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Robert ELBAUM 
Clinique Edith Cavell, Brussels, 
Erasme Universitary Hospital 
Belgium
 Avulsion-fracture of the anterior tibial tubercle (ATT) 
occurs in adolescents, predominantly male. 
 Avulsion fracture of the ATT represents 3% of all 
injuries of the proximal tibia and 0.4 to 2.4% of all 
epiphyseal fractures . 
 From 1853 till now, more than 250 cases have been 
reported in the literature.
 Simultaneous bilateral avulsion fractures of the tibial tubercle 
are very uncommon. 
 Since the first description by Borsch-Madsen in 1955 , 
15 cases have been reported. Associated patellar ligament 
avulsion is also uncommon . 
 We report another bilateral case featuring these two rare 
injuries. 
 We will also discuss the appropriate classification, the 
aetiopathogenenesis of this injury and the proposed 
treatment.
 a 16-year old boy 
 Following a jump on both 
feet. 
 2 swollen knees and a 
marked tenderness over the 
tibial tubercles. 
 Active extension was 
impossible bilaterally. 
 X-Ray :bilateral avulsion 
fracture of the tibial 
tubercle, type 3A according 
to Ogden’s classification.
 L knee: complete avulsion of the 
tibial tuberosity with an intact 
patellar ligament. 
R knee: partial disruption of the 
patellar ligament 
 the fragments were reduced and 
fixed with two cannulated 
screws. The right patellar 
ligament was repaired.
 Six months later the 
cannulated screws were 
removed in one day 
surgery. 
 1Y FU: no pain, no 
functional limitation and 
had resumed his sporting 
activity (judo). 
 X-Ray :complete 
remodeling of the tibial 
tubercle.
WATSON-JONES (1976) OGDEN (1980) 
type I: avulsion fracture of the distal part of 
the tibial tubercle; 
type II: displacement of the lip of the 
anterior part of the tibial epiphysis. 
type III :fracture of the base of the lip with 
propagation into the knee joint. 
3 subgroups A or B, with a possible 
intra-articular extension of the fracture 
as well as comminution of the fragment
 In 1990, Frankl described two cases of ATT 
avulsion-fracture associated with avulsion of the 
patellar ligament. He proposed an addition to 
the classification to include avulsion of the 
patellar ligament (Type I-C). 
 Ryu and Debenham subsequently added a 
fourth type corresponding to an extension of the 
fracture to the posterior cortex through the 
growth plate (Salter Harris type 2).
 The tibial tubercle physis 
is in continuity with that 
of the tibial plateau. The 
physis progressively fuses 
from posterior to 
anterior, making it most 
vulnerable to avulsion in 
adolescents aged 13-16 
years.
 During take-off or a jump, 
the quadriceps mechanism 
forcefully contracts against 
the patellar tendon 
insertion. When the force 
exceeds the strength of the 
tibial tubercle physis, a 
fracture is generated, 
leading to avulsion of the 
tibial tubercle.
 Indirect force caused by sudden 
contraction of the quadriceps 
muscle. 
 Acute passive flexion of the knee 
against a contracting quadriceps, 
such as landing after a jump (as in 
our case) is another mechanism of 
injury
 Osgood Schlatter 
 patella infera 
 tight hamstrings 
 disorders involving physeal abnormalities. 
