Pediatric Tibia Eminence and Tubercle Fractures

Pediatric Tibia Eminence and Tubercle Fractures

Prepared by Dr. Mehmet Yagiz YENIGUN

Pediatric tibial eminence (spine) fractures and tibial tubercle fractures are two distinct injury patterns in growing knees. They differ in mechanism, age groups, treatment approach, and complications. Understanding classification, imaging, surgical indications, and outcomes is crucial for optimal care.

Epidemiology & Mechanism

Feature	Tibial Eminence Fractures	Tibial Tubercle Fractures
Age group	~ 8–14 years (mid‐childhood / early adolescence)	Adolescents, often near skeletal maturity
Sex predilection	Slight male predominance	Much more common in males
Typical mechanism	Sports injury, hyperextension or twisting; anterior cruciate ligament (ACL) avulsion equivalent	Forceful quadriceps contraction (e.g. jumping, sprinting), sudden extension under load

Clinical Presentation

• Hemarthrosis, pain, swelling in knee region
• Tenderness localized to tibial eminence / tubercle
• Extension lag or inability to fully extend knee (especially in eminence fractures if “block”)
• Difficulty walking/weight bearing (more so in tubercle avulsions)

Imaging

• Plain Radiographs: AP + lateral knee. Lateral view critical for displacement and fragment relation.
• MRI: for eminence fractures—to assess entrapped meniscus, ACL status; also helpful in tubercle injuries to see growth plate (physis) involvement.
• CT: when intra‐articular extension or comminution of tubercle fragment, or when radiograph doesn’t clearly show the fragment orientation.

Classification

Tibial Eminence Fractures – Meyers & McKeever Classification

Type	Description
Type I	Nondisplaced (minimal or no elevation)
Type II	Partially displaced, with intact posterior hinge
Type III	Completely displaced fragment
Type IV (Zaricznyj)	Comminuted fragment

Tibial Tubercle Fractures – Ogden Classification (Watson-Jones modification)

Type	Description
Type I	Through secondary ossification center (tubercle tip)
Type II	Into proximal tibial physis but tibial plateau not involved
Type III	Intra-articular extension into knee joint / tibial plateau involvement (most common type)
Type IV	Complete avulsion including tubercle and part of physis
Type V	Periosteal sleeve avulsion or more complex variant

Treatment Principles

Non-operative vs Operative Management

Injury Type / Displacement	Recommended Treatment
Eminence Type I	Immobilization (knee in extension or slight flexion) for ~4–6 weeks + protected weight bearing
Eminence Type II	Attempt closed reduction; if unsuccessful or mechanical block persists → surgical fixation (arthroscopic)
Eminence Type III & IV	Surgical fixation (arthroscopic / open as needed)
Tubercle Type I (nondisplaced)	Cast immobilization (extension) and gradual mobilization
Tubercle Type II-V (displaced or intra-articular)	Open Reduction & Internal Fixation (ORIF) with screws, tension band, etc.

Surgical Indications

• Displacement > ~2 mm, or any intra-articular step-off
• Mechanical block to knee extension (eminence)
• Closed reduction attempts that fail (eminence Type II)
• Open fractures
• Associated compartment syndrome risk (tubercle)
• Physeal involvement that risks growth plate damage

Complications (Short- and long-term)

• Arthrofibrosis – especially in eminence fractures if immobilization too long or inadequate rehabilitation
• Residual laxity (ACL function compromised or healing suboptimal)
• Growth disturbances (rare but possible in tubercle fractures when physis involved)
• Compartment syndrome – particularly relevant in acute tubercle avulsions
• Prominent tubercle / bursitis or cosmetic deformity

Prognosis

• With proper treatment, most eminence and tubercle fractures heal well, with return to pre-injury activity.
• Delay in reduction / fixation, or inadequate rehabilitation, increases risk of stiffness, limited extension.
• Physeal involvement or complications (growth arrest, deformity) more likely in tubercle fractures if mismanaged.

Key Takeaways (Spot Facts)

• Eminence fractures are pediatric ACL‐avulsion equivalents; mechanical block & meniscal entrapment must be sought.
• Tubercle fractures occur near skeletal maturity, risk of compartment syndrome must be considered.
• Displacement, intra-articular extension, physis involvement are red flags → favor surgical treatment.
• Early mobilization (once stable) is critical to prevent stiffness.

References

1. Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1959;41(2):209-222.
2. Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am. 1980;62(2):205-215.
3. 3.Kocher MS, Micheli LJ, et al. Tibial eminence fractures in children: prevalence of meniscal entrapment. J Pediatr Orthop. The American journal of sports medicine, 31(3), 404