Review Question - QID 212973

The patient is presenting with a displaced Salter-Harris II fracture of the distal tibia. Residual gapping of greater than 2 mm has been associated with increased rates of premature physeal closure (PPC).

Pediatric distal tibia fractures pose a treatment challenge due to the potentially high risk of PPC. Increased residual fracture displacement, high energy mechanisms (abduction injuries), and medial malleolar fractures are risk factors for PPC. An anatomic reduction should be achieved by closed means if possible, but increased residual gapping has been associated with interposed periosteum, which necessitates open reduction.

Barmada et al. performed a retrospective review of patients with Salter-Harris I-IV fractures of the distal tibia. The authors found a significant association between PPC and a post-reduction gap of greater than 2 mm, with no significant association with initial fracture displacement. They recommended open reduction and internal fixation in cases of residual gapping to remove interposed periosteum.

Rohmiller et al. performed a retrospective review of patients with Salter-Harris I and II fractures of the distal tibia. The authors found a significant rate of PPC with abduction injuries while skateboarding or playing soccer as well as residual fracture displacement following treatment. The authors recommend achieving an anatomic reduction, whether that requires open or closed methods.

Figures A and B demonstrate and AP and lateral radiograph of a displaced Salter-Harris II right distal tibia fracture and corresponding fibula fracture.

Incorrect Answers:
Answer 1: The amount of initial fracture displacement has been associated with PPC in several studies. However, the risk is greater with increased residual fracture gap following closed reduction.
Answer 2: The number of reduction of attempts was not significantly associated with PPC in Barmada et al.
Answer 3: Increased rates of PPC have been seen with skateboarding injuries with an abduction force across the ankle, not while playing football.
Answer 5: Method of treatment has not been associated with PPC provided an anatomic reduction is achieved.