Surgical Reduction and Fixation of Tibial Spine Fractures in Children
Introduction
Nondisplaced fractures can be treated with long leg cast in 10° to 15° knee flexion
Minimally displaced fracture may be reduced closed and then casted
If there is displacement, there may be entrapment of one of the menisci or intermeniscal ligament; may also have meniscal tear
High potential of arthrofibrosis after surgery
Patient Selection
Indications
Tibial spine fractures displaced 3 mm or more
Fracture that cannot be reduced in extension
Suggestion of extension of fracture into the weight-bearing articular cartilage
Contraindications
Nondisplaced fractures or fractures able to be closed reduced and casted
Lateral view on plain radiographs most helpful
Can identify meniscal entrapment on MRI
CT or MRI can demonstrate comminution or extension to weight-bearing surface not easily seen on plain radiographs
Procedure
Treatment Selection
Surgical treatment with three No. 2 sutures is stronger than single 4-mm screw; sutures minimize risk of impingement
Screw fixation best suited for large fragments
Nonsurgical Treatment
May manipulate mildly displaced fractures, especially those hinged posteriorly, to acceptable position of less than 3 mm
Aspiration, 10 mL lidocaine injection can aid reduction
Perform reduction by putting ankle on bolster and knee in extension
Confirm with lateral radiograph
Place cast in near full extension (10° to 15°)
Room Setup/Patient Positioning
Position knee to allow lateral intraoperative imaging
Suture fixation requires about 20° knee flexion; screw fixation requires 60° to 90° flexion
Paint roller can be placed at end of table to flex knee to 60°
Bump under ipsilateral hip prevents knee from falling outwards
Special Instruments/Equipment/Implants
For suture fixation
No. 2 reinforced braided nonabsorbable suture
45° or 90° suture passer
Anterior cruciate ligament (ACL) tibial drill guide, guide pin
Microfracture awl/pick
Arthroscopic curette
Suture lasso
3.5-mm drill guide
30°, 70° arthroscopes
Arthroscopy camera and shaver
For screw fixation
4.0- or 4.5-mm cannulated screw and washer
Curette
Arthroscopy shaver
Microfracture awl/pick
Kirschner wire set
Nonabsorbable suture to tag washer
Surgical Technique
For Suture Fixation and Screw Fixation
Figure 1Arthroscopic view of a knee with a displaced Meyers and McKeever type III tibial spine fracture shows the notch and the medial compartment. An arthroscopic probe is seen reducing the fracture fragment inferiorly and medially into the crater.
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