Distal Tibial Physeal Fractures Research Articles

Comparison of surgical outcomes between bioabsorbable and metal screw fixation for distal tibial physeal fracture in children and adolescent.

This study aimed to compare the surgical outcomes between bioabsorbable and metal screw fixation for distal tibial physeal fracture in children and adolescents, radiographically and clinically. This study included consecutive 67 children and adolescents who underwent open reduction and internal fixation using metal or bioabsorbable screws for the distal tibia physeal fracture. All patients underwent preoperative radiographs, three-dimensional computed tomography scans, and postoperative follow-up teleradiogram. Patients were divided into metal (N = 40) and bioabsorbable groups (N = 27). We compared the surgical outcomes between the two groups in terms of clinical and radiographic outcomes, length of hospital stays, and medical cost. Follow-up duration were significantly longer in the metal group than that in the bioabsorbable group. There was no significant difference in the incidence of growth arrest after surgery and the scores of the Oxford Ankle and Foot Questionnaire between the two groups. However, the total hospital stay was significantly longer in the metal group (5.2 ± 4.8 days) compared to the bioabsorbable group (2.6 ± 0.5 days). Medical costs were significantly higher in the bioabsorbable group than in the metal group with a difference of 397 US dollars. The use of bioabsorbable screws exhibited therapeutic effects equivalent to that of metal screws for pediatric distal tibia physeal fractures regarding clinical and radiological outcomes. Moreover, it had the advantage of avoiding the need for repeated general anesthesia and secondary operation for implant removal. Therefore, the use of bioabsorbable screws may be a favourable surgical option for treating pediatric fractures.

Long Leg Versus Short Leg Cast Immobilization for Treatment of Salter-Harris II Distal Tibial Fractures After Closed Reduction: A Multisite Retrospective Study

BACKGROUNDDistal tibial physeal fractures are common injuries that can frequently be treated nonoperatively. Most commonly, long leg cast immobilization is recommended after closed reduction. The purpose of this study was to compare outcomes between long leg cast (LLC) and short leg cast (SLC) immobilization after closed reduction of Salter-Harris II (SH-II) distal tibial fractures. METOHDSA retrospective, multicenter comparative study was performed evaluating skeletally immature patients treated with closed reduction of a displaced SH-II distal tibia fracture at three Level I Pediatric Trauma Centers between 2012 and 2018. Radiographs after casting were compared to those at the time of cast removal to assess for the primary study outcome of loss of reduction (LOR). Secondary outcomes included the length of casting, premature physeal closure, time to weight-bearing, and time to release to activities. RESULTSA total of 148 patients with a median age of 12.7 years (IQR 11.2-13.7) met inclusion criteria. LLC were utilized in 110 cases while 38 patients received a SLC. Loss of reduction occurred in 10 patients (6.8%), nine with a LLC and one in a SLC (p=0.454). Those treated in SLC had a shorter length of casting (p=0.030) and quicker release to activities (p=0.004) than those with LLC. CONCLUSIONSFindings of this retrospective, multi-center study show similar rates of loss of reduction between SLC and LLC immobilization for SH-II distal tibial fractures after closed reduction. Patients received less total casting and returned to sports quicker after SLC immobilization. KEYWORDS CONCEPTS•Salter-Harris II distal tibia fractures can be treated with closed reduction and short leg casting without an increased rate of displacement•Distal tibial physeal fractures treated in a short leg cast can possibly return to sports quicker•The rate of interval displacement of a SH-II distal tibia fracture after closed reduction is approximately 6.7%. LEVEL OF EVIDENCELevel III Retrospective Comparative Study

Computed Tomography Analysis of Distal Tibia Physeal Fracture Patterns: A Classification and Technique for Optimizing Screw Trajectory.

