skip to main content

Displaced tibial spine avulsion fracture — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardKnee InjuriesDisplaced tibial spine avulsion fractureMSRA

A 12-year-old boy attends a GP-led urgent treatment centre 3 hours after twisting his right knee while changing direction during football. He felt a pop and developed rapid swelling. He cannot weight-bear and holds the knee flexed at about 25 degrees. There is a large effusion and marked tenderness anteriorly. Despite adequate analgesia, he cannot actively or passively extend beyond 20 degrees of flexion. Distal pulses, capillary refill, sensation and ankle movements are normal. Plain anteroposterior and lateral knee radiographs show a displaced avulsion fracture of the tibial intercondylar eminence, with the fragment elevated and rotated anteriorly. There is no other fracture. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Apply a splint, keep him non-weight-bearing, and arrange same-day paediatric orthopaedic admission

Explanation lettering: E = shown as A · D = shown as B · A = shown as D · B = shown as E

This is a displaced tibial spine (intercondylar eminence) avulsion fracture. In a skeletally immature patient, this is the bony equivalent of an anterior cruciate ligament injury, but the visible displaced intra-articular fracture changes management substantially. The rotated, elevated fragment and persistent passive extension block indicate an unstable injury that requires urgent orthopaedic assessment; normal distal neurovascular findings do not make outpatient management appropriate. Initial NHS emergency guidance for an intercondylar tibial avulsion fracture is splinting and admission. A would be appropriate for some stable or undisplaced fractures, but routine review and unrestricted weight-bearing are inappropriate here. B is suitable for selected stable soft-tissue injuries after exclusion of fracture, not a displaced intra-articular avulsion. C is attractive because MRI can identify associated meniscal or ligament injury, but it must not delay referral after diagnostic radiographs have demonstrated displacement. D is inappropriate in an urgent treatment centre: reduction and possible fixation require paediatric orthopaedic assessment, appropriate imaging and operative capability. E provides immediate protection of the injury and expedites definitive reduction and fixation planning.

Reference: Clinical Guideline: Fracture Management ED GRI (2025) — https://uat.rightdecisions.scot.nhs.uk/media/2720/139-fracture-management-ed-gri.pdf Treatment and Management Outcomes of Tibial Eminence Fractures in Pediatric Patients: A Systematic Review (2013) — https://pubmed.ncbi.nlm.nih.gov/24256714/ Perioperative Management of Tibial Spine Fractures in Pediatric Patients: A Delphi Study to Identify Principles of Treatment (2025) — https://pubmed.ncbi.nlm.nih.gov/39466263/