The X-Files - December 2007

Marshall Deltoff
December 31, 2007
Written by Marshall Deltoff
My sincere thanks to my friend and classmate, Dr. Vince Campo of Toronto, and his son Salvatore (Fig. 1), for sharing this case.

38 Salvatore, age 12, was at a friend's home and they were playing in the pool. He went on the diving board and was bouncing up and down. In the process he felt a snap in his knee and he fell into the pool. At that point in time, he was unable to stand completely on his knee joint and he had immediate swelling which seemed to go down with application of ice. However, he was unable to fully extend his knee. 

The knee was quite swollen and Sal was taken to the Emergency Department. Radiographic examination (Fig. 2) demonstrated a high-riding patella with a fragment of bone, and his clinical exam suggested the potential for patellar tendon rupture.

In surgery, it was discovered that, not only did he fracture the tibial tuberosity at its growth plate but he also split his patellar tendon, and additionally had a fracture of the anterior growth plate of the proximal tibia.

38a Surgery involved reattachment of the fracture fragment and the quadriceps mechanism, as well as repair of the torn patellar tendon. Post-surgical radiographs (Figs. 3 and 4) demonstrate the hardware used to re-stabilize Sal's knee.

Dr. Campo explains his son's rehab:
During the first six weeks, Salvatore was in a Zimmer brace.  Cryotherapy was applied four times a day. In order to prevent adhesions and minimize the scar tissue formation, I utilized Nimmo Receptor Tonus, Myofascial Release, and Graston techniques, as well as castor oil compresses. Sal also received chiropractic care at least three times per week during these six weeks, including Matrix Repatterning, Network Spinal Analysis and Activator technique.

After six weeks, the orthopaedic surgeon gave the go-ahead to commence rehabilitation.

Day 1 was a bit intimidating, since at the start of the session Sal could not demonstrate any use of his quads. The first thing I did was to utilize an AK technique: I stimulated the muscle proprioceptors - the Golgi tendon organs and the neuromuscular spindle cells. I then had Sal perform a few isometric quadriceps contractions. When I asked him to extend his leg (he was sitting with his leg flexed at 90 degrees) he was now able to extend his leg to within 90 per cent of his active range.

Other techniques I have utilized in the rehab period have been ART (Active Release Technique) and Trigenics. Recommended activities include iso-metric contractions, gentle quads and hamstring exercises, quarter squats, and the stationary bike.

My goals are to minimize scar tissue formation, re-educate his muscles, restore normal range of motion. and restore the strength back to the muscles of the knee.

By Day 7 of rehab, as I write these notes, Sal has been progressing daily.  Every day he is getting stronger and the active and passive ROMs are also improving daily.

And what did Sal learn from this experience? "Don't treat a diving board like a trampoline."

I would like to take this opportunity to extend my gratitude to the following doctors for their valuable feedback: Drs. Paul Duperrouzel, Marshall Deltoff, Rocco Guerriero, James Laws, David Leaf and George Roth (chiropractors); and Drs. Hugh Cameron, Mike McKee and Steve Rosenfeld (orthopaedic surgeons).
                                    
Discussion:
Tibial tuberosity fracture commonly occurs in boys 14 to 16 years of age. The distal ligamentous expansion of the insertion of the quadriceps tendon spreads out like a fan as it approximates the proximal tibial surface. The apophysis of the tuberosity is located within this expansion. Because of the diffuse insertion of the quadriceps mechanism, it is rare for the tibial tuberosity to be completely avulsed. 

The classification of tibial tuberosity fracture consists of six subcategories, which are based on the degree of avulsion as well as the involvement of the anterior aspect of the tibial articular surface and growth plate. Most require open reduction. The surgery depends on the degree of displacement and must be directed at anatomical correction. The results of treatment of this injury are generally excellent due to the growth plate being in the final stages of closure; this can avert premature growth arrest. Adequate quadriceps rehabilitation, as is being done in Sal's case, is essential.·

Reference:
Ogden, JA. Skeletal Injury in the Child; 1982, Lea & Febiger, Philadelphia.

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