Fractures involving the anterolateral distal tibia, often referred to as Tillaux or Triplane fractures, are often treated operatively to achieve an anatomic reduction of the ankle joint articular surface. Although axial images from computed tomography scans are commonly obtained to measure displacement, no studies have examined these fracture patterns in the axial plane. This information may be useful to guide screw trajectory with only fluoroscopic imaging intraoperatively. We queried an institutional radiology report database for all "Tillaux" or "triplane" fractures and manually reviewed to identify fractures with an anterolateral tibia fragment. The axial image immediately caudal to the physis or physeal scar was used for measurements. The angle between the incisura and the fracture line exiting the incisura was measured. The width of the fracture fragment and the anterior distal tibia was then measured perpendicular to the incisura, representing the width that would be seen on an intraoperative mortise. A cluster analysis was performed to identify fracture patterns. The average age of patients included in the study was 16 ± 2 years. Sixty-nine patients met inclusion criteria 32 patients with Tillaux fractures (46.4%) and 37 patients with triplane fractures (53.6%) met study inclusion criteria for a total of 69 patients. The cluster analysis demonstrated 3 fracture patterns. For type 1 (n=16), the mean was 24.5 ± 6.5 degrees from the incisura and the mean distance from the tibiofibular joint was 21.1 ± 6.3%. For type 2 (n=20), the mean was 58.6 ± 7.2 degrees and the mean distance was 48.7 ± 8.9%. For type 3 (n=33), the mean was 88.6 ± 6.3 degrees and the mean distance was 49.1 ± 9.7%. This is the first study to identify that pediatric distal tibia physeal fractures occur in 3 common patterns with consistent fragment sizes and fracture planes. This information can optimize screw start point and trajectory in the axial plane when referencing a mortise x-ray and C-arm beam. Diagnostic, Level III.

A More Conservative Approach in the Surgical Management of Pediatric Physeal Ankle Fractures Should be Preferred: Mid to Long-term Functional Outcomes of Three Different Surgical Techniques for Salter-Harris Type II and Triplane Distal Tibial Fractures.

Pediatric physeal ankle fractures carry a high risk of complications. This study aimed to (1) investigate the effect of anatomic reduction of the physis on mid to long-term functional outcomes in Salter-Harris type II and triplane distal tibial physeal fractures (DTPFs) and (2) compare the outcomes of 3 different surgical techniques applied in these fractures. The database of a single level-I trauma center was retrospectively reviewed for DTPFs between 2012 and 2022. A total of 39 eligible patients with operative Salter-Harris type II and triplane fractures between 2012 and 2022 were included. Surgical treatment methods were closed reduction-percutaneous fixation (CR-PF), open reduction-screw fixation, or open reduction-plate fixation. Patients were further divided into subgroups for fractures reduced anatomically (<1 mm) or nonanatomically (1 to 3 mm). The primary outcome measures were the American Orthopaedic Foot and Ankle Society Score, ankle range of motion, presence of premature physeal closure and angular deformities, and Takakura ankle osteoarthritis grade. A total of 39 patients were included, with an average age of 12.9 ± 2.2 years. The mean follow-up time was 68.9±38.0 months. The CR-PF group had higher postoperative fracture displacement ( P = 0.011). American Orthopaedic Foot and Ankle Society scores were excellent in all groups, statistically similar between surgical techniques, and similar between anatomic and nonanatomic reduction groups. The CR-PF group ( P =0.030) and nonanatomic reduction ( P = 0.030) provided a significantly lower ankle osteoarthritis rate. All 4 patients with premature physeal closure were observed in patients treated with open techniques. CR-PF for the treatment of DTPFs should be preferred in suitable cases as it is less invasive and provides satisfactory mid to long-term functional outcomes without increasing complications compared with anatomic reduction and open techniques. Level III.

Rates and Factors Associated With Hardware Removal in Physeal Ankle Fractures: Analysis of the Pediatric Health Information System

Background: Ankle fractures are among the most common physeal fractures in children. When surgical management is warranted, subsequent hardware removal remains controversial. This study was designed to determine rates of hardware removal in patients with physeal ankle fractures and identify risk factors for removal. Procedure data was utilized to compare rates of subsequent ankle procedures in patients with hardware removed and hardware retained. Methods: We conducted a retrospective cohort study utilizing data from the Pediatric Health Information System (PHIS) for the years 2015 through 2021. We longitudinally followed patients treated for distal tibia physeal fractures to determine the rates of hardware removal and subsequent ankle procedures. Patients with open fractures or polytrauma were excluded. We used univariate, multivariate, and descriptive statistics to characterize the rates of hardware removal, identify factors associated with removal, and assess the rates of subsequent procedures. Results: This study included 1008 patients who underwent surgical management of a physeal ankle fracture. The mean age at index surgery was 12.6 years with an SD of 2.2 years, and 60% of patients identified as male. Two hundred forty-two patients (24%) had their hardware removed at an average time of 276 days (range, 21-1435 days) following index surgery. Patients with Salter Harris III (SH-III) or Salter Harris IV (SH-IV) fractures had hardware removed more often than patients with Salter-Harris II (SH-II) fractures (28.9% vs 11.7%, P &lt; .01). Four-year rates of subsequent ankle procedures are similar between patients with hardware removed and hardware retained. Conclusion: The rate of hardware removal in children with physeal ankle fractures is higher than previously reported. Patients of younger age, higher income, and with fractures involving the epiphysis (SH-III and SH-IV) are more likely to undergo hardware removal. Level of Evidence: Level III, retrospective study.

