›Knee dislocation with vascular injury (ICD-10 S83.1 with vascular injury code as applicable)
Mimics and co-injuries
›Mimics and co-injuries
›Osgood-Schlatter apophysitis
›Chronic anterior tibial tubercle pain
›No acute deformity
›ACL injury
›Hemarthrosis
›Pivot injury mechanism
›Meniscal tear
›Locking or catching
›Tibial shaft fracture (ICD-10 S82.2)
›Acute compartment syndrome of leg (ICD-10 T79.A2)
05Laboratory Tests/lt14
Minimal labs for isolated closed injury
›Laboratory strategy
›No routine labs for isolated closed fracture with stable vitals
›Targeted labs for operative pathway or high risk
›If open fracture or planned urgent OR
›Complete blood count for baseline and bleeding concern
›Electrolytes and creatinine for perioperative planning
›Coagulation studies if anticoagulants or liver disease
›If compartment syndrome concern
›Creatine kinase trend support for rhabdomyolysis risk
›Creatinine for renal risk
›Venous blood gas if systemic illness concern
PITFALLS
›Pitfalls
›Normal labs do not exclude compartment syndrome
›Creatine kinase can be normal early in compartment syndrome
06Diagnostic Tests/dt71
Scoring Systems
›Classification and implications
›Ogden classification for tibial tubercle fractures
›Type I
›Through secondary ossification center
›Often less displaced
›Often nonoperative if aligned and extensor mechanism intact
›Type II
›Extends into junction with proximal tibial epiphysis
›Higher displacement risk
›Often operative if displaced
›Type III
›Intra-articular extension into tibial plateau
›Hemarthrosis common
›Typically operative for articular congruity
›Type IV
›Through proximal tibial physis
›Growth plate injury considerations
›Often operative and closer pediatric ortho follow-up
›Type V
›Periosteal sleeve avulsion pattern
›Can appear subtle on radiographs
›MRI useful if diagnosis unclear
›Gustilo-Anderson open fracture
›Grade I
›Wound <1 cm
›Minimal contamination
›Grade II
›Wound 1 to 10 cm
›Moderate soft tissue injury
›Grade III
›Wound >10 cm or high energy
›Extensive contamination or soft tissue loss
›Vascular injury possible
›Salter-Harris classification when physeal injury present
›Growth disturbance risk increases with higher grade
›Gentle handling and avoidance of repeated manipulations
Radiographs
›X-ray approach
›Knee radiographs
›AP view
›Lateral view
›Sunrise or merchant view if patellar injury concern
›Long bone principle
›Tibia and fibula views including knee and ankle if pain extends distally
›Key radiographic features
›Displacement of tibial tubercle fragment
›Proximal tibial physeal extension
›Tibial plateau intra-articular extension
›Patella alta indicator for patellar tendon injury
›Post-immobilization imaging
›Repeat radiographs if alignment changes suspected
MRI
›MRI indications
›Radiographs negative with high clinical suspicion
›Pain over tibial tubercle with extensor weakness
›Suspected periosteal sleeve avulsion
›Soft tissue assessment
›Patellar tendon injury
›Meniscus injury
›ACL or collateral ligament injury
›Contraindications and practical limits
›Metallic implants compatibility
›Need for sedation in younger children
CT
›CT indications
›Suspected intra-articular extension
›Large effusion or hemarthrosis
›Type III pattern on radiographs
›Surgical planning support
›Fragment comminution mapping
›Articular step-off assessment
›Radiation considerations
›Pediatric dose optimization
›Shared decision with orthopedics for borderline cases
07Disposition/dispo27
Ortho urgency and location of care
›Disposition framework
›Discharge with urgent follow-up
›Closed injury
›Neurovascularly intact
›Pain controlled with oral regimen
›Extensor mechanism intact
›Minimal displacement and stable immobilization
›Admission or observation
›Uncontrolled pain
›Need for serial compartment checks
›Unreliable follow-up or unsafe home setting
›Urgent orthopedics in ED
›Displaced fracture
›Extensor mechanism failure
›Intra-articular extension
›Open fracture
›Neurovascular compromise
›Compartment syndrome concern
›Transfer criteria
›No pediatric orthopedics coverage for likely operative injury
