Injury, Int. J.

Care Injured 48S3 (2017) S7–S11

Contents lists available at ScienceDirect

Injury
j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c at e / I n j u r y

Outcome of distal tibia physeal fractures: a review of cases as related to risk factors
Fabio D’Angeloa, *, Giuseppe Solarinob, Davide Tanasa, Alessia Zania, Paolo Cherubinoa, Biagio Morettib
a
Division of Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
b
Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari “Aldo Moro”, Bari, Italy

K E Y W O R D S A B S T R A C T

Premature physeal closure Introduction: The physeal fractures represent the 20–30% of all fractures of the child. The distal tibial physis is the
Distal tibia physeal fractures third most frequently injured. The most important complication is the premature physeal closure (PPC). Aim of
Displacement this study is to evaluate risk factors that can influence the outcome like fracture pattern, fracture displacement,
mechanism of injury and treatment method.
Materials and Methods: The 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 displacement was 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.
Results: There was 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.
Conclusion: The 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 as well 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.
© 2017 Elsevier Ltd. All rights reserved.

Introduction Aim of this study is to evaluate risk factors that can influence the
outcome like fracture pattern, fracture displacement, mechanism of
The physeal fractures are typical of childhood and are the 20–30% injury and treatment method.
of all fractures of the child. The distal tibial physis is the third
most frequently injured physis and constitutes 11% of all physeal Materials and methods
injuries [1–3]. The most important complication is the premature
physeal closure (PPC). The incidence of PPC in distal tibia physeal We retrospectively analyzed 46 patients with diagnosis of distal
fractures is from 2% to 43% [4–6]. Factors that influence PPC include tibial physeal fracture from 2003 to 2013. Data recorded included
fracture pattern, fracture displacement (initial and post reduction), gender, age and the external cause of injury.
number of manipulations, interposed periosteum, mechanism of Thirty-four patients (73.9%) were male and twelve (26.1%) females;
injury and treatment method [2,7–9]. the average age at the time of the trauma was 11 years (range 2–16
years). The peak incidence occurred at the age of 14 years for males and
at the age of 12 for females. Twenty fractures were left-sided and
twenty-six were right-sided.
The more common causes of injury were non-specific falls (45%),
* Corresponding author at: Prof Fabio D’Angelo Division of Orthopaedics and Traumatology,
playing soccer (15%), motor vehicle accidents (12%), biking (8%), playing
Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Viale Borri
57, 21100 Varese, Italy, Tel: +390332 278 824, Fax: +390332278825. basketball (5%) and others (15%). There was a seasonal variation in the
E-mail address: [email protected] (F. D’Angelo). incidence of tibial fractures with peaks during summer months.

0020-1383 / © 2017 Elsevier Ltd. All rights reserved.

Initial X-ray were categorized according to Salter-Harris (SH) [10] routinely performed under sedation in the operating room. Pinning
and Dias-Tachdjian (DT) [11,12] classifications. In respect to Salter- treatment was adopted to maintain a closed reduction when fracture
Harris’ classification we recorded: 3 type I (6.5%), 30 type II (65.2%), 7 was unstable and therefore the risk of secondary displacement was
type III (15.2%), 6 type IV (13.0%); none was classified as type V. considered high. Open reduction was performed if an adequate
According to Dias and Tachdjian’s classification, based on the reduction could not be obtained. During open surgery, interposed
injured mechanism, we identified: 11 fracture in supination-inversion periosteum was removed if necessary. In the post-operative period, all
(23.9%), 10 in supination-plantar flexion (21.7%), 9 in supination- the patients follow the same protocol and were instructed to maintain
external rotation (19.6%), 14 in pronation-eversion-external rotation non-weight-bearing and were secured in a long-leg cast for at least
(30.4%), 1 Tillaux’s fracture (2.2%) and 1 tri-planar fracture (2.2%). four weeks.
Fracture displacement was also recorded in millimeters, measuring the At follow-up evaluations, patients underwent anterior/posterior
largest displacement between the epiphysis and metaphysis on the and lateral X-ray to check any complications such as premature or
anteroposterior or lateral X-ray. The association with a concomitant asymmetrical physeal closure, leg length difference, angular deformity
fibula fracture was observed in 25 cases (54.3%). Two cases (4.3%) were and joint discrepancy. All the X-rays were evaluated by two observers
open fractures. In 12 cases (26.1%) a CT study was made for additional not involved during surgery. The minimum follow up was 48 months.
assessment and better definition of the fracture lines in order to plan We performed a statistical analysis of the value of displacement and
the correct treatment (Figure 1). the following factors: type of fracture according to SH and DT
The methods of treatment were closed reduction and casting, classifications, CT, fracture of fibula and type of treatment. The data
closed reduction and percutaneous pinning or ORIF. Reduction was were statistically analyzed using the R software with the Kruskal-
made if the displacement was greater than 2 mm for both intra- Wallis test. The level of significance was set at p < 0.05. All the statistical
articular and extraarticular fractures. Closed treatment with cast was analysis was performed by an observer not involved in the surgery.

