyseal fixation is needed for secure screw purchase, which will allow early postoperative knee motion. |
Surgical Technique
The following eight steps apply to both arthroscopic suture fixation and screw fixation:
The tourniquet is inflated to improve visualization during a potentially bloody procedure.
Arthroscopy starts with irrigation of any remaining hemarthrosis. The knee joint should be rinsed with saline several times through the arthroscope cannula before placing the arthroscope. An accessory outflow portal can be used if necessary.
FIGURE 3 Photograph shows a leg positioned at about 60° knee flexion using a “paint roller” as a heel stop at the end of the operating table. The ipsilateral hip should be bumped up until the knee balances as shown without flopping into internal or external rotation.
The clot is shaved and curetted from the fracture crater that usually encroaches into the medial compartment. A portion of the anterior fat pad is resected to provide unobstructed visualization of the anterior fracture line and the transverse meniscal ligament (Figure 4, A).Related posts:
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