Open or arthroscopic reduction and fixation of displaced Meyers-McKeever type II-III fractures | intermediate
Surgical Imaging
The trap: Attempting reduction without clearing the intermeniscal ligament or anterior horn of the medial meniscus — the fragment will not reduce and fixation will be non-anatomic.
The fix: Use a probe or small elevator under arthroscopic or open vision to sweep the ligament anteriorly or posteriorly out of the fracture bed before attempting reduction. If the ligament is incarcerated, a small vertical incision in the ligament (not dividing it) may be required.
Location: The proximal tibial physis lies 2-4 mm distal to the tibial spine base in children aged 8-12 years; any drill, screw or suture tunnel that crosses the physis risks partial or complete growth arrest.
Risk: Angular deformity (recurvatum or valgus) or leg-length discrepancy. All fixation must remain entirely within the epiphysis — transosseous sutures exit through the anterior tibial cortex distal to the physis or use all-epiphyseal suture anchors.
Location: Even 2-3 mm of residual anterior displacement or rotation of the fragment creates a mechanical block to terminal extension and leaves the ACL functionally lengthened.
Risk: Permanent loss of extension, chronic anterior laxity, and early degenerative change. Accept only anatomic reduction under direct vision; if the fragment is rotated 180 degrees it must be derotated before fixation.
Type I: Non-displaced or minimally displaced (less than 2 mm) with intact posterior hinge — treated in extension cast or brace for 4-6 weeks.
Type II: Displaced anteriorly with posterior hinge intact (bird-beak sign) — requires reduction and fixation. The trap is treating a type II as type I because the displacement is underestimated on a non-true lateral radiograph.
Why it occurs: The ACL fibres are attached to the avulsed fragment; if the fragment heals in a displaced or rotated position the effective ACL length increases and anterior drawer/ Lachman test remains positive.
Prevention: Achieve anatomic reduction and rigid fixation; verify ACL tension by probing or hook test after fixation. If the fragment is comminuted or too small for screw, use suture fixation through the ACL base.
Incidence: 15-25 percent in published series; the most common cause of re-operation.
Prevention and management: Begin protected range-of-motion exercises (0-90 degrees) from week 2-3 under physiotherapist supervision. Use extension bracing at night. If extension deficit greater than 10 degrees persists at 8-12 weeks, consider manipulation under anaesthesia or arthroscopic lysis of adhesions.
S.P.I.N.E.SPINE — Meyers-McKeever Classification and Decision-Making
F.I.X.A.T.FIXATION — Physeal-Sparing Principles
C.O.M.P.L.COMPLICATION — Prevention of the Five Major Problems
Surgical Indications
Absolute Indications
- Meyers-McKeever type II fracture with greater than 2 mm anterior displacement or any rotation
- Meyers-McKeever type III fracture (completely displaced, often rotated)
- Any displaced fracture causing a mechanical block to terminal extension
- Associated meniscal tear or intermeniscal ligament incarceration requiring intervention
- Open fracture or associated vascular injury
Relative Indications
- Type II fracture in a high-demand adolescent athlete where anatomic restoration of ACL tension is desired
- Comminuted fragment too small for reliable non-operative healing
- Patient or family preference for surgical stabilisation after informed discussion
Contraindications
Absolute:
- Type I fracture with less than 2 mm displacement (non-operative treatment)
- Active infection or open wound at the surgical site
- Medical comorbidities precluding anaesthesia
Relative:
- Skeletally mature patient with mid-substance ACL tear (different management pathway)
- Severe soft-tissue swelling precluding safe arthroscopy or open surgery (delay 7-10 days)
Evidence for Non-Operative versus Operative Treatment
Non-Operative Treatment (Type I Only)
- Long-leg cast or hinged brace locked in full extension for 4-6 weeks
- Serial radiographs at 1, 2 and 4 weeks to confirm maintenance of reduction
- Protected weight-bearing with crutches until radiographic healing
- Success rate greater than 90 percent for type I fractures when displacement remains less than 2 mm
Rationale for Operative Treatment of Type II and III Fractures
- Displaced type II and III fractures left untreated result in:
- Permanent extension block (mechanical impingement of the fragment)
- Residual anterior laxity (effective lengthening of the ACL)
- Increased risk of secondary meniscal and chondral injury
- Early degenerative joint disease
- Anatomic reduction and stable fixation restores ACL isometry and eliminates the extension block
Evidence Summary
Outcomes of Operative versus Non-Operative Treatment
Key Evidence
Tibial eminence fractures in children: prevalence of meniscal entrapment
Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents
Pediatric tibial eminence fractures: evaluation and management
Arthroscopic fixation with intra-articular button for tibial intercondylar eminence fractures in skeletally immature patients
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 9-year-old boy sustains a hyperextension injury to his right knee while playing football. He is unable to fully extend the knee. A lateral radiograph shows a displaced tibial spine fracture with a bird-beak appearance and 4 mm of anterior displacement. What is your diagnosis, classification, and initial management plan?”
“You are performing arthroscopic fixation of a type III tibial spine fracture in an 11-year-old girl. After clearing the intermeniscal ligament you reduce the fragment but notice that the ACL fibres remain slightly lax when the knee is in full extension. What has happened and how do you correct it?”
“A 13-year-old boy with a nearly closed proximal tibial physis undergoes screw fixation of a large type II tibial spine fracture. Six months later he presents with a 12-degree valgus deformity and 1.5 cm leg-length discrepancy. What has occurred and how do you manage it?”