osgood - schlatter disease ( osd ) is a well known condition , characterized by pain over the tibial tubercle with subsequent tubercle prominence .
we report an unusual case of simultaneous bilateral tibial tubercle avulsion fracture in a 16 year old boy who was a known case of osd .
a 16 year old boy a known case of osd presented to the outpatient department with history of jumping from the school compound wall ( two feet height ) while playing , followed by severe pain around anterior aspect of both knees and difficulty in walking .
he was treated successfully with open reduction and internal fixation with tension band wiring . at the end of 22 months
the patient was symptomatically relieved and both the tuberosities were united with the main bone .
even though bilateral osgood - schlatter disease ( osd ) is a well known condition , one should always keep in mind the risk of tibial tubercle avulsion fractures while treating a case of osd .
patient should be advised not to involve in strenuous activities till the disease subsides radiologically or till skeletal maturity .
osgood - schlatter disease ( osd ) is a well known clinical condition , characterized by painful tender disabling swelling over the tibial tubercle . in 1903 , osgood in the united states and schlatter in germany reported this condition independently for the first time [ 1 , 2 ] .
avulsion of the tibial tubercle in an adolescent is rare and is usually produced by sudden violent contraction of the quadriceps muscles .
we report a case of simultaneous bilateral tibial tubercle avulsion fracture in a 16 year old boy who was a diagnosed case of osd .
a 16 year old boy presented to the outpatient department in november 2009 with the history of painful swelling around the anterior aspect of both proximal tibia . on examination
he was diagnosed clinically to have bilateral osd and treated conservatively with nsaids and compression bandage .
he was brought to the outpatient department after 2 months in february 2010 with the history of jumping from the school compound wall ( two feet height ) while playing , followed by severe pain around anterior aspect of both knees and difficulty in walking .
after few minutes the knees were swollen and he was unable to bear weight on both the legs and to flex and extend the knees .
radiographs of both knee joints ap and lateral views were taken which showed bilateral tibial tubercle avulsion fractures .
1 ) according to ogden classification   right side was type iia and leftside was iib tibial tubercle avulsion fracture . both sides were treated with open reduction and internal fixation with tension band wiring ( tbw ) ( fig . 2 and 3 ) .
radiograph of right and left knees respectively showing ogden type iia and iib avulsion fracture of the tibial tubercle .
postoperative radiographs of right knee with tbw in situ postoperative radiographs of right knee with tbw in situ
fracture was reduced and confirmed clinically and radiologically under image intensifier and fixed with two 2 mm k wires and tension band wiring .
the figure - of - eight wire was passed deep to the patellar ligament and through a transosseous tunnel 4 cm distal to the fracture .
kirschner wires provided rotational stability , and were inserted through the proximal part of the tubercle and engaged the posterior cortex of the tibia under direct guidance of image intensification . patient was put on cylindrical slab for 2 weeks and gradual mobilization of knee was started .
patient was followed up clinically and radiologically at 6 weeks , 12 weeks , and 6 months and 12 months and 22 months ( fig .
follow up the knee range was 0 to 120 and completely pain free with patient doing all his activities without any functional limitations 22 months follow up radiograph of both knees showing well united tuberosities
a painful , tender disabling swelling about the tibial tubercle in adolescence is characteristic of osd .
the earliest record of traction epiphysitis is of a middle aged male , dated ninth to tenth century a.d . on the archaeological evidence found in the late saxon buriel ground of st .
the disease starts in the second decade of life and usually resolves spontaneously without any sequelae by the time of skeletal maturity .
initially , the tibial tubercle is painful following physical activity , may be due to chronic micro trauma to the tibial tubercle secondary to overuse of the quadriceps muscle and gradually becomes prominent and constantly painful .
mri will show the patellar tendon attachment more proximally and in a broader area to the tibia ( routine mri was not done in our case as clinico - radiological findings were correlating with the diagnosis ) .
clinical conditions like chondromalacia patellae , patellar tendinitis , osteomyelitis of proximal tibia , pes anserinus bursitis and sinding  larsen - johanson syndrome should be considered as differential diagnosis and should be ruled out before considering osd .
avulsion fractures of the tibial tuberosity are uncommon , comprising only 0.4 to 2.7% of all epiphyseal injuries .
the mechanism of avulsion injury usually consists of violent knee flexion against a tightly contracted quadriceps or a violent quadriceps contraction with a fixed foot like in bad landing from a jump . in our patient
also our patient was already a diagnosed case of osd on conservative management , but was not complying with our advice to refrain from sports activities .
