Tibial Eminence Fractures: A Review and Algorithm for Treatment

Background Fractures of the tibial eminence, first described by Poncet in 1875, are bony avulsions of the ACL from its insertion on the intercondylar eminence of the tibia (Figure 1). Tibial eminence fractures are relatively rare with an incidence of approximately 3 per 100,000 per year, and account for 2 to 5% of knee injuries in the pediatric pediatric population. While most commonly seen in children between 8 and 14 years of age, recent literature suggests that the incidence of tibial eminence fractures in adults is higher than previously thought. Hayes et al found that 40% of tibial eminence fractures reported in the literature occurred in adults. Arthroscopic reduction of tibial eminence fractures has gained popularity due to its successful outcomes, decreased invasiveness, and improved recovery time. However, controversy still exists regarding the optimal method of arthroscopic surgical fixation. The risk of arthrofibrosis, which can diminish range of motion (ROM) of the affected knee, particularly extension, is of primary concern when treating tibial eminence fractures both surgically and non-surgically. Anatomy The tibial eminence is anatomically divided into four distinct regions by the medial and lateral intercondylar spines and anterior and posterior recesses. It serves as the insertion point for the anterior and posterior cruciate ligaments and the menisci. The ACL inserts on the tibial eminence at the anterior intercondylar area in a recess anterior to the medial tibial spine. The anterior attachment of the medial meniscus is anterior to the ACL insertion, and the anterior attachment of the lateral meniscus is posterior to the ACL insertion. The intermeniscal ligament traverses between the medial and lateral menisci anterior to the tibial eminence where it is vulnerable to entrapment within these fractures, thereby blocking reduction.