›Need for emergent fasciotomy capability
›Mobility and restrictions
›Non weight-bearing
›Crutches or walker fitting
›Wheelchair if unable to safely use crutches
›Knee immobilized in extension
›Avoid knee flexion until specialist plan
08Treatment/t94
Immediate life-saving interventions
›Immediate priorities
›Limb ischemia pathway if present
›If pulseless or rapidly worsening perfusion, immediate orthopedics and vascular involvement
›If ischemia signs, avoid delays for advanced imaging when transfer or OR is needed
›Compartment syndrome pathway if suspected
›If concern, remove constrictive wraps
›If concern, keep limb at heart level
›If concern, urgent orthopedics for compartment pressure consideration and fasciotomy readiness
›Open fracture immediate actions
›Cover wound with sterile saline-moistened dressing
›Antibiotics within 60 minutes when feasible
›Tetanus prophylaxis per status
Immobilization and Splinting
›Immobilization selection
›Knee immobilizer
›Full extension
›Rapid application for stable patterns
›Posterior long leg splint
›Full extension
›Preferred with marked swelling or instability
›Position and principles
›Knee extension to relax extensor mechanism tension
›Avoid circumferential casting in acute swelling phase
›Distal padding over malleoli and heel
›Post-application checks
›Pain trend
›Dorsalis pedis pulse
›Posterior tibial pulse
›Toe capillary refill
›Sensation in foot distributions
›Toe and ankle motor function
Reduction
›Reduction considerations
›Typical management
›Closed reduction not routinely performed in ED for tibial tubercle fractures
›Definitive management often immobilization and orthopedic fixation decision
›If gross displacement with threatened skin and orthopedics directs attempt
›Traction and countertraction
›Gentle longitudinal traction
›Avoid repeated forceful attempts
›Post-reduction requirements
›Immediate neurovascular re-check
›Immediate post-reduction radiographs
›Immobilization in extension
›Analgesia and anesthesia options
›Non-opioid base
›Paracetamol 15 mg/kg PO
›Ibuprofen 10 mg/kg PO
›Opioid titration
›Morphine 0.05 mg/kg IV
›Repeat every 10 minutes to effect
›Regional anesthesia option
›Femoral nerve block if trained operator and protocol
›Ropivacaine 0.2 percent
›Maximum 3 mg/kg total dose
›Aspirate before incremental injection
›Procedural sedation if required
›Ketamine IV 1 mg/kg
›Additional 0.5 mg/kg IV every 5 to 10 minutes as needed
›Continuous cardiorespiratory monitoring
›Airway equipment and suction at bedside
›ACEP procedural sedation guidance adherence (ACEP Level B)
Open fracture medications and timing
›Antibiotics and tetanus
›Antibiotics timing
›First dose within 60 minutes when feasible
›Continue per orthopedics and operative plan
›Antibiotics selection
›Gustilo I or II
›Cefazolin 2 g IV
›Repeat every 8 hours
›Gustilo III or heavy contamination
›Cefazolin 2 g IV
›Repeat every 8 hours
›Gentamicin 5 mg/kg IV
›Once daily dosing strategy per local protocol
›Severe beta-lactam allergy
›Clindamycin 600 mg IV
›Repeat every 8 hours
›Tetanus prophylaxis
›Clean minor wound with immunization up to date
›No booster if last dose within 10 years
›Dirty wound or open fracture
›Booster if last dose 5 years or more
›Add tetanus immune globulin if unknown or incomplete series
DVT prophylaxis when relevant
›Thrombosis risk planning
›Pediatric isolated immobilization
›Pharmacologic prophylaxis not routine
›Consider hematology or ortho guidance if major risk factors
›Adult or near adult with prolonged immobilization
›Risk assessment
›Prior VTE
›Active cancer
›Known thrombophilia
›Estrogen therapy
›Marked obesity
›If high risk and low bleeding risk, follow local prophylaxis protocol
09Special Populations/sp35
Pregnancy
›Pregnancy considerations
›Imaging safety
›X-ray acceptable with shielding when possible
›CT only if benefits outweigh risks and affects management
›Analgesia selection
›Paracetamol preferred
›NSAID avoidance in later pregnancy per obstetric guidance
›Opioid short course if required with counseling
›VTE risk
