- [Home](https://ortopediaevolutiva.com/en) - [Conditions](https://ortopediaevolutiva.com/en/conditions) - Tibial spine avulsion fracture in children Injuries & Sport # Tibial spine avulsion fracture in children A fracture of the bony attachment of the ACL. Injury to the ligament fibres or other knee structures may coexist. Displacement, stability and associated injuries guide treatment. Updated: August 2026 · Medically reviewed by [Dr. Daniele Priano](https://ortopediaevolutiva.com/en/about) ## What to do now This chart does not replace a medical visit and does not allow a diagnosis at a distance. After a knee injury, the most useful practical criteria for a family are how quickly swelling appears and whether the child can put weight on the leg. ### Today / right away - Knee swelling within a few hours of the injury - Inability to bear weight or to walk - Knee locked and unable to straighten - Visible deformity, open wound, cold or tingling leg Go to the emergency department: an early X-ray is needed. ### Within a few days - Pain persisting beyond a few days despite rest - The knee swells again when activity is resumed - X-ray reported as normal but pain not improving - A sense of giving way or instability Ask for a paediatric orthopaedic assessment within a few days, bringing any imaging already performed. ### Check-up that can be scheduled - Injury already assessed and documented, pathway under way - Recovery ongoing but questions about movement, weight-bearing or return to sport Plan an orthopaedic review to check range of motion, strength and return criteria. This chart does not replace a medical examination and does not allow a diagnosis at a distance. In children and adolescents with open growth plates, the bone of the **intercondylar eminence** — the small ridge of the tibial plateau where the **anterior cruciate ligament** attaches — is weaker than the ligament itself. A twisting or hyperextension injury of the knee, typical of a fall from a bicycle or a sporting collision, may avulse the bony ligament attachment in a child. Stretching or injury to ACL fibres may coexist, and children can also sustain a tear within the ligament itself. In this fracture the bony anchorage lifts off: this is a **tibial spine (eminence) fracture**, considered the paediatric equivalent of an ACL injury. The typical picture is a knee that swells rapidly within a few hours of the injury (**haemarthrosis**, blood inside the joint), with pain, inability or marked difficulty in weight bearing, and limited extension — especially when the lifted fragment acts as a mechanical block. One practical point: a knee that swells within hours of an injury in a child is never a trivial finding and always deserves an orthopaedic assessment. The good news is biological: healing of the **bony** fragment is central, alongside assessment of any associated injuries, and bone usually unites in 6-8 weeks. The pathway depends on fragment displacement according to the **Meyers and McKeever classification** and on whether an anatomical reduction can be obtained. The risk to keep in mind is not so much failure of healing but **joint stiffness**, which is why restoring motion is planned and monitored from the outset. For the wider picture of joint injuries during growth see also [knee injuries in children and adolescents](https://ortopediaevolutiva.com/en/conditions/knee-injury-children-adolescents) and [paediatric sports injuries](https://ortopediaevolutiva.com/en/conditions/sports-injuries). ## Assessment and treatment ### When to seek evaluation - Knee that swells rapidly (within hours) after a twisting or hyperextension injury - Inability or marked difficulty in weight bearing after the injury - Loss of full knee extension or a sense of blocking - Deep knee pain with a feeling of giving way - X-ray already performed showing a bony fragment lifted from the tibial plateau - Persistent pain beyond a few days even when the X-ray was reported as normal ### What is evaluated - Injury history and presence of joint effusion (haemarthrosis) - Active and passive extension and flexion, looking for a mechanical block - Anterior cruciate stability tests (Lachman) compared with the opposite knee - X-ray in two views: identifies and classifies the fragment - MRI when menisci, cartilage or associated ligament injuries need assessment, or when the X-ray is not conclusive - CT in selected cases, when comminution must be defined precisely or fixation planned ### Treatment options - Type I (undisplaced fragment): conservative treatment with immobilisation in extension or slight flexion and close radiographic follow-up - Reducible type II: conservative treatment after reduction, with radiographic confirmation that reduction is maintained - Irreducible type II, type III and type IV: surgical reduction and fixation, usually arthroscopic - Planned rehabilitation after conservative or surgical treatment, with gradual recovery of motion and load according to union - Clinical and radiographic follow-up until bony healing and, in growing patients, surveillance of limb growth 🏥 ## When Surgery Is Needed When the fragment remains lifted or cannot be reduced, treatment is surgical: the fragment is returned to its anatomical bed and stabilised, restoring the bony insertion of the anterior cruciate ligament while protecting the growth plate. [🔗 View surgical options for this condition →](https://ortopediaevolutiva.com/en/surgery/tibial-spine-fracture) ## Frequently Asked Questions Is a tibial spine fracture the same as an ACL tear? ▼ It is a fracture of the anterior cruciate ligament’s bony attachment on the tibia. Stretching or injury to ligament fibres and other knee injuries may coexist: the ACL should not be assumed to be entirely intact. Treatment aims to restore the bony attachment and separately assesses associated damage. What is the Meyers-McKeever classification? ▼ The Meyers-McKeever classification distinguishes an undisplaced or minimally displaced fragment (type I), a fragment lifted anteriorly but still hinged posteriorly (type II), and a completely displaced fragment (type III). A later modification adds comminuted type IV injuries. Reducibility, stability and associated injuries also guide treatment. When is surgery required? ▼ Generally when the fragment cannot be reduced or does not stay reduced: irreducible type II, type III and type IV. The aim is to restore the bony insertion of the anterior cruciate ligament and prevent the lifted fragment from blocking extension. The [surgical options are described on the dedicated page](https://ortopediaevolutiva.com/en/surgery/tibial-spine-fracture) . Is MRI always needed? ▼ No. A two-view X-ray is the starting examination and is often enough to classify the injury. MRI is useful when associated meniscal, cartilage or ligament injuries are suspected, or when the X-ray does not clarify the picture. CT is reserved for selected cases where the fragment anatomy must be defined precisely. How long before returning to sport? ▼ Bone usually unites in 6-8 weeks, but return to sport depends on recovery of motion, strength and knee control. In typical pathways running is reintroduced around months 3-4 and contact or pivoting sport later, with functional criteria verified. The [detailed rehabilitation protocol](https://ortopediaevolutiva.com/en/rehabilitation/tibial-spine-fracture-fixation) describes phases and criteria. Can any problem remain after healing? ▼ After correct bony healing the knee is usually stable. Mild anterior laxity may remain — measurable but often without practical consequences — because the ligament had already stretched at the time of injury. The main issue to prevent is stiffness, which is why follow-up in the first weeks focuses on recovery of motion. **Important Notice:** The information on this page is for educational and informational purposes only and does not constitute medical advice. Each clinical case is unique: the appropriate treatment is determined during the specialist consultation, based on a thorough clinical examination and, where necessary, diagnostic imaging. For any doubts or concerns, please consult a specialist. ## Complete knee and sport pathway This page is part of the knee and sport pathway. The sports injuries page covers the overall picture. - [1 Overview: sports injuries in the growing athlete How the knee and the growing musculoskeletal system respond to sport.](https://ortopediaevolutiva.com/en/conditions/sports-injuries) - [4 Ligaments and menisci Technical content also aimed at physiotherapists: pathway after ACL reconstruction in the skeletally mature patient.](https://ortopediaevolutiva.com/en/rehabilitation/acl-reconstruction) [ACL in growing patients](https://ortopediaevolutiva.com/en/rehabilitation/pediatric-acl-all-epiphyseal) - [ACL + meniscal repair](https://ortopediaevolutiva.com/en/rehabilitation/acl-with-meniscal-repair) - [Isolated meniscal repair](https://ortopediaevolutiva.com/en/rehabilitation/isolated-meniscal-repair) - [Discoid meniscus](https://ortopediaevolutiva.com/en/blog/discoid-meniscus-children-saucerization-repair) - [Tibial spine avulsion fracture · you are here](https://ortopediaevolutiva.com/en/conditions/tibial-spine-fracture) - [5 Osteochondral lesions Osteochondritis dissecans: when cartilage and subchondral bone are involved.](https://ortopediaevolutiva.com/en/conditions/osteochondritis-dissecans-knee) - [6 Exercises: what they help with and their limits Sheets for anterior pain, apophysitis, patellar instability and limb alignment.](https://ortopediaevolutiva.com/en/parents-kids/exercises/knee) Adjacent clinical pictures: [Knock knees and bow legs](https://ortopediaevolutiva.com/en/conditions/knock-knees-bow-legs) · [Surgical axis correction](https://ortopediaevolutiva.com/en/surgery/knock-knees-bow-legs) ## Learn more - [Surgical options →](https://ortopediaevolutiva.com/en/surgery/tibial-spine-fracture) Related articles - [First patellar dislocation in children: what MRI adds](https://ortopediaevolutiva.com/en/blog/first-patellar-dislocation-in-children-mri) [All conditions](https://ortopediaevolutiva.com/en/conditions)[Medical glossary](https://ortopediaevolutiva.com/en/glossary) --- Canonical: https://ortopediaevolutiva.com/en/conditions/tibial-spine-fracture Le informazioni cliniche sono divulgative e non sostituiscono una valutazione medica diretta.