Tibial Physeal Injuries Research Articles

Ipsilateral Healthy-segment Response to Leg Length Discrepancy.

Few studies address frequency or magnitude of healthy lower-extremity segment response to ipsilateral companion segment shortening. We sought to document and quantify this occurrence in a variety of pediatric etiologies. We reviewed the medical record and radiographs of patients undergoing epiphysiodesis to manage leg length discrepancy. Inclusion criteria for this study were leg length discrepancy of a single lower-extremity segment by identifiable cause and adequate scanograms to allow accurate measurement of all 4 lower-extremity segments before any surgical treatment for the discrepancy. We recorded the etiology of shortening, age of onset of disorder, the length of the lower-extremity segments on scanograms, and age at the time of radiographs. We considered ipsilateral healthy-segment difference from the contralateral ≥ 0.5cm. as clinically significant. Two hundred nine patients met inclusion criteria (126 boys, 83 girls). The average age was 12.5years. 16/60 patients with avascular necrosis of the hip demonstrated ipsilateral tibial shortening averaging 1.2cm whereas 6/60 demonstrated ipsilateral tibial overgrowth averaging 0.6cm. 11/30 Legg-Perthés patients demonstrated ipsilateral tibial shortening averaging 0.7 cm; none had ipsilateral tibial overgrowth. 10/42 posteromedial bow patients had ipsilateral femoral shortening averaging 0.8cm, whereas 6/42 had ipsilateral overgrowth averaging 0.8cm. 13/48 with distal femoral physeal injury demonstrated ipsilateral tibial shortening averaging 1.2cm, whereas 6/48 demonstrated ipsilateral tibial overgrowth averaging 0.8cm. 8/29 tibial physeal injuries (proximal or distal) demonstrated ipsilateral femoral shortening averaging 1.1cm. whereas 7/29 demonstrated ipsilateral femoral overgrowth averaging 0.7cm. Although there are individual exceptions, the ipsilateral healthy segment does not grow appreciably more than the contralateral in patients with avascular necrosis of the hip, Legg-Perthés disease, or physeal trauma. The femur is not a significant component of shortening in patients with posteromedial bow. Level III, retrospective review.

Anti-VEGF antibody delivered locally reduces bony bar formation following physeal injury in rats.

Physeal injuries can result in the formation of a "bony bar" which can lead to bone growth arrest and deformities in children. Vascular endothelial growth factor (VEGF) has been shown to play a role in bony bar formation, making it a potential target to inhibit bony repair tissue after physeal injury. The goal of this study was to investigate whether the local delivery of anti-VEGF antibody (α-VEGF; 7.5 μg) from alginate:chitosan hydrogels to the tibial physeal injury site in rats prevents bony bar formation. We tested the effects of quick or delayed delivery of α-VEGF using both 90:10 and 50:50 ratio alginate:chitosan hydrogels, respectively. Male and female 6-week-old Sprague-Dawley rats received a tibial physeal injury and the injured site injected with alginate-chitosan hydrogels: (1) 90:10 (Quick Release); (2) 90:10 + α-VEGF (Quick Release + α-VEGF); (3) 50:50 (Slow Release); (4) 50:50 + α-VEGF (Slow Release + α-VEGF); or (5) Untreated. At 2, 4, and 24 weeks postinjury, animals were euthanized and tibiae assessed for bony bar and vessel formation, repair tissue type, and limb lengthening. Our results indicate that Quick Release + α-VEGF reduced bony bar and vessel formation, while also increasing cartilage repair tissue. Further, the quick release of α-VEGF neither affected limb lengthening nor caused deleterious side-effects in the adjacent, uninjured physis. This α-VEGF treatment, which inhibits bony bar formation without interfering with normal bone elongation, could have positive implications for children suffering from physeal injuries.

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.

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.

Segmental tibial fracture with physeal and diaphyseal fracture causing popliteal artery and common peroneal nerve injury in a 12-year-old child: A rare case with a unique injury mechanism

Proximal tibial physeal injuries with neurovascular injuries are rare. Here, we report the case of a 12-year-old boy with a rare fracture pattern that is segmental tibia fracture with physeal and diaphyseal fracture with popliteal artery and common peroneal nerve injury, which has never been reported earlier to the best of our knowledge. We also discuss the possible mechanism of injury and also describe the surgical decision-making and highlight the importance of prompt identification and early management of such patients for a good clinical outcome.

