Tibial Eminence Fractures

Overview

  • Avulsion of the ACL insertion, the paediatric equivalent of an ACL tear
  • Children aged 8 to 14, after a bike fall or sport
  • Meyers and McKeever types I to III by displacement, IV comminuted
  • Type I in an extension cast
  • Medial meniscus anterior horn or intermeniscal ligament can block type II reduction
  • Displaced fractures need arthroscopic or open fixation with sutures or screws
  • Arthrofibrosis is a common complication

Western Health Orthopaedic Registrar presentation – Paediatric Tibial Eminence Fractures by Dr Amy Gibbens

Pathology

  • The incompletely ossified epiphysis fails before the ACL
  • Anterior horn of medial meniscus or intermeniscal ligament can become trapped beneath the fragment
  • Peak age 8 to 14 years, commonly from a bicycle fall

Classification

Meyers and McKeever, Zaricznyj modification

TypeDescription
IMinimally displaced
IIAnterior elevation with a posterior hinge, a beak on the lateral film
IIIAComplete separation of the ACL insertion only
IIIBComplete separation of the entire eminence
IVComminuted (Zaricznyj)

Original publication Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1959;41-A(2):209-20; discussion 220-2.

Original publication Zaricznyj B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am. 1977;59(8):1111-4.

Investigations

Tibial Eminence Fractures, imaging of a tibial eminence avulsion fracture
Imaging of a tibial eminence avulsion fracture. Image by Tsan-Wen Huang, Chien-Ying Lee, Szu-Yuan Chen, Shih-Jie Lin, Kuo-Yao Hsu, Robert Wen-Wei Hsu, Yi-Sheng Chan, Mel S. Lee, Wikimedia Commons, CC BY-SA 4.0.
  • Lateral radiograph shows displacement best
  • MRI identifies entrapped meniscus and separates type II from III

Management

  • Type I in a cast or brace for four to six weeks, avoiding hyperextension
  • Type II reduced closed in extension after haemarthrosis aspiration
  • Failed closed reduction suggests soft tissue entrapment
  • Type III and IV need arthroscopic reduction and fixation
  • Recess the fragment slightly to reduce residual laxity
  • Sutures avoid hardware removal and suit comminuted fragments
  • Keep screws within the epiphysis

Complications

  • Arthrofibrosis is the most significant, reduced by early motion and timely surgery
  • Residual laxity from ACL plastic deformation, with a minority needing later reconstruction
  • Growth disturbance from physeal screws or tunnels
  • Elevated malunion causing extension block from notch impingement
  • Nonunion from interposed soft tissue

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.