Tibial Tubercle Fractures

Tibial tubercle fractures mean the injury and dislocation in the anatomy position of the tibial tubercle, where patellar ligament inserts are most frequently seen in sports that involve jumping activities times, dancing, tackling, driving the vehicle, football, cricket, basketball-playing, pressuring break during driving. Injury is caused by solid quadriceps contraction during knee extension such as jumping or by violent knee flexion against a tightly contracting quadriceps, such as landing from a jump [rx]. Damage can also take place during landing when the quadriceps contract and the knee flexes to absorb the impact of landing. [rx] The patellar ligament inserts on the secondary ossification center, which places the tibial tubercle at risk for an avulsion injury. [rx]

During ossification, calumniated cartilaginous cells with poor lastingness transiently replace the fibrocartilage, predisposing the tibial tuberosity to traction injury just before or during the later stages of physiologic epiphysiodesis. The mechanism of injury is typically an indirect force caused by a sudden contraction of the quadriceps muscle. The quadriceps mechanism forcefully contracts against the patellar tendon insertion during sudden acceleration and deceleration forces. When the power is more significant than the strength of the tibial tubercle physis, a fracture occurs, resulting in the avulsion of the tibial tubercle.

Classification

The Ogden classification modifies the original Watson-Jones classification and is commonly used to describe tibial tubercle avulsion fractures. The following types are subject to revision with an “A” signifying non-displaced fractures and “B” signifying displaced fractures:[rx]

  • Class I – fracture through the secondary ossification center
  • Type II – fracture extends to an area between secondary and primary ossification centers
  • Type III – fracture crosses through the secondary and primary ossification centers
  • Type IV – fracture through the proximal tibial physis
  • Type V – extensor mechanism avulsion

Goals for treatment include restoring the articular surface and function of the extensor mechanism.

Causes of Tibial Tubercle Fractures

Causes of Tibial Tubercle Fractures

  • The repetitive impact – to the lower limb bone with weight-bearing exercises occupational work cause microfractures, which consolidate to stress fractures. [rx]
  • Heavy impact – The force of a jump or fall from height can result in a broken ankle. It can happen in foot bone fractures even if you jump from a low altitude.
  • Missteps – You can cause a fracture of the ankle if you put your foot down awkwardly abnormally. Your ankle might twist or roll your foot joint to the side as you put weight on it. It can also happen in stare up or stare down unawkwardly.
  • Sports – High-impact sports such as football, cricket, hockey, volley boll involve intense movements that place stress on the joints, including the ankle bone fracture examples of high-impact sports include cricket, racer of the bike, soccer, football, Horseback riding, Hockey, Skiing Snowboarding In-line skating, Jumping on a trampoline and basketball.
  • Car collisions – The sudden, heavy impact of a car accident bike accident can cause metatarsal bone fractures. Often, these types of injuries need surgical repair. The crushing injuries common in car accidents may cause breaks that require surgical repair.
  • Falls from height – Tripping and falling when walking on uneven surfaces can break bones in your ankles and metatarsal bone, phalanges fractures, as can landing on your feet after jumping down from just a slight height, sudden landings from the plane in the war field, violent trauma, etc.
  • Driving and compressing in the break is one of the significant causes of foot microtrauma for the driver of the car, motorbike, truck, bus, and bicycle runner. During the time of driving, such kind of vehicle frequently has to compress breaks to maintain the vehicle’s speed. Repeated compression causes microtrauma, tendon, cartilage, ligament degeneration, and weakness that may lead to injury in the foot.
  • Missteps – Sometimes, just putting your foot down the wrong way can result in a twisting injury that can cause a broken bone. Fracture also occurs when stairs up or stairs down, especially older people.
  • Unconsciously Toilet Use – It is a widespread and daily increasing incidence of fracture of the ankle joint, foot bone, metatarsal bones, tarsal bone, phalanges, exceptionally high comodo using time and lower limb fractures.
  • High hell Use – It is the most common cause of fracture in the ankle, foot, lower limb fracture, especially for women, abnormal arch, foot angle, the lake of the flat foot, abnormal sole of your footwear, muscle, tendon, cartilage, ligament weakness in the knee, ankle joints.
  • With the increasing technology of nuclear weapons on a battlefield, one country is involved in the war from one country to another country. On the battlefield, millions of armies and general people are falling in injury that is gradually causing ankle, foot, metatarsal, tarsal bone fractures.
  • Have osteoporosis – a disease of your bone that weakens your bones gradually due to inadequate intake of calcium or vitamin D.
  • Weak low muscle mass or poor muscle strength – lack agility or older age muscle strength, mass, power, endurance become weak, and poor balance conditions make you more likely to fall and cause a fracture.
  • Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing, Skiing, Snowboarding, in-line skating, Jumping, playing lead to fracture of the bone in the lower limb.
  • Insufficient vitamin D and sunlight – Insufficient vitamin D and sunlight decrease the intestinal absorption of calcium, leading to abnormal regulation of parathyroid hormone (PTH). Vitamin D also works to upregulate the transcription of genes involved in neovascularization in areas of endochondral ossification, such as a healing fracture site. Vitamin D deficiency is typically characterized as a serum level of 25-hydroxyvitamin D3 of less than 20 ng/mL, and sufficiency is between 20 and 31 ng/mL.[rx]