Reviewing Current Concepts in Distal Tibial Physeal Injuries: New Twists and Old Turns?

Distal tibial physeal injuries are common in children accounting for a significant proportion of the paediatric trauma. They are commonest between the years of 10-16, temporally related to the timing of physeal closure. They are strongly associated with sporting activities where there are significant sudden changes in direction with resulting force applied through the distal physis. This article reviews the anatomy, pathophysiology, imaging, classification systems and management of these injuries. Salter Harris, Tillaux and triplanar fractures are discussed. This article, in addition to informing the reader of the above, we hope will also update the reader of relevant new twists in management strategy as well as re-visit the old turns that have provided the main stay of orthopaedic surgical understanding of these injuries.

Open reduction and internal fixation of SER type distal tibial physeal injuries

Open reduction and internal fixation of SER type distal tibial physeal injuries

Elastic Bandage Traction Technique for Reduction of Distal Tibial Fractures

In the present technique report, we describe a useful noninvasive traction technique that uses a 6-inch elastic bandage that can be obtained in every operating room and can be easily applied around the patient's ankle and the surgeon's waist to offer a stable traction force during minimally invasive plate fixation of distal tibial fractures. This technique frees the surgeon's hands to focus on applying other forces, such as rotational, varus, or valgus forces, to reduce the fracture and stabilize the reduction and alignment during percutaneous insertion and fixation of the plate. This technique, although simplistic and old-fashioned, is also useful for the closed reduction of distal tibial physeal injuries in children, because it can provide a significant amount of traction force while allowing the surgeon to apply other forces for fracture reduction. This technique can be used in the emergency room, where an ankle distractor is not usually present, and in some cases could be useful during ankle arthroscopy.

Reliability and Necessity of Computed Tomography in Distal Tibial Physeal Injuries

Reliability and Necessity of Computed Tomography in Distal Tibial Physeal Injuries

Exceptional Functional Recovery and Return to High-impact Sports After Van Nes Rotationplasty

Rotationplasty involves wide resection of lower-extremity malignancy and approximately 180° rotation of the tibia to allow the ankle to function similarly to the former knee joint. It is most commonly used for sarcomas around the knee, such as the distal femur and proximal tibia, in adolescent and young adult patients and is an option for patients with proximal femoral focal deficiency (congenital short femur). Rotationplasty is an alternative to ablative procedures when functional outcome is a consideration or when resection of involved areas and endoprosthetic reconstruction is not possible. This article describes functional status and return to competitive sport after rotationplasty for a lower-extremity bone sarcoma with 3-year follow-up. Despite a postoperative course complicated by a distal tibial physeal injury and femoral neck stress fracture, the patient recovered fully by 1 year postoperatively. Pain free at rest and with activity and with no loss of function, the patient is a successful athlete, playing basketball and baseball and skiing competitively. The patient used a custom-made prosthesis that likely played a role in his high level of function. The patient's high function is evidenced by a maximal or near-maximal possible score on all subsections of the Short Form 36 health survey. Although this level of function is exemplary, it may be more expected in younger, more active, highly motivated, and emotionally and socially mature individuals.

Lower limb deformity following proximal tibia physeal injury: long-term follow-up

BackgroundProximal tibial physeal injuries are quite rare, but their complications can be of great importance. The purpose of this study was to evaluate the effect of this injury on the axis and length of a child’s limb.Materials and methodsThis study focused on 12 patients with proximal physeal injury of the tibia (8 boys and 4 girls; mean age at the time of injury: 8.9 years). Injuries were classified according to the Salter–Harris scheme into 5 types (type II—7 patients, type III—3 patients, type IV—1 patient, type V—1 patient). In 5 cases, a coexisting fracture of the injured limb was observed (fibular fracture—3 cases, intercondylar fracture—1 case, tibial tubercle fracture—1 case). Ten patients were treated conservatively and 2 patients underwent an operation. Seven of the 12 patients were available for long-term follow-up, with a mean duration of 14.4 years (11.2–22.0 years).ResultsAngular deformity was observed in 6 of the 7 patients, with a mean valgus deformity of 2.7°, within an average of 5.8 months after the injury. After 3 years of follow-up, complete remodeling was observed in all of those 6 cases (4 of the patients were treated conservatively and 2 underwent surgery). One patient developed 6 mm of tibial shortening. No functional limitation or pain was recorded in any of the patients during the follow-up.ConclusionsInjury to the proximal tibial epiphysis, while rare, may result in angular or length disturbance, regardless of the initial treatment (conservative or surgical). Parents should always be informed of this possibility, and long follow-up is indicated. Nevertheless, this type of injury rarely results in functional limitations.