Fig. 1. (A,B) X-ray of a SH IV type fracture; a fibula fracture is also present. (C,D) The CT is useful to better define the pattern of the fracture and to plan the treatment.
 F. D’Angelo et al. / Injury, Int. J. Care Injured 48S3 (2017) S7–S11 S9

Results 0.8 mm. The reduction and synthesis of epiphyseal tibia was performed
with a screw and a Kirschner wire.
Eight patients were treated with closed reduction under anesthesia The PPC was diagnosed at 12 months after injury (Figure 2). He was
and protected in a femoral-podalic cast, 3 with reduction and treated elsewhere for the correction of the angular deformity with an
percutaneous pinning with Kirshner wires and 35 with ORIF. In the external fixation system.
ORIF group, according to SH classification, we treated: one type 1,
twenty-five type II, five type III and four type IV fractures. In fractures Discussion
with an intact fibula, we found significantly less preoperative
displacement (2.6 mm vs 10.4 mm) ( p < 0.0001). A significant higher The physeal fractures are very common in children and the main
value of pre-reduction displacement (mean value 10.5 mm) was goal is to avoid any complications in the management of these
observed in patients with a mechanism of injury in pronation- fractures, with attention to the risk factors associated.
eversion-external rotation according to the DT classification ( p = A premature physeal closure, partial or complete, is the most
0.0005). There were no significant differences between the values of common complication after a distal tibial physeal injury. The arrest
displacement in the groups according to SH classification ( p > 0.05). is caused by injury to the germinal layer of the physis [13].
Patients also evaluated by a CT study had a greater value of preoperative Complications of physeal injury also include shortening and/or
displacement (mean value 8.9 mm), but the correlation of the data was angular deformity [14].
not statistically significant ( p > 0.05). There was significantly less Risk factors are high-energy injuries, significant initial displace-
residual displacement in patients who had open reduction and internal ment, mechanism of injury and multiple attempts at closed reduction.
fixation (0.8 mm) versus those who had closed reduction (1.9 mm) and A physeal arrest can appear even after two years from trauma;
percutaneous pinning or only plaster ( p = 0.019). Only one fracture was therefore, extended follow-up is important. If an arrest is suspected,
complicated by PPC. This patient had a distal tibial physeal fracture of the plain radiographs may show a bony bar. Comparative X-rays of the
type III according to SH classification associated with a fractured fibula. contralateral ankle may be helpful. CT or magnetic resonance imaging
The injured mechanism based on the classification of DT was from (MRI) can be used to evaluate the extent of a bony bar [15].
supination-inversion. A preoperative CT study was also performed. Spiegel et al. suggested that fractures could be associated to high,
Preoperative displacement was 3 mm, while the post-treatment was low and unpredictable risk of complications considering skeletal

Fig. 2. (A,B) Preoperative X-rays showing a SH type III fracture with also a distal physeal injury of the fibula. (C,D) Postoperative X-rays showing treatment with a percutaneous
Kirschner wire and a screw. (E,F) PPC with an angular deformity of the distal tibia was seen after twelve months of treatment.
S10 F. D’Angelo et al. / Injury, Int. J. Care Injured 48S3 (2017) S7–S11

