Accepted Manuscript

Title: Classification of proximal tibial epiphysis fractures in

children: Four clinical cases

Author: B.R.J. Aerts B. ten Brinke T.S.C. Jakma B.J. Punt

PII: S0020-1383(15)00298-3
DOI: http://dx.doi.org/doi:10.1016/j.injury.2015.05.039
Reference: JINJ 6229

To appear in: Injury, Int. J. Care Injured

Received date: 5-4-2015

Accepted date: 14-5-2015

Please cite this article as: Aerts BRJ, ten Brinke B, Jakma TSC, Punt BJ, Classification
of proximal tibial epiphysis fractures in children: Four clinical cases, Injury (2015),
http://dx.doi.org/10.1016/j.injury.2015.05.039

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1 Classification of proximal tibial epiphysis fractures in children: four
2 clinical cases
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4 B.R.J. Aerts1, B. ten Brinke1, T.S.C. Jakma1, B.J. Punt1
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6 Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands

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15 Corresponding author:
16 B.R.J. Aerts
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17 Department of Surgery
18 Albert Schweitzer Hospital
19 P.O. Box 444
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20 3300 AK Dordrecht
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21 The Netherlands
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23 Tel: +31-78-6541111
24 Fax: +31-78-6541736
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25 basaerts@hotmail.com
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2 Classification of proximal tibial epiphysis fractures in children: four
3 clinical cases
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8 Keywords:

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9 Epiphysiolysis proximal tibia; tibial tuberosity, fractures, Watson Jones classification, treatment
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2 Abstract
3 Fractures of the proximal tibial epiphysis are not commonly seen and most often occur in young male
4 adolescents. In this article four cases of tuberosity fractures will be discussed. Also the
5 pathophysiology, classification, and treatment of these fractures will be outlined. An additional
6 modification of the Watson-Jones classification will be suggested by the authors.

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Introduction
Fractures of the proximal tibial epiphysis are rare and include 0.3-2.7% of all epiphysiolyses[1–7].
Usual mechanisms of trauma include external forces on the proximal tibia and flexion or torsion
injuries. Fractures of the proximal tibial epiphysis mostly occur in adolescents between 14 and 16
years and are more frequently diagnosed in boys than in girls ranging from 14:1 to 37:1[1, 5–9].
The classification of fractures of the proximal tibial epiphysis has first been described by Watson and

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Jones in 1955[10]. In the following years several authors made modifications to the original

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classification. Treatment of these type of fractures consists of conservative or surgical treatment
depending on the classification of the fracture.

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In this article, we describe four consecutive cases of adolescents seen on our Emergency Department
with epiphysiolyses of the proximal tibia. The treatment of this rare injury will be discussed, as well as

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the classification. An additional modification of the Watson-Jones classification will be suggested by
the authors.

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Cases
Case 1
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A 14-year old boy was brought into the Emergency Department with acute onset of pain in the left
knee that had started during a kick-off in a free running session. He was unable to bear weight on the
leg and the knee was significantly swollen. Because of the swelling and pain, a full physical
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examination was not possible. The neurovascular status was intact. Conventional radiographs of the
knee showed an epiphysiolysis of the apophysis of the tibial tuberosity and of the proximal tibia with
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dorsal angulation (Watson-Jones type IIIB, figure 1).

Open reduction and internal fixation was performed. Peroperatively, a large periosteal flap was found
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in the fracture, which was removed out of the fracture and later re-attached with sutures. The fracture
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was reduced, using two K-wires and two cannulated lag screws. In order to repair the knee extensor
mechanism a cable was led behind the insertion of the patellar tendon and then was fixed in a figure of
eight position through a drill hole in the anterior tibia.
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Postoperatively, patient was treated with a removable brace in extension for six weeks, followed by
full weight-bearing mobilisation. Eleven weeks after surgery, all osteosynthesis material was removed
and the patient continued the rehabilitation succesfully.

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Case 2
A healthy 17-year old boy was seen at the Emergency Department after he fell on his left knee, trying
to make a wheelie with his scooter. The knee was very painful at clinical examination and he was
unable to bear weight on his left leg. Radiographs of the knee showed a comminuted avulsion of the
apophysis and a fracture of the proximal epiphysis (Watson-Jones type IIIB, figure 2).
Open reduction and internal fixation was performed, using four lag screws. A large periosteal flap was

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fixed using vicryl sutures. After surgery, our patient was treated by non-weight bearing mobilisation

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for six weeks. Radiographic consolidation was seen after six weeks and patient started mobilisation,
without residual complaints.

