VOL. 84-B, NO. 4, MAY 2002 579 P. J. B. Hallam, FRCS, Registrar M. A. Fazal, MA, FRCS, Registrar H. E. Ware, FRCS, Consultant Orthopaedic Surgeon Chase Farm Hospital NHS Trust, The Ridgeway, Enfield, Middlesex EN2 8JL, UK. N. Ashwood, FRCS, Orthopaedic Registrar Whittington Hospital, Highgate Hill, London N19 5NF, UK. M. M. S. Glasgow, FRCS, Consultant Orthopaedic Surgeon Norfolk and Norwich Health Care NHS Trust, Brunswick Road, Norwich, Norfolk, UK. J. M. Powell, FRCS, Consultant Orthopaedic Surgeon The Ipswich Hospital NHS Trust, Heath Road, Ipswich, Suffolk 1P4 SPD, UK. Correspondence should be sent to Mr P. J. B. Hallam at 8, St James School, Georges Road, London N7 8HD, UK. ©2002 British Editorial Society of Bone and Joint Surgery 0301-620X/02/410372 $2.00 An alternative to fixation of displaced fractures of the anterior intercondylar eminence in children P. J. B. Hallam, M. A. Fazal, N. Ashwood, H. E. Ware, M. M. S. Glasgow, J. M. Powell From Chase Farm Hospital NHS Trust, Enfield, England F ractures of the anterior intercondylar eminence in children are relatively uncommon. There is considerable debate as to the best treatment of displaced fractures, but most methods described in the literature involve an open procedure combined with some form of fixation. Using human anatomical dissections, we have shown that the transverse meniscal ligament can become incarcerated within the fracture and act as a block to reduction. We describe an arthroscopic technique which requires no fixation device and report the results of its use in eight displaced fractures. This method gives reliable results and offers the advantage of less potential morbidity. J Bone Joint Surg [Br] 2002;84-B:579-82. Received 19 July 2000; Accepted after revision 3 November 2000 The anterior intercondylar eminence of the tibia lies between the anterior poles of the menisci, anterior to the anterior tibial spine (Fig. 1). The anterior cruciate ligament is attached to it. Fractures in this area are uncommon in adolescence with a reported annual incidence of 3 in 100 000. They have been classified into three types by Meyers and McKeever. 2 Type I is the least severe with minimal displacement of the avulsed fragment and a high degree of bone apposition. Type II is displaced, but retains some apposition to the intercondylar eminence and type III is displaced with no apposition (Fig. 2). A modification of this classification describes a type-IV fracture in which the fragment is displaced and comminuted. 3 While most authors agree that undisplaced type-I frac- tures should be treated conservatively, there is much debate as to the best treatment of displaced type-II and type-III fractures. Most treatments described for displaced fractures involve some form of open reduction and internal fixation using absorbable sutures, 2 multiple pins, 3 Kirschner wires 4 wire sutures 5 or screws. 6 We undertook a clinical and cadaver study which identi- fied the transverse meniscal ligament as the main obstacle to reduction and now describe an arthroscopic technique to treat these fractures without internal fixation. Patients and Methods We performed the anatomical study on five fresh adult (two male, three female) cadaver knees which were dissected leaving the anterior structures intact. The anterior inter- condylar eminence was osteotomised to simulate a dis- placed fracture and the structures incarcerated within the fracture identified. The best method of reduction of the fracture was then sought and the reduction compared with the knee held in flexion and extension. For the clinical study, we treated and followed up eight adolescents (six girls, two boys) with a mean age of 12.6 years (11 to 14) with type-II or type-III fractures of the anterior intercondylar eminence, according to Meyers and McKeever, 2 as judged by plain anteroposterior and lateral radiographs. There were five fractures of the left knee and three of the right. Although patients were unable to describe the exact mechanism of injury, three fractures occurred after a fall from a cycle and the remaining five during sporting activities. Six were type-II and two were type-III injuries. All patients underwent examination under anaes- thesia and arthroscopy within 48 hours of injury. After washout of the haemarthrosis, the transverse meniscal liga- ment was seen to obstruct reduction. Using a probe, the ligament was pulled out of the site of the fracture which was then reduced by firm pressure. The reduction could be maintained by keeping the knee in hyperextension. An above-knee plaster cylinder was then applied with the knee in the hyperextended position. After observation overnight,