maturity, severity of injury, fracture type, degree of comminution and in the present study, the Authors found that an associated fibular
displacement as well as adequacy of reduction [16]. fracture was a risk factor for the latter complication. Previously, Seel
Kling et al. reviewed 65 distal tibia physeal fractures and showed et al. had underlined the importance of an intact fibula, having found
that medial malleolar fractures (SH III and IV) and “perhaps type II” significantly less initial displacement in those with an intact (4.7 mm)
fractures, commonly result in higher incidence of growth disturbances. vs. a fractured fibula (7.4 mm) and also a significantly shorter time to
Anatomic physeal reduction by open or closed methods can decrease union (6.27 vs. 7.55 weeks) [21].
the incidence of these complication [9]. These results appear to be in contrast with previous ones reported
The indications to perform a CT derived from observation of the several years ago by Spiegel et al., who found that the incidence of
abnormalities on the X-ray (intraarticular or comminuted fracture, complications were correlated with the type of fracture according to
complex injury pattern, indistinct plain images) and also included the SH classification, the severity of displacement or comminution and
patient factors such as mechanism and energy of injury. The idea of CT the adequacy of reduction, but regardless the association of fibular
scanning all intrarticular fractures to assess displacement and fracture fracture [16]. Also Leary et al. found statistically significant correlation
configuration to aid anatomical fixation is supported by Cutler et al. between the amount of initial fracture displacement and the rate of PPC
[17]. In patients studied with CT scan, due to a more accurate definition [15]. This may be related more to the mechanism of injury. In our study,
of fracture, the value of post reduction displacement was less than the in fact, we observed a great displacement in patients with a mechanism
ones who did not undergo CT study. In 26.1% of our cases we decided to of injury in pronation-eversion-external rotation according to the DT
require a CT evaluation for a better visualization and pattern of the classification. An intact fibula was found in 45.7% of patients with a
bony lesions: such a behavior is in accordance with the guidelines distal tibial physeal injury. We found that mean initial displacement in
drawn in a review by Wuerz and Gurd and even more with a recent patients with intact fibula was significantly less than in patients with a
paper by Nenopoulos et al. [18,19]. They assessed 64 distal tibial fractured fibula according to the mechanism of injury.
fractures with intra-articular involvement on two separate occasions in Analysis of treatment methods showed that the minimal displaced
a blinded study, in order to classify the fracture and decide the fractures tend to be treated into plaster meanwhile the most displaced
appropriate treatment approach: initially sole plain radiographs were fractures were treated with ORIF. All treatments gave a mean residual
used to diagnose the type of the fracture, thereafter CT scans were displacement of less than 2 mm. Historically, patients have been
performed in the same patients in order to re-evaluate diagnosis and divided in two groups: the first with displacements of 2 mm or less, the
select the appropriate treatment. Their results were that surgical second with more than 2 mm. This value is considered the limit for
treatment was decided in 18 patients and non-surgical in 46 according requiring the need of manipulation or not [21]. Our data showed that
to plain radiographs, whilst the number of patients referred for surgical 36% of fractures having 2 mm displacement or less receiving surgical
treatment raised to 42 leaving only 22 patients to be treated treatment, although the previous concept. This suggests that clinical
conservatively after CT scan evaluation. The Authors conclude that judgment plays a significant role in management decisions.
the sole use of plain radiographs may lead to misdiagnosis and Actually, it is still under discussion whether surgical management
subsequent erroneous selection of suitable treatment; therefore, reduce the risk of premature physeal closure. In fact, Russo et al. have
patients with transitional distal tibial fractures as well as patients demonstrated, in SH type II fractures occurred in 96 patients with a
with displaced SH III and IV fractures must undergo CT examination in mean age of 12.6 years at presentation, that surgical fixation with
order to make the most accurate diagnosis possible. Also in a study by anatomic reduction and removal of interposed tissue, although it may
Thawrani et al. it is shown that five independent observers, that were be necessary, does not reduce the incidence of PPC. They report the PPC
asked to evaluate 50 distal tibial physeal fractures on 2 separate rates after four different treatments: 55% in 38 patients with >4 mm of
occasions for SH classification and treatment decision, had an displacement treated with ORIF, 46% of PPC in 11 patients with 2–4 mm
agreement of 75% that CT scan was useful, especially in guiding of displacement treated with ORIF, 33% of PPC in 33 patients with 2–
screw placement [20]. Interestingly, with regard to the outcome, a 4 mm of displacement treated with a non-weight-bearing long-leg cast
statistically significant less residual displacement is predictable in and 29% of PPC among the 14 patients with <2 mm of post reduction
patients who had a computed tomography scan before the interven- displacement treated with a non-weight-bearing long-leg cast.
tion versus those who did not, according to Seel et al. [21]. Finally, Eventually, some of these patients with PPC had to undergo a
Crawford suggests that triplane and Tillaux fractures, due to rotational subsequent procedure (epiphsyiodesis, osteotomy) to improve joint
and compression stresses, have unpredictable multiplanar fracture alignment [6].
patterns and thus the fracture may appear different on different x-ray
projections, making computed tomography mandatory to determine Conclusion
the number of fragments [22].
Rohmiller consider multifactorial causes for complication citing the The development of complications after distal tibial fractures is due
mechanism of injury, type of treatment and post reduction displace- to multiple factors. Investigation with CT improves fracture analysis,
ment as important contributing factors. These results show a high treatment planning and fracture reduction in high SH grades or intra-
proportion of PPC in SH II which may be due to the higher mean articular fractures. Good anatomical reduction with or without ORIF is
residual displacement of 1.82 mm, compared with SH types I, III and IV. one of the most important factors in reducing complication rates, and
This difference in residual displacement probably reflects the more we suggest that ORIF is indicated in fractures with a residual
aggressive management of type III and IV fractures treated operatively, displacement of 2 mm or more, even if statistically supported results
that allow to a higher reduction of displacement [23]. have not been described yet. The presence of intact fibula at the time of
Initial displacement has also been shown to have a prognostic use in tibial fracture has a significant positive influence on fracture outcomes.
development of complications, as well as residual displacement and
thus treatment methods should be defined in respect to the distance of Conflict of interest
fracture displacement: we decided to obtain an appropriate reduction
if fracture displacement was greater than 2 mm [24]; this is in
The authors declare no conflict of interest.
accordance to a publication by Cai et al., who reported the results of
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