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Case 3

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Another 14-year old boy presented at our Emergency Department with a painful right knee. During a
soccer game, he fell on the ground while he tried to kick the ball. At clinical examination, the knee

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was swollen and the lower leg was dorsally angulated. The neurovascular status of his lower leg was
not compromised. X-rays of the right knee showed an epiphysiolysis of the proximal tibia with dorsal
angulation. In addition, a fracture of the proximal fibula was seen (Watson-Jones type IV, Salter
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Harris type II). Surgery was performed on the same day. A cannulated screw and an additional K-wire
were used to secure the fracture parts (figure 3). After surgery, non-weight-bearing mobilisation was
prescribed for six weeks. After six weeks, he started weight-bearing mobilisation. Eight weeks
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postoperatively, the K-wire was removed. The screw was removed 8 months postoperatively and
patient was mobilising without residual functional impairment.
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Case 4
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A 16-year old boy was referred to the Emergency Department complaining of severe pain in his right
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lower leg, which arose acutely while he took-off for a smash in a volleyball game. He was unable to
stand on his right leg. At physical examination severe swelling was seen around the proximal tibia.
The pain was mainly located at the medial side of the tibial tuberosity. He was unable to actively
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elevate his extended leg. The neurovascular status was intact. A fracture of the proximal fibula and an
epiphysiolysis of the lateral tibial plateau were seen on conventional radiographs (Watson-Jones type
IV; Salter Harris type II). A CT-scan was performed preoperatively to provide more detailed images of
the fracture.
The fracture was reduced by closed reposition and two K-wires were used to secure the reposition.
After that, the fracture was fixated with two hollow screws. K-wires were removed after placement of
the screws (figure 4). A removable brace was applied for four weeks. After four weeks patient started
full weight-bearing. Eight weeks postoperatively, radiographs showed progressive fracture
consolidation and patient was able to mobilize without pain. The screws were removed 6 months
postoperatively.

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Discussion
In this article, four cases were presented of a rare fracture of the proximal tibial epiphysis. One of the
factors leading to these fractures of the tibial tuberosity in adolescents include the vulnerability of the
dorsal cartilage of the apofysis. During the ossification phase of the epiphysis and the fusion of the
apophysis with the metaphysis, this cartilage is under the influence of traction forces. The secondary

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ossification centres appear between the age of nine and fourteen years and the ossification process is

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completed between the age of seventeen and nineteen years[5,6,9,11,12]. Furthermore, the epiphysis
of the proximal tibia is the second longest epiphysis of the human body after the distal femur. The low

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incidence of this fracture may be explained by the protection of several ligaments around the proximal
tibia and the protection of the epiphysis that bends over the anterior side of the growth plate and the

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metaphysis[5,13].
The anterior and posterior part of the epiphysis of the proximal tibia do not close similarly. According

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to the literature, the posterior part closes earlier than the anterior part[5]. As a result of that, the
anterior part is more vulnerable to traction forces. If the posterior part of the epiphysis is already
closed, the fracture line ends in the posterior metaphysis (Salter Harris type II) as can be seen in the
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third and fourth case.
Several mechanisms of trauma could lead to this type of fracture. In first place, direct trauma such as a
vehicle accident can cause these fractures. In second place, three mechanisms are described that can
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occur during sport activities: 1) abrupt contraction of the patellar tendon during abrupt extension of the
leg (take-off phase of jumping), 2) contraction of the quadriceps tendon with a fixated tibia and 3)
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acute passive flexion of the knee with a contracted quadriceps muscle (landing phase of jumping)[7–
9,11].
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The classification of fractures of the proximal tibial epiphysis has first been described by Watson and
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Jones in 1955[10]. This classification included three fracture types. The first type is an avulsion
fracture of the apophysis with dislocation upward. In the second type, the complete apophysis is
hinged upward and in the third type the entire tuberosity is fractured and the fracture line continues
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across the articular surface in proximal and posterior direction. In 1980, Ogden et al. proposed a
supplement to this classification and added two subtypes[14]. Subtype B consist of a comminuted
fracture with more dislocation compared to subtype A.
Subsequently, Ryu et al. and Inoue et al. both proposed a fourth type to this classification[11,15].
In this type, the fracture involves the complete epiphysis from anterior to posterior (Salter Harris type
I). In 2002, Davidson et al. added a fifth type, which is a sleeve avulsion of the tuberosity expanding
in the anterior metaphysis of the tibia (figure 5)[3].
Using the modified classification of Watson and Jones, the last two cases described in this manuscript
can not be classified appropriately. Therefore, the authors suggest to expand the current classification

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with type IV-B (Salter Harris type II), in which there is a full epiphysiolysis with the fracture
expanding in the metaphysis at the posterior side of the tibial plateau.

For treatment of proximal epiphysiolyses of the tibia, the algorithm of Frey et al. can be followed[16].
According to this algorithm, type IA, IB and IIA can be treated conservatively with a long leg cast
during 4-6 weeks after reposition. After 8-12 weeks, patients will start full weight bearing

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mobilisation. If conservative treatment fails, patients should be treated surgically with (open)

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reduction and internal fixation (ORIF). Type IIB, IIIA, IIIB and IV are treated by osteosynthesis,
followed by immobilisation for 4-6 weeks. The type of osteosynthesis is variable and depends on the

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experience of the surgeon. Commonly used osteosynthesis consists of cerclage wires and screws. In
the case of a type V fracture, separate treatment of the epiphysiolysis and the fracture of the

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metaphysis is advised, followed by the same immobilisation as in the treatment of type IIB, IIIA, IIIB
and IV fractures[1,2,5,7,12,13,16,17].