Incidence of growth disturbance after distal tibia physeal fracture in children.

To analyze the growth disturbance after distal tibia physeal fracture in children. Data about children with distal tibia physeal fractures between September 2015 to September 2018 were collected, including age, gender, affected side, Salter-Harris classification, initial maximal displacement, with or without fibula fracture, open or closed reduction, the method of fixation, time to surgery, blood loss, duration of operation, and complications. Patients were placed in the growth disturbance group when leg length discrepancy was equal to or greater than 1.5cm, or when they had more than 5 degrees of varus or valgus deformity. Others were placed in the no-growth disturbance group. A total of 143 patients (96 boys and 47 girls) were enrolled in this study. The length of the follow-up periods averaged 29.34 ± 7.46months (26 to 61months). Among the total of 143 patients, the incidence of growth disturbance was 15.39% (22/143). The no-growth disturbance group consisted of 121 patients (84 boys and 37 girls), with a mean age of 11.50 ± 3.20years, and there were 68, 52, and 1 injuries to the left, right, and bilateral sides, respectively. The average maximal displacement was 5.51 ± 3.18mm, and 27.27% (33/121) of patients also had a fibula fracture. The growth disturbance group contained 22 patients (12 boys and 10 girls) with a mean age of 9.32 ± 3.56years, and there were 12, 10, and 0 injuries on the left, right, and bilateral sides, respectively. The average maximal displacement was 5.77 ± 4.89mm, and 45.45% (10/22) of patients also had a fibula fracture. There was a significant difference in age (p = 0.004) and fibula fracture (p = 0.011) between the two groups. More patients had Salter-Harris types III and IV fractures in the growth disturbance group than in the no-growth disturbance group (p = 0.043). Children with Salter-Harris types III and IV fractures, younger children, and children with fibula fractures all have a higher incidence of growth disturbance after distal tibia physeal fractures. Level III-Prognostic study.

Pediatric distal third tibial shaft fractures: a comparison of surgical fixation methods and incidence of concomitant physeal fractures.

The purposeof this study was to compare outcomes of operatively treated pediatric distal third tibial shaft fractures fixed with elastic nailing or plate fixation and to evaluate the incidence of concurrent distal tibia physeal fractures. Retrospective review identified skeletally immature patients that underwent operative fixation of distal third tibia fractures at a level 1 children's hospital from 2010 to 2020. Patient and fracture characteristics were recorded. Analysis of treatment outcomes was performed and rates of concurrent distal tibia physeal fractures were evaluated. Of the 214 surgically treated tibial shaft fractures, 43 were distal third fractures. A concurrent distal tibia physeal fracture was present in 32.6% of patients. These were significantly associated with spiral distal third tibial shaft fractures. The presence of concurrent physeal fractures did not affect patient treatment outcomes. Comparing elastic nailing versus open reduction and plating revealed no difference with time to fracture union, time of postoperative immobilization, or time to full weight-bearing. While elastic nailing was associated with increased coronal angulation, translation, and shortening of fractures on initial postoperative imaging, there was no difference in rates of malunion at final follow-up. In our series, there were no differences in treatment outcomes based on fixation method. Our operatively treated distal third tibial shaft fractures had a higher rate of associated distal tibial physeal fractures than previously published in the pediatric orthopedic literature. We recommend careful evaluation of the ankle for concurrent physeal injuries in patients with distal third tibial shaft fractures indicated for operative treatment. Level of evidence: level III therapeutic study - retrospective comparative study.

