Type I: Undisplaced avulsion fracture
Type II: Anterior portion displaced & hinged
Type IIIA: Displaced
Type IIIB: Displaced & Rotated
I - III A
Attempt closed reduction
- anaesthesia / II control
- long leg cast in full extension
- trap fragment under condyles
Block to reduction
- usually medial meniscus / intermeniscal ligament
IIIB & Failed MUA
1. Medial arthrotomy / arthroscopically
- need to remove portion of fat pad for visualisation
- intermeniscal ligament usually blocks reduction
- removed callus / hematoma
- replace fragment under intermeniscal ligament
- want to impact fragment to tension stretched ACL
2. Repair Options
A. No 2 suture
- bunnell suture through ACL above bony fragment
- pass 2 x limbs through bony fragment
- insert beath pins to retrieve suture limbs through tibial insertion
- two separate tunnels
- tie over bony bridge in tibia
- protect in plaster in extension
B. ORIF physeal sparing screw
- II guided
- directed posteriorly and obliquely
Stability
Some stretch of ligament occurs, but most knees are stable
Malunion
Occasionally fragment can block full extension