1 Introduction

Soccer is the most widely embraced sport globally and a highly popular sport that has seen a significant rise in participation.^1,2Avulsion fractures of the tibial tubercle are uncommon, occurring in about 0.4–2.7 % of cases, and they constitute 1 % of all physeal injuries.^3,4 Tibial tubercle fractures are a common injury in athletics, particularly among soccer players, basketball players, volleyball players, and high jumpers, often leading to the end of their careers.³

Avulsion fractures of the tuberosity occur when the knee is completely extended or at approximately 30° of flexion, and do not impact the proximal epiphysis of the tibia.⁴The intervention strategy consisted of performing open reduction and fixation using cannulated screws, as well as repairing the detached periosteum sleeve.⁴ The purpose of this study was to report two unusual occurrences of avulsion fracture of the tibial tuberosity in soccer players children who underwent successful surgical treatment.

2 Case presentation

2.1

2.1 Case: 1

A 15-year-old male presented to our orthopaedic emergency department after falling and injuring himself on his left knee during a soccer game. He had sustained a closed left knee injury that was very painful following a fall, and he was unable to extend his left knee joint. He was a young, healthy male with no known comorbidities and an isolated knee injury. He was clinically healthy and had normal vital signs on a clinical assessment. He had knee swelling, anterior tibial tuberosity tenderness, and difficulty extending or maintaining it. He had intact distal pulses and neurological status.

Knee x-rays revealed an anterior tibial tubercle avulsion fracture, which was classified as Ogden type IIB (Fig. 1). The patient underwent a surgical procedure that included open reduction and internal fixation of an avulsed fragment using two cannula screws, as well as augmenting the fixation with a single suture anchor (Fig. 1).

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Fig. 1 Plain radiographs, case 1. A: preoperative showing anterioposterior view and lateral view with type IIB fracture. B: Intraoperative showing a fixed fracture on both views.

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Postoperative management: We placed the patient on a range of motion brace, set at 0–30° for the first six weeks, then 30–90° for another two weeks. We allowed full range of motion, normal gait and core stability at the two-month follow-up. At the six-month follow-up, he had healed successfully and was back playing soccer without limitations (Fig. 2).

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Fig. 2 Postoperative radiographs at six-month follow-up of the left knee showed healed avulsion fractures of the tibial tubercle, and clinical images showing a range of motion.

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2.2

2.2 Case 2

A 15-year-old male presented with a similar history to Case 1, four days apart. He presented with a history of falling during a soccer match and sustained a left knee injury. He was unable to walk due to pain and swelling from the close injury. He had no known comorbidities and had an isolated knee injury. On physical examination, he was clinically well and had no neurological fallout. He had a left knee swelling, anterior tibial tuberosity tenderness, and difficulty extending or maintaining it. Systemic examination was unremarkable.

Left knee x-rays showed an anterior tibial tubercle avulsion fracture, which we classified as Ogden type IIB (Fig. 3). The patient underwent a surgical procedure that included open reduction and internal fixation of an avulsed fragment using two cannula screws, as well as augmenting the fixation with a single suture anchor similar to case 1 (Fig. 3).

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Fig. 3 Plain radiographs, case 2. A: preoperative showing anterioposterior view and lateral view with type IIB fracture. B: Intraoperative showing a fixed fracture on both views.

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The postoperative protocol mirrored that of case 1.This case healed without any complications related to soft tissues or bone. At 6 months review, the patient was back playing soccer without pain and full knee joint range of motion (Fig. 4).

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Fig. 4 Postoperative radiographs at six-month follow-up of the left knee showed healed avulsion fractures of the tibial tubercle, and clinical images showing a range of motion.

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3 Discussion

Tibial tubercle fractures are becoming more prevalent in adolescents who participate in sports, particularly in the male gender. Over 81 % of the injuries are sports-related injuries, mainly basketball, football, and soccer.⁵ With an injury incidence of 34.79 per 100,000 athlete exposures, more male mature soccer players are the most likely to experience traumatic extensor mechanism injuries.⁶ Fractures of the tibial tubercle are accompanied by associated injuries in approximately 10 % of cases.⁷ Acute compartment syndrome appears to be significantly less common (1.35 %) in the paediatric population with tibial tubercle fractures than previously believed.⁸

Adolescents are particularly susceptible to injuries due to their robust quadriceps muscles and the physis's susceptibility during the fusion process. Landing and jumping have a significant correlation with tibial tubercule avulsion fractures. The two suggested mechanisms of injury involve a forceful contraction of the quadriceps during knee extension while jumping or a passive flexion of the knee as the quadriceps contract upon landing on the ground.^9,10 Osgood-Schlatter disease and osteogenesis imperfecta increase the likelihood of tibial tuberosity fractures in patients.^7,8 In this study, the cases did not have any associated disease.

Ogden Classification is a modification of the Watson-Jones classification, developed by multiple authors since its original description. It has five categories with subclasses for displaced and comminution of the fragments.^3–5 We report two cases with Ogden type IIB tibial tubercle avulsion fractures.

Open reduction and internal fixation are universally acknowledged as the standard treatment, especially for patients with Ogden types IIB and greater.⁷ Effective treatment of tibial tubercle avulsion fractures results in favourable overall outcomes.⁷ Internal fixation techniques include pins fixation, screws fixation and sutures, and augmentation using suture anchors, wires, or fibre tapes.⁹ The two cases in this study underwent open reduction and internal fixation with screws, augmented with suture anchors.

Tibial tubercle fractures are not without complications, including neurological, osseous, physeal, hardware-associated joint stiffness, and infection.⁷ In 956 of cases, complications were reported to be 18 % and re-operations accounted for 19 % of cases.⁵ Our two cases showed no complications.

Return to preinjury activities following tibia tubercle fractures is reported to be high, with most patients resuming activities within six months for isolated knee injuries and seven months for bilateral knee injuries.^5,9,10 Tibial tubercle fractures demonstrate nearly 100 % excellent outcomes, with no limitations in the range of motion and the healing rate is stated to be 99 %.⁹ Early diagnosis and surgical intervention are associated with favourable clinical results and a return to sports participation.^1,3,7

4 Conclusion

Young soccer players encounter a considerable risk of enduring orthopaedic injuries. Early diagnosis of tibial tubercle avulsion fractures, with the exclusion of associated injuries, reduces complications. A knee joint injury in adolescents soccer player requires thorough evaluation and meticulous preoperative planning by an orthopaedic surgeon proficient in managing all related injuries to optimize early return to playing sports. It is important to note that despite the excellent outcomes associated with avulsion tibial tubercle fractures, patients still miss school days due to hospitalisation.

CRediT authorship contribution statement

Collen Sandile Nkosi: Conceptualization, participated in data collection, Methodology, Formal analysis, Writing – original draft, Writing – review & editing. Boikobo Reagan Modutlwa: Conceptualization, participated in data collection, Writing – review & editing.

Consent

The authors affirm that human research participants provided informed consent for publication of all data in the manuscript.

Ethic statement

Ethnical approval was received from the university of the Witwatersrand M240753.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.