Outcomes of pediatric distal tibial physeal fractures

BackgroundFractures of the distal tibia involving the physis are relatively common in children. The data reported on long-term complication rates vary between studies. HypothesisPediatric distal tibial fractures cause medium- and long-term growth disturbances. Materials and methodsThis was a retrospective single-center study. We included physeal distal tibial fractures that were treated in the operating room with a minimum 12-month follow-up. The analysis included age, gender, weight status, circumstances and energy of the injury, fracture type, subsequent treatment, complications, duration of follow-up, radiologic findings and functional outcomes using the AOFAS. ResultsA total of 46 patients were included with a mean age of 12.8 years (2.4–15.9 years) and a mean follow-up of 35.8 months (12–119). At the longest follow-up, 7 patients (15.2%) had growth disturbances. The mean AOFAS score was 95/100 and a decreased ankle range of motion was observed in 18 patients, but it was always less than 10°. High-energy injuries (20 patients) resulted in worse clinical outcomes and a significantly higher rate of growth disturbances (p=.03). DiscussionThis study confirmed the presence of growth disturbances following pediatric distal tibial fractures, especially in cases of high-energy trauma. Therefore, these fractures should be monitored until the end of the growth period. Level of evidenceIV; retrospective study.

Combining Salter-Harris and Dias-Tachdjian could be better at determining the prognosis of distal tibial physeal fractures

ObjectivesThe aim of this study is determining the factors that affect prognosis of distal tibial physeal fractures (DTPF) and analyzing whether Salter-Harris (SH) or Dias-Tachdjian (DT) classification is more predictive for outcomes. MethodsPatients treated for DTPF were retrospectively analyzed. Fracture patterns were classified according to SH and DT. Treatment methods and fracture characteristics were noted. Distal tibial angles and joint irregularities were analyzed on patient's final ankle radiographs followed by American Orthopedic Foot and Ankle Score questionnaire. Results75 patients followed-up between 6 and 96 months meeting the inclusion criteria were evaluated. Joint irregularity was observed in 41.3% and partial premature physeal closure (PPC) in 34.7% of the patients. Lateral distal tibial angle (LDTA) and talocrural angle related deformity were detected in 20% and 14.7% of the patients, respectively. Partial PPC and joint irregularities that have been developed in pronation-eversion-external rotation and supination-inversion injuries (SH type 3, 4) were 62% and 50%, and 42% and 75%, respectively. On follow-ups of supination-external rotation injuries (SH type 2) joint irregularity has never been observed. Following supination-external rotation and supination-plantar flexion injuries, a low rate of partial PPC have been developed; LDTA related deformity was revealed at a high rate of 39.1% after supination-inversion injuries. There weren't any differences observed between the initial displacement, residual displacement or surgical technique and PPC, joint irregularity and angular deformities. Patients treated by ORIF technique had lower AOFAS scores than patients treated by other surgical techniques. ConclusionsIn this study it was revealed that SH classification system is not sufficient alone to determine the prognosis of DTPF, the injury mechanisms causing SH types might be also significant in prediction of the prognosis of DTPF.

Percutaneous Pinning for Recent Lower Tibial Epiphyseal Injury in Pediatric

Background: Physeal fractures of long bones are common injuries treated by orthopedists. Distal tibial physeal fractures account for 11% of all physeal injuries. Objectives: The aim of the work is evaluation of the clinical and radiological outcome of lower tibial epiphyseal injury managed by percutaneous pinning. Patients and Methods: This was a prospective randomized study carried out on 12 cases with distal tibial epiphyseal injuries admitted to Zagazig University with follow up period up to six months. The youngest patient was 8 years old, while the oldest was 16 years old, with an average of 12 years; the high incidence was in the age group 10-15 years. Results:Overall results obtained from 12 cases were satisfactory in 11 cases (91.66%) and unsatisfactory in 1 cases (8.37%). More satisfactory results in this work were in the age group 10-15 years. However, age did not affect the results significantly. Cases with closed injury showed more satisfactory results (100%) than those with open injury, the difference was statistically highly significant. All cases in this study were presented within the first 48 hours from onset of trauma. 8 cases were immobilized for 8 weeks and 4 cases for 6 weeks. The difference was statistically insignificant. 2 cases were managed by open reduction and internal fixation and the difference was statistically insignificant. Conclusion: The percutaneous pinning for lower tibial epiphyseal injury showed good reduction of fracture, satisfactory functional outcome and less complications. The technique provided speed recovery, secure fixation and avoiding prolonged cast immobilization and conservative treatment.