 …
AUTHORS YEAR SEX AGE N Classification Circonstance Mechanism simultaneity TR last FU 
BORCH-MADSEN 1954 M 17 1 W-J TYPEIII ORIF 
OGDEN and coll 1980 M 14 1 W-J TYPEIII ORIF 
HENRARD et coll 1983 M 1 ORIF 
MAAR et coll 1988 M 16A 1 W-J TYPE III Basketball jump YES ORIF 3Y 
LEPSE et coll 1988 M 14A 1 W-J TYPE III Gymnast forward flip YES ORIF 1Y 
INOUE et coll 1991 M 16Y 1 W-J Type IV 
SIEBERT et coll 1995 M 16A 1 OGDEN 1B L 
+SALTER 2 R 
Athletism Starting YES ORIF 20W 
MIRLY and coll 1996 M 
MOSIER et coll 2000 M 15Y 1 OGDEN IIIB+ IV YES 
ERGUN et coll 2003 M 16Y 1 OGDEN 2B Bilat Basketball landing 
after 
forcefull 
jump 
YES ORIF 27M 
HAMILTON et coll 2006 M 13Y 1 TYPE I R+TYPE II L Soccer jump YES ORIF 
SLOBOGEAN et coll 2006 M 16Y 1 TYPE IV L+TYPE III 
R 
Running sudden stop YES L:Closed 
reduction 
R:ORIF 
1Y 6M 
GEORGIOU et coll 2007 M 17Y 1 W-J TYPE III Sport jump YES ORIF 
NEUGBAUER et coll 2007 M 16Y 1 OGDEN 3A bilat Gymnast jump YES ORIF 
ARREDONDO-GOMEZ 
et coll 
2007 M 14Y 1 OGDEN3 A R 
+OGDEN 3B G 
Soccer Indirect YES ORIF 
SCHAFFER et coll 2008 M 13Y 1 SALTER 2 R+ 
SALTER 3 L 
Long Jump take off and 
landing 
YES ORIF
 Male,13 - 17 y ,close to skeletal maturity. 
 Causal mechanism :sudden jump with a landing on the 
ground while contracting the quadriceps muscle. 
 According to the Watson-Jones and Ogden 
classifications, most cases were type IIIA or B. 
 The type III fractures involving a growth plate and 
extending through the articular surface, appear to do 
well following open reduction and internal fixation 
despite their bilateral nature. 
 No report of growth disturbance of the proximal tibial 
epiphysis after that type of injury.
 Recommandation for type III fracture: CT scan to 
evaluate the intraarticular surface. 
 Accurate diagnosis of the lesion is important to 
determine the appropriate treatment in order to 
avoid malfunction of the extensor mechanism of 
the knee in case of avulsion of the patellar 
ligament (type 1-C). 
 Open reduction with internal fixation (screw, 
wiring or K-wire) has been the common treatment 
for this type of lesion.
 Bilateral simultaneous avulsion fracture of the 
anterior tibial tubercle (ATT) are extremely rare. 
 We believe that treatment should always include 
open reduction and internal fixation for all type II 
or III lesions. 
 It appears from the literature that the recovery 
and functional outcome of bilateral injuries is 
comparable to those of unilateral tibial tubercle 
avulsion fractures: results have been good to 
excellent in most of the cases.
Avulsion simultanée bilatérale tubérosité tibiale antérieure

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Avulsion simultanée bilatérale tubérosité tibiale antérieure

  • 1. Robert ELBAUM Clinique Edith Cavell, Brussels, Erasme Universitary Hospital Belgium
  • 2.  Avulsion-fracture of the anterior tibial tubercle (ATT) occurs in adolescents, predominantly male.  Avulsion fracture of the ATT represents 3% of all injuries of the proximal tibia and 0.4 to 2.4% of all epiphyseal fractures .  From 1853 till now, more than 250 cases have been reported in the literature.
  • 3.  Simultaneous bilateral avulsion fractures of the tibial tubercle are very uncommon.  Since the first description by Borsch-Madsen in 1955 , 15 cases have been reported. Associated patellar ligament avulsion is also uncommon .  We report another bilateral case featuring these two rare injuries.  We will also discuss the appropriate classification, the aetiopathogenenesis of this injury and the proposed treatment.
  • 4.  a 16-year old boy  Following a jump on both feet.  2 swollen knees and a marked tenderness over the tibial tubercles.  Active extension was impossible bilaterally.  X-Ray :bilateral avulsion fracture of the tibial tubercle, type 3A according to Ogden’s classification.
  • 5.  L knee: complete avulsion of the tibial tuberosity with an intact patellar ligament. R knee: partial disruption of the patellar ligament  the fragments were reduced and fixed with two cannulated screws. The right patellar ligament was repaired.
  • 6.  Six months later the cannulated screws were removed in one day surgery.  1Y FU: no pain, no functional limitation and had resumed his sporting activity (judo).  X-Ray :complete remodeling of the tibial tubercle.
