Type IV Tibial Tubercle Fractures in Adolescents-Is Operative Treatment Necessary?

Tibial tubercle fractures (TTF) in adolescents can be treated operatively or nonoperatively depending on fracture configuration and displacement. In the modified Ogden classification, the type IV fracture is extra-articular and exits through the posterior physis or metaphysis. No previous publications have reviewed a series of these injuries and compared clinical and radiographic outcomes of operative and nonoperative treatment.

Patients under the age of 18 with Ogden type IV TTFs treated at a single institution between 2013 and 2023 were evaluated. Mechanism of injury, weight percentile, concern for compartment syndrome, time to full weight bearing, time to return to sport/activity, method of treatment, follow-up time, and complications were collected from the electronic medical record (EMR). Posterior tibial slope angle (PTSA), medial proximal tibial angle (MPTA), and anterior fracture gap were measured from the initial injury, postreduction, and final follow-up radiographs.

A total of 36 limbs in 33 patients were followed for an average of 182 days, 18 of which were treated nonoperatively and 18 operatively. The mean pretreatment PTSA was 22.4° in the nonoperative and 25.0° in the operative group ( P =0.25). The mean final follow-up PTSA was 15.1° in the nonoperative and 14.3° in the operative group ( P =0.54). The mean pretreatment MPTA was 84.7° for both groups ( P =0.99). The final follow-up mean MPTA was 84.2° in the nonoperative and 85.5° in the operative group ( P =0.08). There were no significant differences noted in time to full weight bearing, return to sport/activity, or total follow-up. There were 7 cases with complications, 4 in the nonoperative and 3 in the operative group.

The present study suggests that nonoperative and operative treatment for type IV TTFs are equivalent in terms of radiographic and clinical outcomes. Given that joint incongruity is not an issue in these fractures, closed reduction can be attempted unless contraindicated by impending compartment syndrome. Operative management should be performed for failure of closed reduction.

Level IV.