Clinical and radiological results in distal tibial physeal injuries

In this study, we evaluated the clinical and radiological results of the distal tibial epiphyseal fractures in children treated with surgery. We evaluated 59 patients (33 boys, 26 girls) retrospectively. Physeal fractures were classified according to the Salter-Harris classification: 4 fractures were type I, 22 type II, 29 type III, and the remaining 4 type IV. Closed reduction and internal fixation were performed in 29 patients, while open reduction and internal fixation were performed in 30 patients. Mean age at the time of trauma was 10.9 years (6-14). Patients were evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score. Patients were operated in a mean of 3.8 hours (3-72). Fixation was performed with Kirschner (K)-wire in 50 patients, with screw in 6 patients, and with both K-wire and screw in 3 patients. Mean follow-up time was 71.7 months (12-149). Due to premature physeal arrest, 1 cm shortening and valgus deformity were seen in only one patient. However, no infection, nonunion, or osteonecrosis was observed in any patient. Mean AOFAS score was 86.6 (65-100) at the last follow-up. Successful results with fewer complications could be obtained in ankle physeal fractures with early management through adequate reduction and stabilized fixation.

Reliability and Necessity of Computerized Tomography in Distal Tibial Physeal Injuries

Reliability and Necessity of Computerized Tomography in Distal Tibial Physeal Injuries

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.

Outcome of distal tibial physeal injuries

In a retrospective review of 725 children's tibial fractures between 1990 and 2004, we found paediatric tibial fractures to have a bimodal distribution according to age, peaking at the age 14 years with incidence of 17.1 in 1000 in boys and 5.1 in 1000 in girls. Two hundred and twenty-five (31.0%) cases involved the distal tibial physis, associated with Salter-Harris (SH) I (0.4%), SH II (56.9%), SH III (21.7%) and SH IV (20%) injury patterns. Of these fractures, 77% had initial displacement of more than 2 mm and independent of treatment modality, 20% of cases still had residual displacement of more than 2 mm after reduction. There was significantly less residual displacement in patients who had a computed tomography scan before the intervention versus those who did not (0.3 vs. 1.4 mm, P=0.003). Twelve cases (11.2%) of premature physeal closure were identified after SH II (67%), SH III (17%) and SH IV (17%) fractures. No significant link was found between premature physeal closure and displacement (either initial or residual), mechanism of injury, or treatment modality. In those fractures with an intact fibula, we found significantly less initial displacement (4.7 vs. 7.4 mm, P<0.05) and significantly shorter time to union (6.27 vs. 7.55 weeks, P=0.001). Good anatomical reduction with or without open reduction and internal fixation is one of the important factors in reducing complication rates, and we suggest but cannot statistically prove that open reduction and internal fixation is indicated in fractures with a residual displacement of 2 mm or more. The presence of an intact fibula at the time of tibial fracture has a significant positive influence on fracture outcome. Level III: Retrospective Review.

Physeal injuries of the distal tibia: long-term results in 376 patients

The aim of this study was to evaluate our treatment of distal tibial physeal injuries retrospectively and explain the relationship between the trauma mechanism, the radiographic injury pattern, the subsequent therapy and the functional outcome, as well as to further deduce and verify prognostic criteria. At the Department of Trauma Surgery, Vienna Medical University, 419 children and adolescent patients with physeal injuries of the distal tibia were treated from 1993 to 2007, of these 376 were included in our study and evaluated retrospectively. Seventy-seven displaced physeal fractures of the distal tibia were reconstructed anatomically by open or closed reduction and produced 95% excellent results. A perfect anatomical reduction, if necessary by open means, should be achieved to prevent a bone bridge with subsequent epiphysiodesis and post-traumatic deformities due to growth inhibition and/or retardation.

