Don’t forget about the (tibial) spine!
Author: Katie Dolbec, MD
Peer-reviewer: Mark Hopkins, MD
Final editor: Alex Tomesch, MD
A 13-year-old patient presents to the Emergency Department after sustaining a twisting knee injury while playing soccer. There was a pop, and the patient was subsequently unable to bear weight secondary to pain and instability. In the hours following the injury the swelling and pain increased. On examination, there is a large knee effusion and a positive Lachman test.
Images 1 and 2. Case courtesy Dr. Jeremy Jones, Radiopaedia.org, rID: 27372
What is your diagnosis?
Anterior tibial spine avulsion fracture with anterior cruciate ligament (ACL) injury.
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Pearl: The anterior tibial spine is the insertion point of the ACL. This injury occurs more commonly in pediatric patients than adults [1], likely because the pediatric ACL is more elastic as well as stronger than its incompletely ossified bony attachment [2,3].
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Pearl: Tibial spine avulsion fractures can be caused by a twisting or pivoting knee injury, hyperextension, or direct trauma, with or without concomitant ACL injury [4].
Image 3. Case courtesy Dr. Jeremy Jones, Radiopaedia.org, rID: 27372. Arrow by author.
For more reading about Tibial spine and ACL injuries go to WikiSM.
References
[1] Weerakkody, Y., Bell, D. Anterior cruciate ligament avulsion fracture. Reference article, Radiopaedia.org. (accessed on 01 Oct 2021) https://radiopaedia.org/
[2] Wiley JJ, Baxter MP. Tibial spine fractures in children. (1990) Clinical orthopaedics and related research. Pubmed
[3] Noyes FR, DeLucas JL, Torvik PJ. Biomechanics of anterior cruciate ligament failure: an analysis of strain-rate sensitivity and mechanisms of failure in primates. (1974) The Journal of bone and joint surgery. American volume. 56 (2): 236-53. Pubmed
[4] Mayo MH, Mitchell JJ, Axibal DP, et al. Anterior Cruciate Ligament Injury at the Time of Anterior Tibial Spine Fracture in Young Patients: An Observational Cohort Study. J Pediatr Orthop. 2019;39(9):e668-e673. doi:10.1097/BPO.
[5] Tuca M, Bernal N, Luderowski E, Green DW. Tibial spine avulsion fractures: treatment update. Curr Opin Pediatr. 2019;31(1):103-111. doi:10.1097/MOP.
[6] Osti L, Buda M, Soldati F, Del Buono A, Osti R, Maffulli N. Arthroscopic treatment of tibial eminence fracture: a systematic review of different fixation methods. Br Med Bull. 2016;118(1):73-90. doi:10.1093/bmb/ldw018, 10.1093/bmb/ldw018
[7] Monk APaul, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011166. DOI: 10.1002/14651858.CD011166.pub2
[8] Dolbec KWD. Winter Wipeout: Skiing and Snowboarding Injuries. Critical Decisions in Emergency Medicine. January 2019; 33(1): p. 20.