Symptoms

Symptoms of Tibial Tubercle Fractures include

  • The first is intense pain, swelling, tenderness, and limited range of motion.
  • May present with pain, swelling, tenderness, hematoma directly over the mid-foot in athletes. Construction workers may present various pain and swell over the foot, worsening with exercise and walking.
  • Pain with or after regular activity
  • Pain that goes away when resting time and then returns when standing, walking, or during activity
  • Pinpoint pain at the site of the fracture when touched
  • Swelling but no bruising may be present if it becomes microtrauma.
  • Bruising or discoloration that extends to nearby parts of the foot bones.
  • Pain with walking and weight-bearing
  • Swelling in the heel area
  • Pain may decrease with rest but increases again with activity.
  • Pain at the fracture site, which in some cases can extend from the foot to the knee.
  • Significant swelling may occur along the length of the leg or may be more localized.
  • Blisters may occur over the fracture site after some days.
  • Bruising that develops soon after the injury time.
  • Inability to walk; it is possible to walk with less severe breaks and fractures, so never rely on walking as a test of whether or not a bone has been fractured.
  • Change in the color and appearance of the ankle will look different from the other ankle.
  • Bone protruding fracture through the skin signifies that immediate emergency care is needed. Fractures that pierce the skin require attention because they can lead to severe infection and take a prolonged time to recover.
  • This pain may occur or feel in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with discomfort or pain of worsening quality or duration over time.

Diagnosis of Tibial Tubercle Fractures

History

Your doctor in the emergency department may ask the following questions.

  • How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
  • When – How long has this fracture been present? (e.g., chronic less than one month or acute, more than six months)
  • What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
  • Where – Where on the body parts is it located? Is it a complex area to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
  • What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit, anabolic steroid uses for athletes, etc.?

Physical Examination

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.

  • Inspection – Your doctor also checks superficial tissue skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the fatty tissues or full-thickness opens through the dermis. Adipose exposes muscle; bone evaluates and measures the fracture’s depth, length, and width. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached, evaluate for signs and symptoms of infect warm, pain, and delayed healing.
  • Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture. Condition of the surrounding skin and soft tissue, quality of vascular perfusion and pulses, and the integrity of nerve function.
  • Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means that the muscles and tendons work correctly and do not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is incorrect. The jerk and manual tests are also performed to investigate the motor function.
  • Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side. Sensory 2-point discrimination
  • Range of motion – A range of motion examination of the fracture associate joint and its surrounding joint may help assess the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the communal injured area.
  • Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart. It is pressed, the toe turns white (capillary refill).

Lab Test

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

Imaging Test

  • X-Ray – Recommended views include an AP and lateral knee radiograph. Optional arguments have an indoor rotation view bringing the tibial tuberosity into profile or a contralateral knee radiograph for comparison widening of open apophysis typically demonstrating a displacement of proximal apophysis hemarthrosis if there’s an intra-articular extension patella Alta.
  • CT Scan –  Given these findings, computerized tomography (CT) is the gold standard for diagnosis, though only 91% of fractures were adequately evaluated with a CT scan at A level trauma center. CT should be a part of routine surveillance of ankle injuries that have swelling and pain disproportionate to radiographic findings, as 6.9% of talus fractures were undiagnosed at the time of presentation. Even when an x-ray demonstrates the fracture pattern, CT provides additional information on the degree of comminution, articular involvement, and surgical planning.

Treatment of Tibial Tubercle Fractures

Initial Treatment Includes

  • Get medical help immediately – If you fall on an outstretched leg, play cricket, get into a car accident, or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in your leg, foot, ankle joint, and part of your leg closer to the base of your shank. If the accident is substantial, you keep your leg at the same heart position and then clean and treat any wounds on the skin of the injured leg.
  • Aggressive wound care – Patients must reach a safe position with the proper ventilation for contaminated wounds. Injured are clear with disinfectant material [rx]
  • ICE and elevation – It help for prevention swelling edema
  • Rest – Sometimes, rest is all that is needed to treat a traumatic fracture of the foot, ankle, tarsal and metatarsal fracture. Sometimes rest is the only treatment required to eradicate healing of a stress or traumatic fracture of a metatarsal bone fracture.
  • Compression – a bandage will limit swelling edema and help to rest the joint. A tubular compression bandage is frequently used but should be removed at night by easing it off gradually. Please put it on again before you are out of bed in the morning. Mild to moderate pressure that is not too uncomfortable or too tight, and does not stop blood flow, is ideal depending on the swelling. Pain, edema, you may be advised to remove the bandage for good after 48 hours.
  • Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot upright on a chair or pillow to at least hip level when sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in fractures.
  • Splinting – The toe may be fitted with a splint to keep it in a fixed position.
  • Rigid or stiff-soled shoes – Wearing stiff-soled solid shoes to protect the toe and help properly position it. A postoperative splint, shoe, or boot walker is also helpful.
  • Avoid the offending activity – Because fractures result from repetitive stress trauma, it is essential to avoid the movement that led to the rupture more seriously. Crutches, a wheelchair, or other types of supporting splint are sometimes required to offload weight from the foot to give it time to heal.
  • Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  • Casting or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  • Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is essential for healing. This may mean using crutches or even a wheelchair.

Do no HARM for 72 hours after injury.

  • Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc., has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to create, and warmth can be soothing.
  • Alcohol – stimulates the central nervous system, can increase bleeding and swelling, and decrease healing.
  • Running and movement – Running and walking may cause further damage and causes healing delay.
  • Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may soothe the pain.

Medication

Your doctor may consider the following medications to relieve acute and immediate pain long-term treatment.

What To Eat and What to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients to heal appropriately and promptly. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to repair your fracture correctly. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones or fractures need abundant minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
  • Essential vitamins that are needed for bone healing include vitamin C (needed to make collagen that your important body element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgery

Surgically treatment depends on the individual fracture characteristics, the size of fractures, the degree of displacement, the location, comminution, the condition of integrity of the soft tissues of the foot, the presence of associate bones, ligament injuries on the foot, comorbidities, and overall functional movement status. [rx]

References