Detection of soft-tissue interposition in Watson-Jones type IV proximal tibial epiphysis injury by FRACTURE: A case report

Detection of soft-tissue interposition in Watson-Jones type IV proximal tibial epiphysis injury by FRACTURE: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Detection of soft-tissue interposition in Watson-Jones type IV proximal tibial epiphysis injury by FRACTURE: A case report Yasuyuki Omichi, Yuto Sugimine, Kaori Momota, Michihiro Takai, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4862475/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Fast field echo resembling a CT using restricted echo-spacing (FRACTURE) is a method of magnetic resonance bone imaging that provides CT-like image contrast based on a high-resolution 3D gradient sequence. This is the first report to describe the detection of soft-tissue interposition in a patient with proximal tibial epiphysis injury by FRACTURE. We present a case of Watson-Jones type IV proximal tibial epiphysis injury in an 11-year-old boy. FRACTURE revealed soft-tissue interposition into the epiphyseal line. Intraoperatively, soft-tissue interposition to the epiphyseal line was confirmed. In addition to the benefit of radiation-free imaging, FRACTURE also allows for the detailed assessment of fracture and the prediction of soft-tissue interposition, which may be useful in determining the treatment strategy for proximal tibial epiphysis injury. proximal tibial epiphysis injury FRACTURE soft-tissue interposition Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Proximal tibial epiphysis injury is a rare injury, accounting for 0.4–2.7% of pediatric fractures and < 1% of all physeal injuries ( 1 ). This injury is typically seen in adolescents with an average age of 14 years, with a higher incidence in boys than in girls ( 1 ). The injury is primarily caused by movements that require sudden contraction of the quadriceps muscle or knee flexion against contraction, which occur mostly in sports involving jump-landings. This tensile force causes the patella tendon to pull the tibial apophysis, resulting in epiphyseal injury originating from the distal part of the tibial epiphyseal line. Proper evaluation and treatment are essential because growth plate injury may cause deformity. Proximal tibial epiphysis injury is usually diagnosed by physical examination and plain radiography ( 1 ). Additional computed tomography (CT) is performed for cases with unclear findings or complex fractures, but this involves additional radiation exposure. In recent years, various approaches have been proposed in order to reduce radiation exposure and to replace CT. Magnetic resonance (MR) bone imaging is one such approach. MR bone imaging can provide comparable bone assessment to CT, and detect microscopic fractures ( 2 ). Several techniques have been studied to improve the ability of magnetic resonance imaging (MRI) to image bone, including ultrashort echo time, zero echo time, black bone imaging, and fast field echo resembling a CT using restricted echo-spacing (FRACTURE) ( 2 ) ( 3 ). Ultrashort echo time/zero echo time sequences, both based on fast gradient echo sequences, shorten the echo time to less than 1 ms and can rapidly image the signal from the short T2 components in tissues between transmit and receive models, and visualize very short T2 tissues (e.g., cortical bone) as hyperintense signals ( 2 ). FRACTURE, which is based on a high-resolution 3D gradient sequence, can provide CT-like images contrast by utilizing multiple echoes with a constant echo-spacing and post-processing subtraction ( 3 ). In orthopedics, MR bone imaging is useful for the diagnosis and treatment of various diseases in addition to fractures ( 2 ). However, there are no reports on the application of MR bone imaging in the evaluation of epiphysial injury. We present the first report of the application of MR bone imaging in the detection of soft-tissue interposition in a patient with proximal tibial epiphysis injury and describe the treatment strategy. Case Report An 11-year-old Japanese boy with no previous medical history presented to the emergency department with an inability to walk and severe left knee pain while running a short distance. There was no trauma to the left knee during the event. He was 151 cm tall, weighed 45 kg, and had a body mass index of 19.7 kg/m 2 . Clinical examination revealed left knee swelling and tenderness in the anterior over the tuberosity. He was unable to bear weight on or bend his left knee. The left limb was distally neurovascularly intact, and there was no evidence of compartment syndrome. Radiographs revealed a proximal tibial epiphysis injury of the left knee (Fig. 1 ). The epiphyseal line was displaced 7 mm. Accordingly, the injury was classified as Waston-Jones type IV. short T1 inversion recovery (STIR) condition with MRI (Philips Ingenia Ambition, 1.5 T) showed extensive edema of the soft tissue and bone around the avulsed epiphyseal line (Fig. 2 a). FRACTURE, MR bone imaging, revealed the interposition of soft tissue into the epiphyseal line (Fig. 2 b). Interposition in the epiphyseal line detected by FRACTURE showed low signal on STIR and T1 weighted imaging (T1WI), and high signal on fat saturation proton density weighted image (FS-PDWI) (Fig. 2 a,c,d). Surgery was performed the day after the injury. First, closed reduction was performed under general anesthesia, but the avulsed epiphyseal line was not reduced. Therefore, we performed open reduction and internal fixation. An anterior midline approach was used. Damaged anterior soft tissue was observed, but the patellar tendon was intact. Soft-tissue interposition to the epiphyseal line was confirmed. (Fig. 3 a). The interposed soft tissue was released by lower extremity traction or soft tissue pulling (Fig. 3 b), and the avulsed epiphyseal line was easily reduced to its native position. Internal fixation was performed using two ⌀2.4 mm Kirschner wires (Fig. 4 a,b). After surgery, the knee was immobilized in a cylindrical cast for 4 weeks, and then range of motion exercise was started. The Kirchner wires were removed at 6 weeks postoperatively. One-third weight-bearing was permitted from 6 weeks, and full weight-bearing was permitted from 9 weeks. At 6 months postoperatively, radiographs showed no lower extremity deformity, shortening, or epiphyseal line abnormality (Fig. 4 c,d). He obtained a full range of motion and returned to normal activities of daily living without knee pain. Informed consent was obtained from the patient and his parents for the publication of his clinical information in this report. Discussion This is the first report to describe the detection of soft-tissue interposition in a patient with proximal tibial epiphysis injury by FRACTURE. In contrast to zero echo time/ultrashort echo time, FRACTURE, which is based on a high-resolution 3D gradient sequence, does not require high-technology hardware or software, and is suitable for almost all MR scanners ( 3 ). FRACTURE converts structures with a low-signal level, such as cortical bone, calcification, ligament, tendon, air, and bleeding, to structures with a high-signal level by inverting them to black and white. In our case, based on the intraoperative findings, interposition into the epiphyseal line is thought to be ruptured periosteum and soft tissue around the epiphyseal line. FRACTURE may have shown a high-signal depiction of interposition due to bleeding of the soft tissue around the epiphyseal line. Several classification systems for proximal tibial epiphysis injury have been described (Fig. 5 ) ( 1 ). The Watson-Jones classification is based on the fracture location and displacement relative to the tibial physis and included three types of tuberosity fractures. The Watson-Jones classification was later modified by Ogden to include several subtypes based on degree of displacement and comminution. Ryu and Debenham added type IV injury, where the fracture extends posteriorly through the entire proximal tibial physis. Recently, McKoy and Stantiski added type V injury, which is defined as a two-part fracture with a “Y” shaped fracture pattern in the proximal region of the knee. The primary goals of treatment for proximal tibial epiphyseal injury are restoration of the extensor mechanism, anatomic reduction, and restoration of the joint surface ( 1 ). Some type IV injuries may be misclassified as type II or type III, so CT scanning is considered an effective method for evaluating suspected type IV injuries for the presence of a posterior metaphyseal component and the amount of displacement ( 4 ). In type IV injuries, it is considered difficult to obtain adequate bone fusion due to soft-tissue interposition into the epiphyseal line in the proximal epiphysis injury ( 5 ). There is a report of soft-tissue interposition in type IV injury ( 6 ), and Pace et al. reported that 3 of 5 patients with closed treatment for type IV injuries were not successfully treated ( 4 ). If fracture dislocation or instability is present in type IV injury, open reduction and internal fixation should be performed to check for soft-tissue interposition. FRACTURE, which provides detailed bone assessment and can predict soft-tissue interposition, may be useful in determining the treatment strategy for proximal tibial epiphysis injury. MR bone imaging has many advantages, the greatest of which is the ability to perform detailed evaluation without radiation exposure. Radiation exposure from CT scans in childhood, even at low doses, has been shown to increase the risk of leukemia and brain tumors ( 7 ). MR bone imaging is well-suited for the field of orthopedics and is thought to be an alternative procedure for reducing patient radiation exposure. MR bone imaging is also considered useful for the evaluation of osteoarthritis. The ability to evaluate bone marrow edema, ligaments, and cartilage with conventional MRI scans, combined with the evaluation of bone cortex by MR bone imaging, gives MRI an overall advantage over CT. In addition, MR bone imaging improves image reading skill by adding the information obtained from CT-like images when reading MRI in daily clinical practice ( 8 ). MR bone imaging has a limitation. In pediatric patients, MRI examination may not proceed smoothly if patients are unable to remain still due to the characteristic noise of MRI. The technology of MR bone imaging is still improving and is expected to solve this problem in the future. In conclusion, this is the first report to describe the detection of soft-tissue interposition in a patient with proximal tibial epiphysis injury by FRACTURE. In addition to being radiation-free, FRACTURE also allows for the detailed assessment of fractures and the prediction of soft-tissue interposition, which may be useful in determining the treatment strategy for proximal tibial epiphysis injury. MR bone imaging technology is still improving and is expected to have broad clinical applications in the future. Abbreviations CT computed tomography FRACTURE fast field echo resembling a CT using restricted echo-spacing FS-PDWI fat saturation proton density weighted image MR magnetic resonance MRI magnetic resonance imaging STIR short T1 inversion recovery T1WI T1 weighted imaging. Declarations Author Contribution YO contributed to data curation, formal analysis, and conceptualization, and wrote the original draft. YS, KM, MT, RS, TE, TG, SN, and YN interpreted the clinical data and revised the manuscript critically for important content. KS supervised the study. All authors have reviewed and approved the final manuscript. References Cole WW 3rd, Brown SM, Vopat B, Heard WMR, Mulcahey MK (2020) Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents. JBJS Rev 8(4):e0186 Chong LR, Lee K, Sim FY (2021) 3D MRI with CT-like bone contrast - An overview of current approaches and practical clinical implementation. Eur J Radiol 143:109915 Johnson B, Alizai H, Dempsey M (2021) Fast field echo resembling a CT using restricted echo-spacing (FRACTURE): a novel MRI technique with superior bone contrast. Skeletal Radiol 50(8):1705–1713 Pace JL, McCulloch PC, Momoh EO, Nasreddine AY, Kocher MS (2013) Operatively treated type IV tibial tubercle apophyseal fractures. J Pediatr Orthop 33(8):791–796 Bolesta MJ, Fitch RD (1986) Tibial tubercle avulsions. J Pediatr Orthop 6(2):186–192 Venunathan G, Tewari A, Thakur K (2023) A Type IV Tibial Tuberosity Avulsion Fracture in an Adolescent - A Case Report. J Orthop Case Rep 13(7):56–59 Bosch de Basea Gomez M, Thierry-Chef I, Harbron R, Hauptmann M, Byrnes G, Bernier MO et al (2023) Risk of hematological malignancies from CT radiation exposure in children, adolescents and young adults. Nat Med 29(12):3111–3119 Feuerriegel GC, Kronthaler S, Weiss K, Haller B, Leonhardt Y, Neumann J et al (2023) Assessment of glenoid bone loss and other osseous shoulder pathologies comparing MR-based CT-like images with conventional CT. Eur Radiol 33(12):8617–8626 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4862475","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":347930757,"identity":"54ca55d3-4429-4b99-bec4-277a6447e403","order_by":0,"name":"Yasuyuki Omichi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYDACZjB5gIGfmbHxwQcGhgSoOBthLZLtzYcNZxClhQGqxeDMsTRpHoQW3IC/nf3h44KaO/IMN3KMjW3b7PL42RsYP3xg4MvDpUXiMEOy8YxjzwwbZ+QYPs5tSy6W7DnALDmDga0YpzWHGY5J87AdZmyWANqS28acuOFGAhszDwNbYgMOHfKHGdt/8/w7bN8mkWMmbdlWT1iLwWFmNmbetsOJPTxA7zMCGQS1GB5mY5bm7TucPIMdGMg9544nzuw52Cw5wwC3X+TOH3/4mefbYdv9h4FR+aOsOrGfvfnghw8Vx3CGGCpgBEcgI9BJBscSiNPC8AfOqiFWyygYBaNgFAx/AAA3s1qgb1RRxgAAAABJRU5ErkJggg==","orcid":"","institution":"Tokushima Municipal Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yasuyuki","middleName":"","lastName":"Omichi","suffix":""},{"id":347930758,"identity":"76dd1423-9f68-4a2a-85f7-978cf9b0118e","order_by":1,"name":"Yuto Sugimine","email":"","orcid":"","institution":"Takamatsu Red Cross Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuto","middleName":"","lastName":"Sugimine","suffix":""},{"id":347930763,"identity":"0e8694b3-e1e6-491f-b4f6-5ef085969a46","order_by":2,"name":"Kaori Momota","email":"","orcid":"","institution":"Tokushima Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kaori","middleName":"","lastName":"Momota","suffix":""},{"id":347930765,"identity":"86878cc6-02ec-4cd9-b01b-6966ddb23903","order_by":3,"name":"Michihiro Takai","email":"","orcid":"","institution":"Tokushima Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Michihiro","middleName":"","lastName":"Takai","suffix":""},{"id":347930768,"identity":"85113493-bfe4-410f-87ac-6bafee65fcf9","order_by":4,"name":"Ryosuke Sato","email":"","orcid":"","institution":"Tokushima Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ryosuke","middleName":"","lastName":"Sato","suffix":""},{"id":347930770,"identity":"570decc4-d681-45e0-b843-49763d4c4b90","order_by":5,"name":"Tetsuya Enishi","email":"","orcid":"","institution":"Tokushima Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tetsuya","middleName":"","lastName":"Enishi","suffix":""},{"id":347930772,"identity":"2c0ed199-6b89-4059-a6f0-8e1f99bb68f4","order_by":6,"name":"Tomohiro