Review Question - QID 215123

This patient sustained a distal tibial physeal fracture. External rotation through the physis is frequently unrecognized until the patient has been walking for a few months.

Distal tibial physeal injuries are common following a twisting mechanism. Radiographs often show only mild physeal widening. Rotational deformity may occur through the physis. Healing in this rotated position can lead to changes in foot progression angle, more often resulting in increased external rotation of the foot. It is critical to evaluate for rotational deformity at the time of injury and correct this rotation at the time of casting with a closed reduction.

Phan et al. reviewed the cases of 23 children with either a Salter-Harris (SH) 1 or SH 2 fracture of the distal tibia. They reported that 14 of 23 children had increased external foot progression angle in both feet with significantly more external rotation on the injured side. They concluded that no patient developed an internal rotation deformity.

Broock et al. reviewed a case report of a 7-year-old child who sustained an external rotation injury to the ankle with only physeal widening on radiographs. They reported an associated 45-degree external rotation deformity of the foot/ankle. They concluded that recognition and proper reduction may prevent an external rotation deformity.

Figure A demonstrates anterior widening of the distal tibial physis. Figure B shows widening of the medial aspect of the distal tibial physis.

Incorrect Answers:
Answer 2: External rotation deformity is far more common than an internal rotation deformity following these injuries
Answers 3&4: Procurvatum and recurvatum are often appreciated on initial imaging and often corrected with a closed reduction at the time of casting
Answer 5: This patient has a distal tibia physeal injury. If growth arrest occurred, a varus deformity would ensue from the continued growth of the fibula