Below-Knee Cast Immobilization for Distal Tibial Physeal Fractures

Distal tibial physeal injuries are one of the most commonly reported fractures in children. Traditionally, treatment recommendations consist of utilization of a long leg cast for initial immobilization. The purpose of this study was to evaluate the efficacy of below-knee cast immobilization in the closed treatment of distal tibial physeal fractures. We reviewed all patients with distal tibial physeal fractures treated with below-knee immobilization at our tertiary care facility between January 2002 and September 2015. Radiographs were analyzed for displacement and angulation at the time of injury, after closed reduction and/or casting, and at completion of immobilization to evaluate for loss of reduction. In total, 120 fractures (120 patients) were reviewed with 63 (52.5%) extra-articular fractures and 57 (47.5%) intra-articular fractures. The mean initial displacement was 4 mm (range 0-26 mm) with 34 patients having greater than 2 mm of displacement at presentation. Closed reduction was performed on 33 (27.5%) patients with the remaining 87 (72.5%) receiving immobilization alone without formal reduction. All fractures successfully healed with only 2 (1.67%) patients experiencing a loss of reduction. Both patients that lost reduction had undergone an initial closed reduction. No nondisplaced fractures lost reduction. These findings suggest that below-knee immobilization is an effective alternative in the treatment of both nondisplaced and displaced distal tibial physeal fractures, including those with intra-articular involvement, as well as those undergoing closed reduction. This creates an opportunity to provide increased patient mobility and early knee range of motion.

Risk of premature physeal closure in fractures of distal tibia.

The reported incidence of premature physeal closure (PPC) in fractures of the distal tibia has varied between 5 and 36%, but there is no consensus on the cause. We wanted to determine incidence and predictors of PPC in distal tibia physeal fractures in a population-based patient cohort. Two hundred forty-one patients (195 Peterson type I-V fractures and 46 transitional fractures) treated for a physeal fracture of the distal tibia during a 5-year period in two tertiary-level teaching hospitals. Odds ratios (OR) for developing PPC for different parameters (Peterson fracture type, associated fibula fracture, primary and postreduction displacement, number of reductions and the method of treatment) were calculated by binary logistic regression analysis. In 195 children with Peterson type I-V fractures PPC was diagnosed in 21 children (11%), of which 11 (6%) had surgery at mean 14 months from the fracture to correct either angular deformity or leg length discrepancy. The incidence of distal tibia PPC is at least 0.05/1000 children. More than one reduction attempt was the most significant risk factor (OR 7.0) for PPC. Peterson fracture type, associated fibula fracture, initial or post-reduction displacement or type of treatment did not correlate with PPC. The incidence of distal tibia PPC is at least 0.05/1000 children. The number of reductions correlates positively with the risk of PPC.

Surgical treatment of distal tibia physeal fractures

Surgical treatment of distal tibia physeal fractures

What is the reason for out-toeing gait on the injured side after surgical treatment of distal tibia physeal fractures?

Aim: The aim of this study was to analyze the cause of out-toeing gait pattern in children who underwent anatomic reduction and internal fixation for distal tibial physeal injury. Material and Methods: This IRB-approved, Level IV review study included traumatic distal tibia epiphyseal injury treated surgically at a single institution between 2010 and 2015. Patients were called back to return for additional follow-up. All clinical (foot progression angle-FPA, hip rotations, thigh foot angle-TFA) and radiological (distal tibial measurements) evaluations were done by 2 independent observers to assess inter- and intra-observer reliability using intraclass correlation coefficients (ICC). Results: There were 38 patients with an average age of 11.4±3.8. There was a non-significant trend noted towards externally in FPA on the injured side. TFA was similar in both extremities (p: 0.56). Hip external rotation was significantly high in injured side, whereas hip internal rotation was similar. Hip external rotation was significantly high.Conclusion: Anatomic joint reduction is mandatory to prevent growth arrest and to maintain lower extremity alignment. Considering that there is no pathology of the hip and no radiologic signs of mal-alignment of the ankle, we think that hip external rotators may shortened due to post-operative resting position, which was ended up with out-toeing gait pattern on the injured side.

Fracture Pattern and Periosteal Entrapment in Adolescent Displaced Distal Tibial Physeal Fractures: A Magnetic Resonance Imaging Study.