osd has been reported to be a associated risk factor for tibial tuberosity avulsion [ 11 - 18 ] although scientific correlation is still inconclusive .
ogden commented that structural modification in the physeal cartilage , probably change in the columnar cartilage to fibrocartilage may weaken the physis to tensile strain .
our case supports the hypothesis that patients with osd have a risk for developing tibial tuberosity avulsion and should be allowed for a adequate period of restricted activities , specially sports related activities .
there have been 230 published cases with tibial tuberosity avulsion fractures ,   but simultaneous bilateral tibial tubercle avulsions are uncommon , with only few cases reported [ 3 - 5,21 - 25 ] and reports in a case of pre - existing osd are still rare [ 6,15 , 16,17,18 ] . thus our case is among rare bilateral presentations that strengthen the association between pre - existing osd and tibial tubercle avulsion fracture . accepting the association between osd and avulsion fractures ,
we reviewed the literature with respect to duration between diagnosis of osd and avulsion fractures .
inoue et al too reported one case with pre exiting asymptomatic osd but did not comment on the duration between diagnosis and avulsion . mosier and stanitsk   reported another case that presented with avulsion fracture after three weeks of diagnosis of osd .
chow et al reported one case of avulsion fracture with prior diagnosis of osd 6 months back .
levi et al reported one case in 13 year old boy who had history of osd in left knee since one year .
thus a time variation from 3 weeks to 1 year has been reported between diagnosis of osd and avulsion fractures , however data is insufficient to make comment on the period after diagnosis of osd , in which activities should be restricted to prevent tibial avulsion fracture
. it would be probably safe to have sports restrictions up till the physeal fusion or complete radiological healing of the primary osd .
the latter point was not commented on in the reviewed literature and probably a non healed osd will have a higher propensity for avulsion fractures as seen in our case .
the original classification system was provided by sir reginald watson - jones which defined three types .
type i was an avulsion of a small part of the tibial tubercle , distal to the proximal tibial physis .
ryu and debenham described a fracture of the tibial tuberosity that extends posteriorly along the proximal tibial physis creating an avulsion of the entire proximal epiphysis ( type iv ) .
in our case both knee had ogden class ii fractures and were treated with k wires and tension band wiring .
open reduction of type ii injuries is essential   and many methods of fixation for avulsed tibial tubercle are available like tension band wiring , screw fixation with washer , suture anchor fixation , bone staples fixation etc [ 19,29 - 30 ] . in ogden type iii injuries where there is comminution and intraarticular extension the range of motion may be limited [ 3 , 30 ] , however as our case was extraarticular type ii injury the recovery of range of motion was full as reported by other such studies [ 6 , 15,21,30 ] .
we report a rare case of bilateral tibial tuberosity avulsion fracture in a case of pre - existing osd .
this case shows association between these factors and we can probably suggest to patients to restrict activities till complete radiological healing of the osd to prevent risk of tibial tubercle avulsion .
our case was an extraarticular avulsion and open reduction internal fixation results in good clinical and functional results .
high strain and sports activities should be restricted till healing of diagnosed osd to prevent risk of tibial tubercle avulsion fractures . in cases with avulsion fracture of tibial tuberosity in adolescent
 introduction : osgood - schlatter disease ( osd ) is a well known condition , characterized by pain over the tibial tubercle with subsequent tubercle prominence . 
 avulsion fracture following osd is a rare complication . 
 we report an unusual case of simultaneous bilateral tibial tubercle avulsion fracture in a 16 year old boy who was a known case of osd.case presentation : a 16 year old boy a known case of osd presented to the outpatient department with history of jumping from the school compound wall ( two feet height ) while playing , followed by severe pain around anterior aspect of both knees and difficulty in walking . 
 radiographs showed bilateral tibial tubercle avulsion fracture . 
 he was treated successfully with open reduction and internal fixation with tension band wiring . at the end of 22 months 
 the patient was symptomatically relieved and both the tuberosities were united with the main bone.conclusion:even though bilateral osgood - schlatter disease ( osd ) is a well known condition , one should always keep in mind the risk of tibial tubercle avulsion fractures while treating a case of osd . 
 patient should be advised not to involve in strenuous activities till the disease subsides radiologically or till skeletal maturity . 
Introduction:
Case presentation:
Conclusion:
INTRODUCTION
CASE REPORT
SURGICAL PROCEDURE
DISCUSSION
CONCLUSION: