Tibial Spine Avulsion Injuries in Children and Adolescents: A Narrative Review of Anatomy, Management Strategies, and Return-to-Sport Considerations

Tibial spine avulsion injuries represent a distinct pattern of anterior cruciate ligament (ACL) injury in children and adolescents, reflecting the unique anatomical and biomechanical properties of the skeletally immature knee. Unlike midsubstance ACL ruptures, these injuries involve avulsion of the tibial insertion and pose specific diagnostic and therapeutic challenges. Management strategies remain heterogeneous, particularly for partially displaced fractures, with variation in surgical indications, fixation techniques, and rehabilitation protocols. This narrative review provides a structured synthesis of current evidence on the anatomy, biomechanics, clinical presentation, and management of pediatric tibial spine avulsion injuries. Nonoperative and operative approaches are compared, with attention to fixation strategies, complications, physeal considerations, and rehabilitation principles. Return-to-sport (RTS) outcomes are examined, with available evidence suggesting that RTS rates may be comparable between operative and nonoperative management in selected patients, although interpretation is limited by heterogeneous and predominantly retrospective data. Early mobilization appears important for reducing arthrofibrosis risk, while rehabilitation should be individualized. RTS decision-making remains inconsistent, with commonly used criteria largely extrapolated from ACL reconstruction literature and lacking validation in pediatric populations. Multifactorial assessment incorporating functional testing and patient-reported outcomes is increasingly advocated, although evidence for psychological readiness remains limited. Overall, the current literature is characterized by methodological heterogeneity and limited comparative data, restricting definitive conclusions. This review provides a clinically oriented synthesis while highlighting key uncertainties and priorities for future research.