What is the recommended treatment for a 12-year-old patient with a tibial tubercle fracture, considering potential growth plate involvement?

Treatment of Tibial Tubercle Fracture in a 12-Year-Old

Displaced tibial tubercle fractures in a 12-year-old require open reduction and internal fixation (ORIF) with screw fixation, while non-displaced fractures can be managed with immobilization alone. 1, 2

Initial Assessment and Classification

• Obtain AP and lateral radiographs of the knee immediately to classify the fracture using the Ogden/Watson-Jones system and determine displacement 2
• Assess for compartment syndrome urgently - this occurs in approximately 20% of cases and requires immediate fasciotomy if present (look for pain out of proportion, tense swelling, pain with passive stretch) 2
• Examine for associated injuries including patellar ligament avulsion (occurs in ~40% of displaced fractures) and meniscal tears (occurs in ~25% of displaced fractures) 1
• Document any history of pre-existing Osgood-Schlatter disease, present in approximately 15-25% of patients with tibial tubercle fractures 1, 2

Treatment Algorithm Based on Displacement

Non-Displaced Fractures (Type IA)

• Treat with cast immobilization in extension for 4 weeks 1
• These fractures have excellent outcomes with orthopedic treatment alone and should be considered a separate entity 1
• No complications are expected with this approach 1

Displaced Fractures (Types IB, II, III, IV)

• Perform ORIF with anterior-to-posterior screw fixation as the primary treatment 1, 2, 3
• Type IV fractures (with posterior metaphyseal extension) may require supplemental plate fixation to adequately stabilize the proximal tibia - this variant accounts for 18.5% of all tibial tubercle fractures 3
• Consider arthroscopic-assisted techniques to identify and address associated meniscal injuries or intra-articular pathology 2
• Repair any patellar ligament avulsions identified during surgery - these are common associated injuries that must be addressed for optimal outcome 1, 4

Postoperative Management

• Immobilize for approximately 4 weeks postoperatively (range 3-7 weeks depending on fracture stability) 1, 2
• Begin range of motion exercises at 4-5 weeks after surgery 2
• Allow return to sports at approximately 4 months postoperatively once full range of motion and strength are restored 2
• Monitor closely for compartment syndrome in the immediate postoperative period as this remains a significant concern 2

Critical Pitfalls to Avoid

• Do not attempt closed reduction for displaced fractures - three patients in one series lost reduction after closed treatment and required subsequent ORIF 1
• Do not miss associated soft tissue injuries - failure to identify and repair patellar ligament avulsions or meniscal tears leads to poor functional outcomes 1
• Do not underestimate Type IV fractures - these require careful assessment and often need supplemental plate fixation beyond standard screw fixation 3
• Maintain high suspicion for compartment syndrome both at presentation and postoperatively, as delayed recognition leads to permanent complications 2

Expected Outcomes

• Non-displaced fractures have universally excellent outcomes with orthopedic treatment 1
• Displaced fractures have good-to-excellent outcomes in approximately 60% of cases after surgical treatment, with complications occurring in about 40% including stiffness, hardware pain, and growth disturbances 1, 2
• Growth disturbances are rare when anatomic reduction is achieved 3