Goto","email":"","orcid":"","institution":"Tokushima Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tomohiro","middleName":"","lastName":"Goto","suffix":""},{"id":347930774,"identity":"35b2f7cd-a657-47a0-9c75-8f013c8b8549","order_by":7,"name":"Shunji Nakano","email":"","orcid":"","institution":"Tokushima Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shunji","middleName":"","lastName":"Nakano","suffix":""},{"id":347930775,"identity":"3957ead6-3680-448f-9f04-931c40ede035","order_by":8,"name":"Yukako Nishiyama","email":"","orcid":"","institution":"Tokushima Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yukako","middleName":"","lastName":"Nishiyama","suffix":""},{"id":347930776,"identity":"4242b1e1-2853-4ba3-8435-cd9a5d1374fe","order_by":9,"name":"Koichi Sairyo","email":"","orcid":"","institution":"Tokushima University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Koichi","middleName":"","lastName":"Sairyo","suffix":""}],"badges":[],"createdAt":"2024-08-05 13:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4862475/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4862475/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64321281,"identity":"f9dec414-8d51-4377-9119-de2f6e38dbc1","added_by":"auto","created_at":"2024-09-11 15:28:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":149064,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative anteroporsterior and lateral radiographs. Radiographs showed widened epiphysis and Watson-Jones type IVinjury (white arrow).\u003c/p\u003e","description":"","filename":"Fig1total.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4862475/v1/7c1cfaf3aeda24e10b9c57fa.jpg"},{"id":64320553,"identity":"1843230c-709a-4897-9fc9-34f08e5ad399","added_by":"auto","created_at":"2024-09-11 15:20:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":165484,"visible":true,"origin":"","legend":"\u003cp\u003eMagnetic resonance imaging. \u003cstrong\u003ea\u003c/strong\u003e STIR imaging showed extensive edema of the soft tissue around the avulsed epiphyseal line. \u003cstrong\u003eb\u003c/strong\u003e FRACTURE revealed soft-tissue interposition into the epiphyseal line (white arrow). STIR, short T1 inversion recovery; FRACTURE, fast field echo resembling a CT using restricted echo-spacing.\u003c/p\u003e","description":"","filename":"Fig2adtotal.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4862475/v1/3c0041ec6e77998fa0a2a8f3.jpg"},{"id":64320549,"identity":"f1a938e9-e78d-4728-976e-46a6721a0fd7","added_by":"auto","created_at":"2024-09-11 15:20:49","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":416125,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative findings.\u003cstrong\u003e a\u003c/strong\u003e Soft-tissue interposition to the epiphyseal line was confirmed. (white arrow). asterisk: tibial tuberosity, \u003cstrong\u003eb\u003c/strong\u003e After the release of soft-tissue interposition (white arrow).\u003c/p\u003e","description":"","filename":"Fig3abtotal.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4862475/v1/e85e23fdeed3bca6d95080d8.jpg"},{"id":64320552,"identity":"2d85bdd8-cb35-4c47-b845-8fc218a95118","added_by":"auto","created_at":"2024-09-11 15:20:49","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":383105,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative radiographs. \u003cstrong\u003ea,b\u003c/strong\u003ePostoperative anteroporsterior and lateral radiographs radiographs of the left knee. \u003cstrong\u003ec,d\u003c/strong\u003e Lower extremity radiographs at 6 months postoperatively.\u003c/p\u003e","description":"","filename":"Fig4adtotal.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4862475/v1/f9fe7f4c817c6594bec650c5.jpg"},{"id":64320550,"identity":"06aeeb33-af36-4c8d-a98d-df3be9101de6","added_by":"auto","created_at":"2024-09-11 15:20:49","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":91115,"visible":true,"origin":"","legend":"\u003cp\u003eClassification of proximal tibial epiphysis injuries.\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4862475/v1/4c06945d7a149d39d26db05a.jpg"},{"id":72629231,"identity":"b36f4bfb-9280-4713-8ccf-77faf1f70e38","added_by":"auto","created_at":"2024-12-30 13:53:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1445215,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4862475/v1/c35eeb50-3671-4800-88da-2f8226e34a2a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Detection of soft-tissue interposition in Watson-Jones type IV proximal tibial epiphysis injury by FRACTURE: A case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProximal tibial epiphysis injury is a rare injury, accounting for 0.4\u0026ndash;2.7% of pediatric fractures and \u0026lt;\u0026thinsp;1% of all physeal injuries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This injury is typically seen in adolescents with an average age of 14 years, with a higher incidence in boys than in girls (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The injury is primarily caused by movements that require sudden contraction of the quadriceps muscle or knee flexion against contraction, which occur mostly in sports involving jump-landings. This tensile force causes the patella tendon to pull the tibial apophysis, resulting in epiphyseal injury originating from the distal part of the tibial epiphyseal line. Proper evaluation and treatment are essential because growth plate injury may cause deformity.\u003c/p\u003e \u003cp\u003eProximal tibial epiphysis injury is usually diagnosed by physical examination and plain radiography (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Additional computed tomography (CT) is performed for cases with unclear findings or complex fractures, but this involves additional radiation exposure. In recent years, various approaches have been proposed in order to reduce radiation exposure and to replace CT. Magnetic resonance (MR) bone imaging is one such approach. MR bone imaging can provide comparable bone assessment to CT, and detect microscopic fractures (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Several techniques have been studied to improve the ability of magnetic resonance imaging (MRI) to image bone, including ultrashort echo time, zero echo time, black bone imaging, and fast field echo resembling a CT using restricted echo-spacing (FRACTURE) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Ultrashort echo time/zero echo time sequences, both based on fast gradient echo sequences, shorten the echo time to less than 1 ms and can rapidly image the signal from the short T2 components in tissues between transmit and receive models, and visualize very short T2 tissues (e.g., cortical bone) as hyperintense signals (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). FRACTURE, which is based on a high-resolution 3D gradient sequence, can provide CT-like images contrast by utilizing multiple echoes with a constant echo-spacing and post-processing subtraction (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn orthopedics, MR bone imaging is useful for the diagnosis and treatment of various diseases in addition to fractures (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, there are no reports on the application of MR bone imaging in the evaluation of epiphysial injury. We present the first report of the application of MR bone imaging in the detection of soft-tissue interposition in a patient with proximal tibial epiphysis injury and describe the treatment strategy.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eAn 11-year-old Japanese boy with no previous medical history presented to the emergency department with an inability to walk and severe left knee pain while running a short distance. There was no trauma to the left knee during the event. He was 151 cm tall, weighed 45 kg, and had a body mass index of 19.7 kg/m\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eClinical examination revealed left knee swelling and tenderness in the anterior over the tuberosity. He was unable to bear weight on or bend his left knee. The left limb was distally neurovascularly intact, and there was no evidence of compartment syndrome.\u003c/p\u003e \u003cp\u003eRadiographs revealed a proximal tibial epiphysis injury of the left knee (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The epiphyseal line was displaced 7 mm. Accordingly, the injury was classified as Waston-Jones type IV. short T1 inversion recovery (STIR) condition with MRI (Philips Ingenia Ambition, 1.5 T) showed extensive edema of the soft tissue and bone around the avulsed epiphyseal line (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). FRACTURE, MR bone imaging, revealed the interposition of soft tissue into the epiphyseal line (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). Interposition in the epiphyseal line detected by FRACTURE showed low signal on STIR and T1 weighted imaging (T1WI), and high signal on fat saturation proton density weighted image (FS-PDWI) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea,c,d).\u003c/p\u003e \u003cp\u003eSurgery was performed the day after the injury. First, closed reduction was performed under general anesthesia, but the avulsed epiphyseal line was not reduced. Therefore, we performed open reduction and internal fixation. An anterior midline approach was used. Damaged anterior soft tissue was observed, but the patellar tendon was intact. Soft-tissue interposition to the epiphyseal line was confirmed. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). The interposed soft tissue was released by lower extremity traction or soft tissue pulling (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb), and the avulsed epiphyseal line was easily reduced to its native position. Internal fixation was performed using two ⌀2.4 mm Kirschner wires (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea,b).\u003c/p\u003e \u003cp\u003eAfter surgery, the knee was immobilized in a cylindrical cast for 4 weeks, and then range of motion exercise was started. The Kirchner wires were removed at 6 weeks postoperatively. One-third weight-bearing was permitted from 6 weeks, and full weight-bearing was permitted from 9 weeks. At 6 months postoperatively, radiographs showed no lower extremity deformity, shortening, or epiphyseal line abnormality (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ec,d). He obtained a full range of motion and returned to normal activities of daily living without knee pain.\u003c/p\u003e \u003cp\u003eInformed consent was obtained from the patient and his parents for the publication of his clinical information in this report.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first report to describe the detection of soft-tissue interposition in a patient with proximal tibial epiphysis injury by FRACTURE. In contrast to zero echo time/ultrashort echo time, FRACTURE, which is based on a high-resolution 3D gradient sequence, does not require high-technology hardware or software, and is suitable for almost all MR scanners (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). FRACTURE converts structures with a low-signal level, such as cortical bone, calcification, ligament, tendon, air, and bleeding, to structures with a high-signal level by inverting them to black and white. In our case, based on the intraoperative findings, interposition into the epiphyseal line is thought to be ruptured periosteum and soft tissue around the epiphyseal line. FRACTURE may have shown a high-signal depiction of interposition due to bleeding of the soft tissue around the epiphyseal line.\u003c/p\u003e \u003cp\u003eSeveral classification systems for proximal tibial epiphysis injury have been described (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The Watson-Jones classification is based on the fracture location and displacement relative to the tibial physis and included three types of tuberosity fractures. The Watson-Jones classification was later modified by Ogden to include several subtypes based on degree of displacement and comminution. Ryu and Debenham added type IV injury, where the fracture extends posteriorly through the entire proximal tibial physis. Recently, McKoy and Stantiski added type V injury, which is defined as a two-part fracture with a \u0026ldquo;Y\u0026rdquo; shaped fracture pattern in the proximal region of the knee.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe primary goals of treatment for proximal tibial epiphyseal injury are restoration of the extensor mechanism, anatomic reduction, and restoration of the joint surface (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Some type IV injuries may be misclassified as type II or type III, so CT scanning is considered an effective method for evaluating suspected type IV injuries for the presence of a posterior metaphyseal component and the amount of displacement (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In type IV injuries, it is considered difficult to obtain adequate bone fusion due to soft-tissue interposition into the epiphyseal line in the proximal epiphysis injury (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). There is a report of soft-tissue interposition in type IV injury (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and Pace et al. reported that 3 of 5 patients with closed treatment for type IV injuries were not successfully treated (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). If fracture dislocation or instability is present in type IV injury, open reduction and internal fixation should be performed to check for soft-tissue interposition. FRACTURE, which provides detailed bone assessment and can predict soft-tissue interposition, may be useful in determining the treatment strategy for proximal tibial epiphysis injury.\u003c/p\u003e \u003cp\u003eMR bone imaging has many advantages, the greatest of which is the ability to perform detailed evaluation without radiation exposure. Radiation exposure from CT scans in childhood, even at low doses, has been shown to increase the risk of leukemia and brain tumors (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). MR bone imaging is well-suited for the field of orthopedics and is thought to be an alternative procedure for reducing patient radiation exposure. MR bone imaging is also considered useful for the evaluation of osteoarthritis. The ability to evaluate bone marrow edema, ligaments, and cartilage with conventional MRI scans, combined with the evaluation of bone cortex by MR bone imaging, gives MRI an overall advantage over CT. In addition, MR bone imaging improves image reading skill by adding the information obtained from CT-like images when reading MRI in daily clinical practice (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMR bone imaging has a limitation. In pediatric patients, MRI examination may not proceed smoothly if patients are unable to remain still due to the characteristic noise of MRI. The technology of MR bone imaging is still improving and is expected to solve this problem in the future.