Medical Management of Adolescent Athletic Knee Fractures
is a 13-year-old middle school student who was admitted to Antelope Valley hospital complaining of severe pain in the right knee while playing football in his Physical Education class at school. As the patient turned to run for a pass, he twisted his right knee and fell to the ground. C.W. reports that he immediately felt a snapping and popping sensation at his right knee and experienced severe pain. The patient’s knee began to swell and deform following his fall, and he was unable to bear weight. The coach for the Physical Education class called 911, and C.W. was transported by ambulance to Antelope Valley Hospital. X-rays taken in the Emergency Room revealed that the patient had sustained a right proximal tibia fracture. A basic metabolic panel, blood cell profile, PTINR, and PTT were all completed on the patient. C.W.’s labs were all normal, with the exception of his white blood cell count on his blood profile, which was slightly elevated at 14.1 x 10^9/L. No past traumas or pre-existing conditions were reported prior to the knee injury.
Incidence of Medical Diagnosis
X-rays showed that the patient had sustained a complex Salter-Harris type II fracture involving the anterior aspect of the proximal right tibia with elevation of the tibia tuberacle and anterior epiphysis. Adirim and Cheng (2003) report that the areas of the body most commonly injured in young athletes are the ankle and the knee, followed by injuries to the hand and wrist, elbow, shin and calf, head, neck, and clavicle. Moreover, the incidence of emergency department visits for sports-related injuries peaks at roughly averages 2.6 million for individuals aged 5 years to 24 years (Adirim and Cheng, 2003). Experts estimate that approximately 34% of all middle school aged youth will sustain an injury related to sports activity that will need to be treated by a doctor or nurse (Adirim and Cheng, 2003). With respect to apophasis in young athletes, the insertion of the patella tendon on the tibial tubercle is one of the most common sites of injury (Adirim and Cheng, 2003). Moreover, the mechanism of injury for ankle injuries and Salter-Harris type I and type II injuries are the same, the knowledge of which should trigger consideration of these types of injuries in the case of open physes (Adirim and Cheng, 2003). Acute tibial tubercle avulsion fractures are uncommon in adolescents who engage in sports when they have achieved the end of their growth between 14 and 17 years of age (Zrig, et al., 2008). This type of injury occurs in about 3% of the proximal tibial fractures and the incidence rate is about 1% of all physical injuries (Zrig, et al., 2008). The injury sustained by C.W. aligns with available data regarding incidence by age group and activity level / activity type.
Genetic Implications
There is some evidence of an association of patellar femoral pain syndrome (PFPS) and slipped capital femoral epiphysis (SCFE) of the hip in pre-adolescent and early adolescent age groups, with incidence rates higher for boys who are overweight and who are African-American (Adirim and Cheng, 2003). Two considerations with regard to any possibility of an underlying condition include the following: C.W. weighs 190 pounds, which is heavy for his 5-foot, 4-inch frame and C.W. is Hispanic. The family history does not present any conditions, such as osteoporosis, genetic conditions, or bone-affecting cancers, that would be of concern. There is, beyond his disproportionate body weight, with a body mass index of 32.6, no evidence that C.W. had a pre-existing condition that would have increased his risk of this type of knee injury.
Pathophysiology of Medical Diagnosis
There is evidence that an ongoing history of Osgood-Schlatter’s disease is associated with this type of injury (Zrig, et al., 2008). Osgood-Schlatter’s disease is considered to be a common pathology in individuals aged 10 to 14 years (Zrig, et al., 2008). Regardless, a fracture of the anterior tibial tuberosity and Osgood-Schlatter’s disease must be considered to be two different pathologies (Zrig, et al., 2008). Osgood-Schlatter’s affects the anterior part of the epiphysis and/or the ossification center of the tuberosity, while a fracture of the anterior tibial tuberosity brings about a tuberosity separation. It is important to note that the histological changes occurring during Osgood-Schlatter’s disease can cause an alteration of the biomechanical qualities of cartilage and predispose it to disruption (Zrig, et al., 2008). Meniscal damage is the most common injury that occurs in combination with an avulsion fracture of the anterior tibial tuberosity and patellar tendon disruption (Zrig, et al., 2008).
Analysis of Clinical Manifestations
Commonly, fractures may present a constellation of manifestations, including the following: Pain, loss of function, deformity, swelling, bruising, abnormal mobility and crepitus, neurovascular changes, muscle spasm, tenderness, and shock (Black and Hawk, 2009). Patients who sustain a complex Salter-Harris type II fracture involving the anterior aspect of the proximal right tibia with elevation of the tibia tuberacle and anterior epiphysis are likely to manifest a number of common symptoms. Invariably, the patient will express the presence of severe pain in the proximal tibial metaphyseal area (Zrig, et al., 2008). A patient with this type of injury will not be able to bear weight on the injured leg (Zrig, et al., 2008). The area around the knee will be diffusely swollen (Zrig, et al., 2008). C.W. manifested the following upon the day of admission to the hospital for treatment: Pain, deformity, swelling, abnormal mobility, tenderness, distally capillary refill okay, right knee skin intact, and able to clear toes (DF) and able to push off (PF) toes. Upon examination, the patient was unable to move his right knee as any movement of the right knee caused sharp and severe pain, nor was the patient able to bear weight with the right extremity. There was evidence of swelling of the right leg, with capillary refill at less than 3 seconds, and all lower extremities pulses were intact. C.W.’s right leg was tender and warm to the touch. The patient was able to wiggle his toes and able to DFlex and PFlex his toes and his foot.
Fractures of tibial tuberosity frequently occur as a result of an injury sustained while playing sports (Zrig, et al., 2008). Commonly, there is direct mechanism, such as an abrupt contraction of the patellar tendon or a violent extension of the leg as the result of a jump impulse, or a more indirect mechanism, such as a reflex contraction against abrupt knee flexion (Zrig, et al., 2008). C.W.’s description of the mechanism of injury during his football activity aligns with the mechanisms revealed in the literature in association with this type of injury; that is, a complex Salter-Harris type II fracture involving the anterior aspect of the proximal right tibia with elevation of the tibia tuberacle and anterior epiphysis.
Analysis of Laboratory and Diagnostic Tests / Values
An X-ray of the right knee was ordered to verify accuracy of the diagnosis of a complex Salter-Harris type II fracture involving the anterior aspect of the proximal right tibia with elevation of the tibia tuberacle and anterior epiphysis. It was imperative to learn how much trauma was sustained during the injury and radiography is a reliable, noninvasive test for detecting abnormalities in bones. However, since radiography does not reveal abnormalities in soft tissues, tendons, or ligaments, an MRI was also the ordered. An MRI utilizes large magnets to create a detailed image of soft tissue and of bone. Since the fracture typically involves the anterior aspect of the physis and the tibial tuberosity apophysis, an MRI was indicated. Specifically, the MRI would indicate whether the patient had injured the tibia and/or the fibula when he fell. The MRI revealed that the apophysis was not fractured and that the patellar tendon was still attached to the apophysis. Neither computerized tomography nor laminagrams were ordered for the diagnosis of C.W.’s injury (Dias, et al., 1983). Computerized tomography is type of x-ray that provides “slices” of imagery of an area of the body, thereby enabling a more detailed look at a joint with a complex break (Dias, et al., 1983). Laminagrams are x-rays in which the tissues above and below the level of the break are blurred in order to hone in on or emphasize a particular area (Dias, et al., 1983). Laminagrams can be useful to determine if there are fragments in the break and also to check to see if the reduction is adequate (Dias, et al., 1983). However, given the age of the patient, and the adequacy of the reports obtained through the use the x-ray and MRI tests, other diagnostic tests were neither indicated nor warranted. Additionally, lab tests were ordered to determine the existence of any underlying conditions that might have impact on the course of treatment. Lab tests ordered for C.W. include a basic metabolic battery, a blood cell profile, the PTINR, and the APTT. Specifically, the injury required surgery so tests were ordered to ascertain if the patient would heal adequately following the surgery.