To investigate the fracture pattern and periosteal entrapment in adolescent distal tibial physeal fractures. Retrospective case series. Level I academic trauma center. Fifty patients (10-16 years of age) with displaced Salter-Harris type II, III, or IV distal tibial physeal fractures were retrospectively reviewed. Periosteal involvement, fracture pattern. We investigated the incidence and location of periosteal entrapment in those fractures and the angle of the fracture plane of metaphyseal fragments on axial plane by using magnetic resonance imaging. Of the 15 type II, 12 type III (4 malleolar and 8 Tillaux), and 23 type IV (2 malleolar and 21 triplane) fractures, 72.0% (36/50) presented with periosteal entrapment. Among all type II and triplane fractures, periosteal entrapment was observed in the anterolateral corner when there was any displacement on that corner. By contrast, only 1 of 8 Tillaux fractures presented with periosteal entrapment. In almost all supinated foot injuries of type II and triplane fractures, the metaphyseal fracture line was parallel to the intermalleolar axis on axial plane. Salter-Harris type II and triplane fractures have a high risk of periosteal entrapment especially in the anterolateral corner. Therefore, even without preoperative magnetic resonance imaging, surgical repositioning of entrapped periosteum should be considered after failed closed reduction. In cases of supinated foot injuries of type II or triplane fractures requiring surgical fixation, a metaphyseal fracture plane parallel to the oblique coronal plane connecting the medial and lateral malleoli may assist surgeons in achieving appropriate metaphyseal fixation. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome of distal tibia physeal fractures: a review of cases as related to risk factors

IntroductionThe physeal fractures represent the 20–30% of all fractures of the child. The distal tibial physis is the third most frequently injured. The most important complication is the premature physeal closure (PPC). Aim of this study is to evaluate risk factors that can influence the outcome like fracture pattern, fracture displacement, mechanism of injury and treatment method. Material and MethodsThe records of 46 patients treated for distal tibia physeal fractures between 2003 and 2013 were reviewed. Initial injury radiographs were categorized according to Salter-Harris and Dias-Tachdjian classifications and the initial and post-treatment fracture displacementwas measured. Any complex fractures had preoperative CT for additional assessment. Three different types of treatment were compared: closed reduction and casting versus closed reduction and percutaneous pinning versus ORIF. ResultsTherewas significantly less residual displacement in patients who had ORIF versus those who had closed reduction and percutaneous Kirschner wires or plaster only. In fractures with an intact fibula, we found significantly less initial and residual displacement. The Dias-Tachdjian classification is significantly correlated with the displacement. Patients studied with CT show a less degree of post reduction displacement. At the final follow-up we found only one PPC as complication. ConclusionThe physeal fractures are very common in children and the main goal is to avoid any complications. It is clear that the development of complications after distal tibial fractures is due to multiple contributing factors like skeletal maturity, severity of injury, fracture type, degree of comminution and displacement aswell as adequacy of reduction. A premature physeal closure is the most common complication. The fibula fracture can play an important role in initial displacement. The presence of an intact fibula and a good anatomical reduction have a significant positive influence on fracture outcome.

Reliability and Necessity of Computerized Tomography in Distal Tibial Physeal Injuries

Complex distal tibial physeal fractures can be difficult to characterize on plain radiographs. The role of computed tomography (CT) scans in the evaluation and treatment decision of these injuries is unclear. We aimed to determine whether or not the addition of CT would improve the reliability of fracture classification and treatment decision. Five independent observers evaluated 50 distal tibial physeal fractures on 2 separate occasions for Salter Harris (SH) classification and treatment decision (surgical/nonsurgical) using plain radiographs (round 1) and combination of radiographs and CT (round 2). During round 1, observers were asked if they would order a CT, and during round 2, they were asked if the CT was useful. These rounds were repeated at 2 to 4 weeks to assess intraobserver reliability. Statistical analyses were performed to assess inter and intraobserver reliability using Kappa coefficient (κ). Intraobserver reliability for SH classification showed substantial agreement, κ=0.76 and κ=0.80, respectively, during round 1 and 2. Interobserver agreement on the SH class was lower during round 1 and 2 (κ=0.67 and κ=0.57, respectively). There also was almost perfect intraobserver and interobserver agreement in the measurement of displacement at the fracture site during both rounds 1 and 2. Intraobserver reliability for treatment decision was substantial, κ=0.74 and κ=0.80, respectively, during round 1 and 2. However, interobserver agreement for treatment decision was moderate (κ=0.48) and fair (κ=0.36), respectively, during round 1 and 2. Surgeons indicated that they would like to order CT scans for 66% of the time in round 1, but the interobserver agreement as to who would best benefit from the CT was only fair (κ=-0.23). The main purpose of ordering the CT was to delineate fracture anatomy (55% of the time) and the observers felt CT would add to their treatment decision only 26% of the time. During round 2, 75% of time surgeons felt that CT scan was useful. CT was thought to be most useful in guiding screw placement (56% of the time) and not as useful (28% of time) for treatment decision making. Addition of CT in complex distal tibial physeal fractures did not increase interobserver reliability to classify the fracture or the treatment decision. Surgeons reported that the CT was most useful to plan screw placement and changed their treatment decision in about a fifth of the cases.