Mutual Position of the Distal Fibular Physis and the Tibiotalar Joint Space - Radiological Typology and Clinical Significance

The mutual position of the distal fibular physis compared to the tibiotalar joint space in the immature skeleton was investigated in X-ray studies. The clinical relevance of the recorded mutual position was evaluated for paediatric skeletal traumatology. 140 radiographs of immature ankle joints without skeletal injury were reviewed and the mutual position of the distal fibular physis and tibiotalar joint space was tested. We then reviewed a cohort of 30 children with skeletal injuries of both the distal tibial epiphysis and the distal fibula. The type of distal fibular injury was evaluated according to the mutual position of the distal fibular physis and the tibiotalar joint space. We found that in about one-half of cases the distal fibular physis is located distally to the plane of the tibiotalar joint, which has not been considered in the literature. Thus, we defined three radiological types of immature ankle joint according to the vertical position of the distal fibular physis in relation to the tibiotalar joint space: type 1 - distal fibular physis is above the joint space; type 2 - distal fibular physis is on the same level as the joint space; type 3 - distal fibular physis is below the joint space. In the second cohort, we found that type 2 predisposes to physeal fibular injury and type 3 predisposes to metaphyseal fibular injury. All data obtained were statistically evaluated. There are three radiological types of immature ankle joint. Type 1 is only an evolutionary type without clinical significance, type 2 predisposes to physeal and type 3 to metaphyseal fibular injury in combination with distal tibial physeal injury.

Analsis of the Distal Tibial Physeal and Epiphyseal Injury

Analsis of the Distal Tibial Physeal and Epiphyseal Injury

Distal tibial physeal injuries in children: a different treatment concept.

Fifty-six patients with Salter-Harris type II physeal fractures of the distal tibia were treated with a weight-bearing long leg cast for 4 weeks. Forty patients were followed clinically and radiographically for an average of 22 months. There were no nonunions or angular deformities. There was one case of clinically insignificant premature physeal closure. Premature physeal closure results from the trauma to the physis that occurs at the time of injury and is not affected by early weight-bearing. Four weeks of immobilization in a long leg weight-bearing cast allows adequate healing and faster rehabilitation without an adverse effect on the growth of the distal tibia.

Radiology of postnatal skeletal development. VIII. Distal tibia and fibula.

Initially the distal tibial physis is a relatively transverse structure. As the epiphysis matures, undulations develop within the physis and lappet formation occurs peripherally. Within the first two years a significant physeal undulation develops anteriorly above the medial malleolus. This undulation must not be misinterpreted as premature epiphyseodesis following distal tibial fracture. Secondary ossification in the distal tibia begins centrally and initially expands to fill the area over the tibial plafond. At the lateral side of the tibial epiphysis the ossification center may be wedge-shaped. The medial margin adjacent to the medial malleolus is often irregular and may show small peripheral foci of ossification. By seven to eight years, the secondary center extends into the medial malleolus, with complete distal extension often not occurring until adolescence (although usually complete by ten to eleven years). The malleolar tip may exhibit an accessory ossification center. However, this center also may be a traumatic avulsion in the symptomatic patient. Physiologic epiphyseodesis begins over the medial malleolus and subsequently extends laterally. This pattern of closure appears to predispose to fracture of the lateral portion of the distal tibial epiphysis (fracture of Tillaux), as well as to triplane fractures. The articular surface curves onto the lateral side of the distal tibia to form an articulation with the lateral malleolus (distal tibiofibular joint). A similar extension occurs along the medial side of the fibula. These surfaces extend proximally as a recess to the level of the distal tibial physis, at which point the syndesmosis begins. The initially transverse distal fibular physis becomes a convoluted structure, with extensive peripheral lappet formation. Within these regions of physeal overlap there may be small areas of accessory ossification (both medially and laterally) that should not be misinterpreted as fractures. This overlapping also minimizes specific physeal separation and displacement (especially when compared to the incidence of distal tibial physeal injuries). Stress views may be necessary to show such an undisplaced fracture. The fibular physis normally is level with the tibial articular surface or distal extent of the tibial ossification center, especially after the second year of life (however, it may be more proximal in infants). As in the medial malleolus, there may be accessory ossification at the tip of the fibula. While this usually is a normal variant of secondary ossification, occasionally it also may result from trauma. Extensive porosity of the distal fibular metaphysis predisposes to buckling or torus injuries that may have severe, multiangular deformation.