Treatments: Standards of Care Per Literature
The patient required a surgical intervention to repair the bone damage that occurred when he fell and twisted his knee playing football. Open Reduction Internal Fixation (ORIF) was employed to make the repair. The ORIF procedure includes the use of implants to support and guide the healing process of the broken bones. Moreover, the ORIF procedure aid in the setting of the bone and in the open reduction. Open reduction is the notation for the open surgery used to set broken bones — a process that is necessary for some types of fractures. Internal fixation is the notation for fixing plates or screws in intramedullary bone nails, such as the femur, tibia, humerus, to facilitate or enable healing (Black & Hawk, 2009). Following surgery, the treatments included medication and procedures for pain control, including RICE, sequential compression devices (SCD), incentive spirometry, and parenteral analgesics. The conventional Rest-Ice-Compress-Elevate (RICE) treatment is a nonpharmacological approach to reducing pain and inflammation (Ackley & Ladwig, 2011). Sequential compression devices were used to reduce the risk of blood clots forming in the lower extremities (Ackley & Ladwig, 2011). Incentive spirometry was used to ensure that the patient would fully expand his lungs and thereby prevent the occurrence of atelectasis while he was in recovery and fundamentally immobile (Ackley & Ladwig, 2011). Effective pain control supports and expedites healing. For this reason, nonopioid and opioid drugs were used according to the patient’s self-report pain tool and the standards for a patient of his age who has undergone surgical repair of the tibia (Ackley & Ladwig, 2011). Antibiotics were also prescribed for the patient to prevent post-operative infection (Ackley & Ladwig, 2011).
Potential Long-Term Effects / Complications
The patient was instructed to take the prescribed number of antibiotics until they were all consumed (Bowden & Greenberg, 2010). Wound care was accomplished first in the hospital setting and then at home. The surgical site needed to be protected for a minimum of six weeks, so the patient and his parents were taught procedures for ensuring adequate wound protection while C.W. healed (Stavlas, et al., 2010). Moreover, the patient was taught how to use crutches so that he could be safely ambulatory at home and as he ventured out (Stavlas, et al., 2010). Most patients — reportedly 82.3% — who undergo ORIF surgery heal without complications and have results that are considered to be good or excellent by their physicians and by the patients (Stavlas, et al., 2010). Signs that healing was not progressing well include issues with infection, including persistent bone or bone marrow infection, disruption of bone growth, incorrect position of the repair during healing (Nordqvist, 2009). No dietary restrictions were assigned though some mention was made of the importance of a balanced diet during recovery to promote healing, and later on to help bring C.W.’s body weight down to more athletic proportions.
References
Adirim, T.A. And Cheng, T.L. (2003). Overview of injuries in the young athlete. Sports Medicine, 33(1), 75-81.
Ackley, B. And Ladwig, G. (2003, 2011). Nursing diagnosis handbook: An evidence-based guide to planning care. St. Louis, MO: Mosby, Inc.
Black, J. And Hawks, J. (2009). Medical-surgical nursing. St. Louis, MO: Sanudners.
Bout-Tabuku, S. And Best, T.M. (2010). The adolescent knee and risk for osteoarthritis: An opportunity or responsibility for sport medicine physicians? Sports Medicine Reports. Columbus, OH: American College of Sports Medicine.
Bowden, V. And Greenberg, C. (2010). Children and their families. Philadelphia, PA: Wolters Kluwer Health.
Dias, L. And Giegerich, S. (1983). Fractures of the distal tibial epiphysis in adolescence. The Journal of Bone and Joint Surgery, 65-A (4), 438-444.
Nordqvist, C. (2009, September 8). What is a fracture? What are broken bones? Medical News Today.
Stavlas, P., Roberts, C. Xypnitos, F. And Giannoudis, P. (2010). The role of reduction and internal fixation on listfranc fracture-dislocations: A systematic review of the literature. International Orthopedics. 34(8), 1083-1091. Doi: 10.1007/s00264-101-1101-x
Zrig, M., Annabi, H., Ammari, T., Trabelsi, M., Mbarek, M, and Hassine, H.B. (2008). Acute tibial tubercle avulsion fractures in the sporting adolescent. Archives of Orthopedic Trauma Surgery, 128, 1437-1442.
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