Irreducible Salter Harris Type II Distal Tibial Physeal Fracture Secondary to Interposition of the Posterior Tibial Tendon: A Case Report

Pediatric distal tibial fractures generally occur without significant long-term sequelae, and patients are commonly able to return to their preinjury activities after proper management. The literature reports excellent outcomes after anatomical reduction of distal tibial and ankle physeal fractures with closed or open treatment. Treatment options include simple immobilization of nondisplaced fractures, and closed or open reduction for restoration of anatomic alignment of displaced fractures. Soft tissue interposition within the fracture can threaten successful closed reduction, and may warrant open management if closed reduction fails to produce a satisfactory result. Despite the documented possibility of soft tissue interposition preventing closed reduction of pediatric ankle fractures, there is a paucity of literature reporting this complication. We report a unique case of an irreducible Salter-Harris type II distal tibial physeal fracture secondary to interposition of the posterior tibial tendon.

Physeal Fractures of the Distal Tibia

A retrospective review of 124 patients was undertaken to determine the incidence of physeal growth arrest (premature physeal closure [PPC]) after physeal fractures of the distal end of the tibia in children. We also sought to identify clinical predictors of PPC. We defined PPC as radiographic evidence of physeal closure as compared to the uninjured side in this patient population. We reviewed the charts of 124 pediatric patients with distal tibia physeal fractures. All patients were followed up until symmetric growth was noted (by Harris growth lines) for a minimum of 1 year or until physiologic closure of the growth plates had been documented radiographically. We calculated the overall incidence of PPC and the incidence by fracture type. Cox multivariate regression analysis was also performed for a number of clinical variables. The mean follow-up was 57 weeks. Fifteen fractures (12.1%) were complicated by PPC. In our study, 67% of the PPC observed occurred in Salter-Harris II fractures, followed by 13% in Salter-Harris III, 13% in Salter Harris IV, and 7% in triplane fractures. We did not observe any physeal arrest in the Salter-Harris I or Tillaux fractures. Using a Cox multivariate regression analysis, we were able to demonstrate statistically significant correlations between mechanism of injury and PPC and between the amount of initial fracture displacement and the rate of PPC. There was a strong relationship between mechanism of injury and PPC. There were trends seen about residual displacement after reduction and the number of attempted reductions and the rate of PPC, but these correlations were not statistically significant. For each millimeter of initial displacement, there was a relative risk of 1.15 (P < 0.01). Recent articles have shown a much higher rate of PPC after distal tibia physeal fracture than what was observed in our cohort. The amount of initial fracture displacement and the mechanism of injury have a statistically significant predictive value in determining the likelihood of PPC development after distal tibia physeal fracture. Trends were seen regarding residual displacement and the number of fracture reductions but were not statistically significant in predicting the occurrence of a PPC. Level III: Retrospective Review.

Pediatric foot and ankle disorders

Purpose of review Disorders of the pediatric foot and ankle are commonly evaluated and treated in the office setting. Most of these problems can be treated conservatively. This article reviews the current literature over the past year related to pediatric foot and ankle problems and their management. Recent findings The primary management of tarsal coalitions should always be conservative. The diagnosis of tarsal coalition is based on the history, physical examination, radiographs, and advanced imaging such as CT. Surgical correction is the last line of treatment. The standard of treatment for clubfoot deformities is conservative in the infant. There may be a relation between having a clubfoot and an ipsilateral limb length discrepancy. Physical examination will aid in screening for the need of limb equalization procedures in children with clubfeet. When surgical correction of talipes equinovarus is needed, the posterior capsule and the posterior talofibular ligament may not need to be released. Anatomic reduction of distal tibia physeal fractures should be attempted to diminish the chances of premature physeal closure. Summary The treatment of pediatric foot and ankle disorders continues to evolve, with further advancements in evaluation, imaging, and techniques reported in the growing body of published literature.