Tibial Spine Fracture and Physical Therapy Protocol: Difference between revisions
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<div class="editorbox"> '''Original Editor '''- [[User:Ruchi Desai|User Name]] '''Top Contributors''' - {{Special:Contributors/{{Tibial Spine Fracture and Physical Therapy Protocol}}}}</div> | |||
== '''Introduction''' == | == '''Introduction''' == | ||
Tibial spine fracture (also called Tibial Eminence Fracture) is a break at the top of the tibia bone in the lower leg near the knee as a result of high amounts of tension placed upon the anterior cruciate ligament (ACL). This type of injury is most common in | Tibial spine fracture (also called Tibial Eminence Fracture) is a break at the top of the tibia bone in the lower leg near the knee as a result of high amounts of tension placed upon the anterior cruciate ligament (ACL). This type of injury is most common in | ||
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2) The incidence of these fractures is higher among adolescent girls due to their inherent skeletal immaturity. | 2) The incidence of these fractures is higher among adolescent girls due to their inherent skeletal immaturity. | ||
3) It has also been proposed that injury occurs secondary to greater elasticity of ligaments in young people . | 3) It has also been proposed that injury occurs secondary to greater elasticity of ligaments in young people. | ||
4) It can occur during a sporting event or direct trauma with a hyperextension injury causes an avulsion fracture occurring at the tibial eminence while the ACL is spared. | 4) It can occur during a sporting event or direct trauma with a hyperextension injury causes an avulsion fracture occurring at the tibial eminence while the ACL is spared. | ||
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=== Classification and Management for Tibial spine fracture === | === Classification and Management for Tibial spine fracture === | ||
Under the Meyers and McKeever system (with modifications by Zaricznyj) injuries are classified into four main types: | Under the Meyers and McKeever system (with modifications by Zaricznyj) injuries are classified into four main types: | ||
* '''Type I is the minimal displacement of an avulsed fragment:''' | * '''Type I is the minimal displacement of an avulsed fragment:''' This injury is treated conservatively by closed reduction, where the tibia is set into place without a surgical incision. and then the knee is immobilized in a long-leg cast or a fracture brace set at 10 to 20 degrees of knee flexion. Fixed flexion is recommended due to the fact that full extension may place excessive tension on the ACL and popliteal artery. Immobilization is then recommended for approximately 6 weeks depending on the patient's age, healing rate, and radiological findings. | ||
* '''Type II classification is the displacement of half | * '''Type II classification is the displacement of half of the anterior third of the ACL insertion causing a posterior hinge:''' In most cases, closed reduction and immobilization may be attempted after aspirating knee haemarthrosis. Knee extension allows femoral condyles to reduce the displaced fragment. If acceptable reduction is achieved conservative management should be continued. If there is persistent superior displacement of the fragment seen in the x-ray then it is preferable to do arthroscopic reduction and internal fixation because chances for soft tissue entrapment at the fracture site are high. | ||
* '''Type III is the complete separation of the avulsion site:''' | * ''' Type III is the complete separation of the avulsion site:''' | ||
* '''Type IV was later added by Zariczynj | * '''Type IV was later added by Zariczynj to include comminuted fractures of the tibial spine:''' Type III & Type IV Treatment of displaced tibial spine avulsion fractures has evolved over a period of time from conservative management to open reduction and internal fixation to arthroscopic reduction and internal fixation. Various methods of fixation are used in the operative treatment of these fractures varying from retrograde wires /screws, antegrade screws, sutures, suture anchors, and a recently described suture bridge and K wire and tension band wiring technique. | ||
=== Post -Operative Rehabilitation === | === Post-Operative Rehabilitation === | ||
{| class=" | {| class="wiki table" | ||
|+ | |+ | ||
! | ! | ||
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'''(0-6 Weeks)''' | '''(0-6 Weeks)''' | ||
| | | | ||
* Protect fracture fixation with the use of brace and specific exercises. | * Protect fracture fixation with the use of a brace and specific exercises. | ||
* Minimize effects of immobilization, inflammation & edema (ice x2 weeks) | * Minimize effects of immobilization, inflammation & edema (ice x2 weeks) | ||
* Advance to Full WB, wean off crutches, obtain motion | * Advance to Full WB, wean off crutches, obtain motion | ||
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* Quad sets, Hamstring curls, Heel slides | * Quad sets, Hamstring curls, Heel slides | ||
* Non-weight bearing stretching of Gastro-Soleus | * Non-weight bearing stretching of Gastro-Soleus | ||