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Complications after treatment of proximal tibial epiphysiolyses are rare. Acute compartment
syndrome, injury of the cruciate ligaments or menisci, quadriceps tendon rupture, hypotrophic
quadriceps, hypertrophy of the tibial tuberosity and calcification of the patella tendon are
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described[8,14,16].
The prognosis of fractures of the proximal tibial epiphysis is good and in most cases there are no
residual symptoms. Premature (radiologic) closure of the epyphysis has been described, nevertheless
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without length discrepancy because the epiphysis was almost closed at the moment of trauma in the
described cases[11].
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Conclusion
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Fractures of the proximal epiphysis of the tibia are rare and occur mostly in male adolescents. These
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fractures are classified by the modified Watson-Jones classification. Using this classification, a
conservative or operative treatment can be chosen depending on the type of fracture and the success of
conservative treatment. Complications of these fractures are rare and the prognosis is excellent in
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general, without difference in leg length. The authors suggest to extend the existing modified
classification of Watson-Jones with a type IV-B to complete the classification for the purpose of
fractures of the posterior metaphysis.

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References

[1] Aitken AP. Fractures of the proximal tibial epiphysial cartilage. Clin Orthop Relat Res
1965;41:92-97

[2] Burkhart SS, Peterson HA. Fractures of the proximal tibial epiphysis. J Bone Joint Surg Am.
1979:61(7):996-1002

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[3] Davidson D, Letts M. Partial sleeve fractures of the tibia in children: an unusual fracture
pattern. J Pediatr Orthop. 2002:22(1);36-40

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[4] Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone
fractures in children aged 0-16 years. J Pediatr Orthop. 1990:10(6);713-6

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[5] Mudgal CS, Popovitz LE, Kasser JR. Flexon-type Salter-Harris I injury of the proximal tibial
epiphysis. J Orthop Trauma. 2000:14(4);302-5

[6] Nanni M, Butt S, Mansour R, Muthukumar T, Cassar-Pullicino VN, Roberts A. Stress-induced

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Salter-Harris I growth plate injury of the proximal tibia: first report. Skeletal Radiol.
2005:34(7);405-10

[7] Shelton WR and Canale ST. Fractures of the tibia through the proximal tibial epiphyseal
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cartilage. J Bone Joint Surg Am. 1979:61(2):167-73

[8] Bolesta MJ, Fitch RD. Tibial tubercle avulsions. J Pediatr Orthop. 1986:6(2); 186-92
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[9] Käfer W, Kinzl L, Sarkar MR. Epiphyseal fracture of the proximal tibia: review of the
literature and report of simultaneous bilateral fractures in a 13-year-old boy. Unfallchirurg
2008:111(9);740-5
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[10] Wilson J. Injuries of the knee, Watson-jones Fractures and Joint injuries. Edinburgh: Churchill
Livingstone; 1976, p 1047–50
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[11] Inoue G, Kuboyama K, Shido T. Avulsion fractures of the proximal tibial epiphysis. Br J
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Sports Med. 1991:25(1);52-6

[12] Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop.
2004:24(2);181-4
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[13] Kempink D, van der Velde D, Hegeman J. Een patiënte met epifysiolyse salter-harristype I van
de proximale tibia. Ned Tijdschr Traum. 2009:17;47-9

[14] Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint
Surg Am. 1980:62(2);205-15

[15] Ryu RK, Debenham JO. An unusual avulsion fracture of the proximal tibial epiphysis. Case
report and proposed addition to the Watson-Jones classification. Clin Orthop Relat Res.
1985:194;181-4

[16] Frey S, Hosalkar H, Cameron DB, Heath A, David Horn B, Ganley TJ. Tibial tuberosity
fractures in adolescents. J Child Orthop. 2008:2(6);469-74

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[17] Pécasse G, de Jong T, van Bommel F. Avulsiefractuur van de tuberositas tibiae bij kinderen -
Twee case reports en bespreking van de literatuur. Ned Tijdschr Traum. 2013:21;8-11

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Figure Legends

Figure 1: pre- and postoperative radiographs of Case 1; Watson-Jones type IIIB

Figure 2: pre- and postoperative radiographs of Case 2; Watson-Jones type IIIB

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Figure 3: pre- and postoperative radiographs of Case 3; Watson-Jones type IV, Salter Harris type II

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Figure 4: pre- and postoperative radiographs of Case 4; Watson-Jones type IV, Salter Harris type II
with a fracture of the proximal fibula.

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Figure 5: modified classification of Watson-Jones, Ogden et al., Ryu and Inoue and Davidson et al.
The authors suggest to add type IV-B, in which the fracture expands in the metaphysis at the posterior

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side of the tibial plateau.
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Figure 1

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Figure 2

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Figure 3

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Figure 4

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Figure 5

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