  • 7. WATSON-JONES (1976) OGDEN (1980) type I: avulsion fracture of the distal part of the tibial tubercle; type II: displacement of the lip of the anterior part of the tibial epiphysis. type III :fracture of the base of the lip with propagation into the knee joint. 3 subgroups A or B, with a possible intra-articular extension of the fracture as well as comminution of the fragment
  • 8.  In 1990, Frankl described two cases of ATT avulsion-fracture associated with avulsion of the patellar ligament. He proposed an addition to the classification to include avulsion of the patellar ligament (Type I-C).  Ryu and Debenham subsequently added a fourth type corresponding to an extension of the fracture to the posterior cortex through the growth plate (Salter Harris type 2).
  • 9.  The tibial tubercle physis is in continuity with that of the tibial plateau. The physis progressively fuses from posterior to anterior, making it most vulnerable to avulsion in adolescents aged 13-16 years.
  • 10.  During take-off or a jump, the quadriceps mechanism forcefully contracts against the patellar tendon insertion. When the force exceeds the strength of the tibial tubercle physis, a fracture is generated, leading to avulsion of the tibial tubercle.
  • 11.  Indirect force caused by sudden contraction of the quadriceps muscle.  Acute passive flexion of the knee against a contracting quadriceps, such as landing after a jump (as in our case) is another mechanism of injury
  • 12.  Osgood Schlatter  patella infera  tight hamstrings  disorders involving physeal abnormalities.  …
  • 13.
  • 14. AUTHORS YEAR SEX AGE N Classification Circonstance Mechanism simultaneity TR last FU BORCH-MADSEN 1954 M 17 1 W-J TYPEIII ORIF OGDEN and coll 1980 M 14 1 W-J TYPEIII ORIF HENRARD et coll 1983 M 1 ORIF MAAR et coll 1988 M 16A 1 W-J TYPE III Basketball jump YES ORIF 3Y LEPSE et coll 1988 M 14A 1 W-J TYPE III Gymnast forward flip YES ORIF 1Y INOUE et coll 1991 M 16Y 1 W-J Type IV SIEBERT et coll 1995 M 16A 1 OGDEN 1B L +SALTER 2 R Athletism Starting YES ORIF 20W MIRLY and coll 1996 M MOSIER et coll 2000 M 15Y 1 OGDEN IIIB+ IV YES ERGUN et coll 2003 M 16Y 1 OGDEN 2B Bilat Basketball landing after forcefull jump YES ORIF 27M HAMILTON et coll 2006 M 13Y 1 TYPE I R+TYPE II L Soccer jump YES ORIF SLOBOGEAN et coll 2006 M 16Y 1 TYPE IV L+TYPE III R Running sudden stop YES L:Closed reduction R:ORIF 1Y 6M GEORGIOU et coll 2007 M 17Y 1 W-J TYPE III Sport jump YES ORIF NEUGBAUER et coll 2007 M 16Y 1 OGDEN 3A bilat Gymnast jump YES ORIF ARREDONDO-GOMEZ et coll 2007 M 14Y 1 OGDEN3 A R +OGDEN 3B G Soccer Indirect YES ORIF SCHAFFER et coll 2008 M 13Y 1 SALTER 2 R+ SALTER 3 L Long Jump take off and landing YES ORIF
  • 15.  Male,13 - 17 y ,close to skeletal maturity.  Causal mechanism :sudden jump with a landing on the ground while contracting the quadriceps muscle.  According to the Watson-Jones and Ogden classifications, most cases were type IIIA or B.  The type III fractures involving a growth plate and extending through the articular surface, appear to do well following open reduction and internal fixation despite their bilateral nature.  No report of growth disturbance of the proximal tibial epiphysis after that type of injury.
  • 16.  Recommandation for type III fracture: CT scan to evaluate the intraarticular surface.  Accurate diagnosis of the lesion is important to determine the appropriate treatment in order to avoid malfunction of the extensor mechanism of the knee in case of avulsion of the patellar ligament (type 1-C).  Open reduction with internal fixation (screw, wiring or K-wire) has been the common treatment for this type of lesion.
  • 17.  Bilateral simultaneous avulsion fracture of the anterior tibial tubercle (ATT) are extremely rare.  We believe that treatment should always include open reduction and internal fixation for all type II or III lesions.  It appears from the literature that the recovery and functional outcome of bilateral injuries is comparable to those of unilateral tibial tubercle avulsion fractures: results have been good to excellent in most of the cases.