* Straight-leg raise with brace in full extension until quad strength returns (no extension lag | * Straight-leg raise with a brace in full extension until quad strength returns (no extension lag | ||
|- | |- | ||
|'''Phase II: (Weeks 7-12)''' | |'''Phase II: (Weeks 7-12)''' | ||
| | | | ||
* Maintain full extension, obtain full flexion | * Maintain full extension, obtain full flexion | ||
* Increase hip, quadriceps,hamstring and calf strength | * Increase hip, quadriceps, hamstring, and calf strength | ||
* Increase proprioception | * Increase proprioception | ||
| | | | ||
* Begin unlocking in 30⁰ increments (every 3-4 days) after Week 6. | * Begin unlocking in 30⁰ increments (every 3-4 days) after Week 6. | ||
* Unlocked when weight bearing by the start of Week 8. | * Unlocked when weight-bearing by the start of Week 8. | ||
* Discontinue after Week 8 (once patient has full extension and no lag) | * Discontinue after Week 8 (once the patient has full extension and no lag) | ||
| | | | ||
* | * | ||
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* Begin straight-ahead, treadmill running after Week 12 | * Begin straight-ahead, treadmill running after Week 12 | ||
* Continue flexibility and ROM exercises as appropriate for patient | * Continue flexibility and ROM exercises as appropriate for a patient | ||
* Progressive hip, quad, hamstring and calf strengthening (Mini-Wall Squats (0-60⁰) , Lateral Lunges & Step-Ups , Hip Abduction/Adduction Short-Arc Leg Press) | * Progressive hip, quad, hamstring, and calf strengthening (Mini-Wall Squats (0-60⁰) , Lateral Lunges & Step-Ups , Hip Abduction/Adduction Short-Arc Leg Press) | ||
* Cardiovascular/endurance training via stair master, elliptical and bike Advance proprioceptive activities and agility drills | * Cardiovascular/endurance training via stair master, elliptical and bike Advance proprioceptive activities and agility drills | ||
|- | |- |
Revision as of 13:06, 29 July 2023
Introduction[edit | edit source]
Tibial spine fracture (also called Tibial Eminence Fracture) is a break at the top of the tibia bone in the lower leg near the knee as a result of high amounts of tension placed upon the anterior cruciate ligament (ACL). This type of injury is most common in
1) children ages 8 to 14 years of age.
2) The incidence of these fractures is higher among adolescent girls due to their inherent skeletal immaturity.
3) It has also been proposed that injury occurs secondary to greater elasticity of ligaments in young people.
4) It can occur during a sporting event or direct trauma with a hyperextension injury causes an avulsion fracture occurring at the tibial eminence while the ACL is spared.
This type of force causes the ACL to pull on the tibial spine. Because the bones of children this age still have open growth plates, the ACL is stronger than the tibial spine and can pull away from the bone (avulse), causing a fracture.
Classification and Management for Tibial spine fracture[edit | edit source]
Under the Meyers and McKeever system (with modifications by Zaricznyj) injuries are classified into four main types:
- Type I is the minimal displacement of an avulsed fragment: This injury is treated conservatively by closed reduction, where the tibia is set into place without a surgical incision. and then the knee is immobilized in a long-leg cast or a fracture brace set at 10 to 20 degrees of knee flexion. Fixed flexion is recommended due to the fact that full extension may place excessive tension on the ACL and popliteal artery. Immobilization is then recommended for approximately 6 weeks depending on the patient's age, healing rate, and radiological findings.
- Type II classification is the displacement of half of the anterior third of the ACL insertion causing a posterior hinge: In most cases, closed reduction and immobilization may be attempted after aspirating knee haemarthrosis. Knee extension allows femoral condyles to reduce the displaced fragment. If acceptable reduction is achieved conservative management should be continued. If there is persistent superior displacement of the fragment seen in the x-ray then it is preferable to do arthroscopic reduction and internal fixation because chances for soft tissue entrapment at the fracture site are high.
- Type III is the complete separation of the avulsion site:
- Type IV was later added by Zariczynj to include comminuted fractures of the tibial spine: Type III & Type IV Treatment of displaced tibial spine avulsion fractures has evolved over a period of time from conservative management to open reduction and internal fixation to arthroscopic reduction and internal fixation. Various methods of fixation are used in the operative treatment of these fractures varying from retrograde wires /screws, antegrade screws, sutures, suture anchors, and a recently described suture bridge and K wire and tension band wiring technique.
Post-Operative Rehabilitation[edit | edit source]
Goals | Brace | Weight Bearing | ROM | Exercises | |
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Phase -I
(0-6 Weeks) |
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Phase II: (Weeks 7-12) |
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Phase III: (Weeks 13-18) |
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Phase IV: (Months 5-6 )- Return to Sport |
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