\u003c/p\u003e \u003cp\u003eIn conclusion, this is the first report to describe the detection of soft-tissue interposition in a patient with proximal tibial epiphysis injury by FRACTURE. In addition to being radiation-free, FRACTURE also allows for the detailed assessment of fractures and the prediction of soft-tissue interposition, which may be useful in determining the treatment strategy for proximal tibial epiphysis injury. MR bone imaging technology is still improving and is expected to have broad clinical applications in the future.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFRACTURE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efast field echo resembling a CT using restricted echo-spacing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFS-PDWI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efat saturation proton density weighted image\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTIR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eshort T1 inversion recovery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT1WI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eT1 weighted imaging.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYO contributed to data curation, formal analysis, and conceptualization, and wrote the original draft. YS, KM, MT, RS, TE, TG, SN, and YN interpreted the clinical data and revised the manuscript critically for important content. KS supervised the study. All authors have reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCole WW 3rd, Brown SM, Vopat B, Heard WMR, Mulcahey MK (2020) Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents. JBJS Rev 8(4):e0186\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChong LR, Lee K, Sim FY (2021) 3D MRI with CT-like bone contrast - An overview of current approaches and practical clinical implementation. Eur J Radiol 143:109915\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson B, Alizai H, Dempsey M (2021) Fast field echo resembling a CT using restricted echo-spacing (FRACTURE): a novel MRI technique with superior bone contrast. Skeletal Radiol 50(8):1705\u0026ndash;1713\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePace JL, McCulloch PC, Momoh EO, Nasreddine AY, Kocher MS (2013) Operatively treated type IV tibial tubercle apophyseal fractures. J Pediatr Orthop 33(8):791\u0026ndash;796\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBolesta MJ, Fitch RD (1986) Tibial tubercle avulsions. J Pediatr Orthop 6(2):186\u0026ndash;192\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVenunathan G, Tewari A, Thakur K (2023) A Type IV Tibial Tuberosity Avulsion Fracture in an Adolescent - A Case Report. J Orthop Case Rep 13(7):56\u0026ndash;59\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBosch de Basea Gomez M, Thierry-Chef I, Harbron R, Hauptmann M, Byrnes G, Bernier MO et al (2023) Risk of hematological malignancies from CT radiation exposure in children, adolescents and young adults. Nat Med 29(12):3111\u0026ndash;3119\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeuerriegel GC, Kronthaler S, Weiss K, Haller B, Leonhardt Y, Neumann J et al (2023) Assessment of glenoid bone loss and other osseous shoulder pathologies comparing MR-based CT-like images with conventional CT. Eur Radiol 33(12):8617\u0026ndash;8626\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"proximal tibial epiphysis injury, FRACTURE, soft-tissue interposition","lastPublishedDoi":"10.21203/rs.3.rs-4862475/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4862475/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFast field echo resembling a CT using restricted echo-spacing (FRACTURE) is a method of magnetic resonance bone imaging that provides CT-like image contrast based on a high-resolution 3D gradient sequence. This is the first report to describe the detection of soft-tissue interposition in a patient with proximal tibial epiphysis injury by FRACTURE. We present a case of Watson-Jones type IV proximal tibial epiphysis injury in an 11-year-old boy. FRACTURE revealed soft-tissue interposition into the epiphyseal line. Intraoperatively, soft-tissue interposition to the epiphyseal line was confirmed. In addition to the benefit of radiation-free imaging, FRACTURE also allows for the detailed assessment of fracture and the prediction of soft-tissue interposition, which may be useful in determining the treatment strategy for proximal tibial epiphysis injury.\u003c/p\u003e","manuscriptTitle":"Detection of soft-tissue interposition in Watson-Jones type IV proximal tibial epiphysis injury by FRACTURE: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-11 15:20:44","doi":"10.21203/rs.3.rs-4862475/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fd52d746-6a25-419f-a42e-68c60a6c0baa","owner":[],"postedDate":"September 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-30T13:53:09+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-11 15:20:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4862475","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4862475","identity":"rs-4862475","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}