›Elevated baseline risk in pregnancy
›Early obstetric input for prophylaxis decisions if immobilization prolonged
Geriatric
›Older adult considerations
›Mechanism differences
›Lower energy mechanisms possible with osteopenia
›Baseline mobility and fall risk
›Physiotherapy needs and assistive device safety
›Medication risks
›Opioid delirium and constipation risk
›NSAID renal and bleeding risk
›Admission threshold
›Higher likelihood of unsafe discharge if non weight-bearing
Pediatrics
›Pediatric priorities
›Typical demographic
›Adolescent age range
›Sports related jumping mechanisms
›Physeal considerations
›Growth plate involvement risk in higher Ogden types
›Avoid repeated manipulations
›Compartment syndrome vigilance
›Lower threshold for serial exams
›Early escalation with increasing pain or agitation
›Weight-based dosing
›Paracetamol 15 mg/kg PO
›Ibuprofen 10 mg/kg PO
›Morphine 0.05 mg/kg IV titration
10Background/b33
Epidemiology
›Epidemiology
›Frequency
›Reported 0.4 to 2.7 percent of pediatric fractures
›Rare overall compared with other knee injuries
›Typical population
›Adolescent males predominance
›High association with jumping and sprint sports
›Complication frequency
›Acute compartment syndrome reported in a minority of cases
›Vascular injury uncommon but limb-threatening when present
Pathophysiology
›Mechanism and anatomy
›Avulsion at tibial tubercle apophysis from quadriceps contraction via patellar tendon
›Vulnerable phase during partial closure of proximal tibial physis in adolescence
›Intra-articular extension possible into tibial plateau in higher grade injuries
›Vascular risk
›Injury to anterior tibial recurrent vessels can contribute to compartment syndrome
›Extensor mechanism disruption
›Loss of active knee extension with displaced avulsion
Therapeutic Considerations
›Management rationale
›Immobilization in extension reduces traction on avulsed fragment
›Operative fixation indications
›Displacement
›Extensor mechanism failure
›Intra-articular extension
›Open fracture
›Compartment syndrome
›Nonoperative pathway considerations
›Stable alignment
›Intact extensor mechanism
›Reliable follow-up and adherence to non weight-bearing
›Compartment syndrome surveillance
›Early recognition prevents irreversible muscle and nerve injury
›Escalation triggers override normal imaging timelines
11Patient Discharge Instructions/pdi28
Copy discharge instructions
›Discharge instructions
›Immobilizer and care
›Keep knee immobilizer or splint on at all times
›Keep splint dry
›Do not insert objects inside splint
›Activity
›Non weight-bearing on injured leg
›Crutches or walker use as instructed
›Elevation above heart when resting
›Swelling control
›Ice 15 to 20 minutes at a time
›Repeat every 2 to 3 hours while awake for first 48 hours
›Pain plan
›Paracetamol 1000 mg every 6 hours as needed
›Ibuprofen 400 mg every 6 to 8 hours with food as needed
›Opioid only if prescribed for breakthrough pain
›Return to ED now
›Increasing pain not controlled with medication
›Numbness or tingling in foot or toes
›Foot becoming cold, pale, or blue
›Increasing tightness of leg or severe pain with toe movement
›New weakness moving toes or ankle
›Splint too tight or causing severe pressure pain
›Fever or drainage from any wound
›Follow-up
›Orthopedics within 24 to 72 hours if displaced or extensor weakness
›Orthopedics within 5 to 7 days if stable and improving
›Return earlier if symptoms worsen
12References/r7
Evidence-based sources and guidelines
›Reference set
›Pediatric Orthopaedic Society of North America resources on tibial tubercle fractures
›AAOS general fracture care principles and immobilization guidance
›Standard orthopedic trauma texts for Ogden classification and operative indications
›ATLS principles for initial trauma assessment and limb threat evaluation
›ACEP procedural sedation guidance for ED sedation safety (ACEP Level B)
›ACEP acute pain management principles for multimodal analgesia (ACEP Level B)
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
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