Proximal Tibia Metaphyseal Fractures - Pediatric - Pediatrics

Introduction

Proximal tibia metaphyseal fractures are significant for their tendency to develop a late valgus deformity
- etiology of valgus deformity is unknown
- known as Cozen's fracture or phenomenon
Epidemiology
- most common in children 3-6 years of age
Mechanism
- typically low-energy with valgus force across the knee
- classic mechanism is child going down slide in the lap of an adult
Prognosis
- valgus deformity resolves spontaneously

Classification

Classification of pediatric proximal tibia metaphyseal fractures is descriptive.
- important radiographic parameters include:
  - complete versus incomplete
    - majority are incomplete
  - displaced or nondisplaced
  - presence and location of associated fibula fracture

Presentation

Symptoms
- pain
- refusal to bear weight
Physical exam
- valgus deformity
- evaluate carefully for compartment syndrome

Imaging

Radiographs
- recommended views
  - required
    - AP and lateral
- findings
  - look for incomplete vs complete and presence of a proximal fibula fracture which may indicate a more unstable fracture pattern

Treatment

Nonoperative
- long leg cast in extension with varus mold
  - indications
    - nondisplaced fracture
  - technique
    - casts are maintained for 6-8 weeks with serial radiographs
    - weight bearing may be allowed after 2-3 weeks.
- reduction followed by long leg cast in extension with varus mold
  - indications
    - displaced fracture
  - technique
    - requires conscious sedation or general anesthesia
    - cast in near full extension (10 degrees flexion)
    - varus mold at fracture site
Operative
- open reduction
  - indications
    - inability to adequately reduce a displaced fracture
    - secondary to soft tissue interposition
  - technique
    - limited medial approach to proximal tibia
    - periosteum or tendons of pes anserinus may block reduction
    - internal fixation not commonly required

Complications

Valgus deformity
- may be observed for 12-24 months with expectation of spontaneous correction
- parents should be counseled in advance
- treatment
  - if deformity fails to resolve
    - medial hemi-epiphysiodesis in skeletally immature patient
    - corrective osteotomy in skeletally mature patient
Limb length discrepancy
- affected tibia is often longer (average 9mm)
- typically does not require intervention however parents should be counseled that this does not resolve

TAG

(OBQ10.177) A 5-year-old girl falls off of a trampoline and sustains a tibia fracture. The tibia fracture is reduced and placed into a long leg cast in the emergency room. A post-reduction radiograph is provided in Figure A. The parents should be counseled that a temporary tibial deformity may occur. Which of the following best describes the deformity? Topic

Review Topic

FIGURES: A

1. Recurvatum
2. Varus
3. Malrotation
4. Valgus
5. Procurvatum

PREFERRED RESPONSE ▶

DISCUSSION: Pediatric proximal tibia metaphyseal fractures, or Cozen fractures, heal reliably but often progress to a valgus deformity. The valgus deformity seen with Cozen fractures is secondary to an increase in metaphyseal growth medially. Zionts and MacEwen peformed a retrospective review of 7 patients with Cozen fractures and found that the valgus angulation progressed most rapidly during the first year after the injury, and then continued at a slower rate for as long as seventeen months.

Tuten et al then re-reviewed this same cohort at 15 year followup and found that the valgus angulation completely resolved in 100% of cases. However, the affected tibia was longer than the contralateral tibia in 100% of cases with an average limb-length discrepancy of 9 mm.

The retrospective review by Ogden et al found radiographic evidence that the medial metaphysis was longer in every instance compared to the distance laterally. Illustration A is another example of a proximal tibia fracture that developed valgus overgrowth as evidenced in Illustration B. This particular case underwent medial stapling for guided growth.

Illustrations: A

REFERENCES:

1. Ogden JA, Ogden DA, Pugh L, Raney EM, Guidera KJ. Tibia valga after proximal metaphyseal fractures in childhood: a normal biologic response. J Pediatr Orthop. 1995 Jul-Aug;15(4):489-94. PMID:7560041 (Link to Abstract)

2. Tuten HR, Keeler KA, Gabos PG, Zionts LE, MacKenzie WG. Posttraumatic tibia valga in children. A long-term follow-up note. J Bone Joint Surg Am. 1999 Jun;81(6):799-810. PMID:10391545 (Link to Abstract)

3. Zionts LE, MacEwen GD. Spontaneous improvement of post-traumatic tibia valga. J Bone Joint Surg Am. 1986 Jun;68(5):680-7. PMID:3722224 (Link to Abstract)

Question Authors:

Michael Hughes MD, Eric Shirley MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 11 Ratings

TAG

(OBQ05.179) A 3-year-old boy sustained a minimally displaced proximal metaphyseal tibia fracture of the left leg 6 months ago that was treated with a molded long leg cast. His current AP radiograph is shown in Figure A. What is the most appropriate management? Topic

Review Topic

FIGURES: A

1. Follow-up radiographs in 6 months
2. Ring fixator placement with distraction osteogenesis
3. Hemiepiphyseodesis of the proximal tibia
4. Follow-up radiographs in 3 months and placement of knee-ankle-foot (KAFO) orthosis
5. Closing wedge proximal tibial osteotomy

PREFERRED RESPONSE ▶

DISCUSSION:
Pediatric proximal tibia metaphyseal fractures that are minimally displaced are also named Cozen fractures. They heal reliably but often progress to a valgus deformity. The valgus deformity seen with Cozen fractures is secondary to an increase in metaphyseal growth medially and are treated with observation as they almost always spontaneously correct over time.

Zionts et al peformed a retrospective review of 7 patients with Cozen fractures and found that the valgus angulation progressed most rapidly during the first year after the injury, and then continued at a slower rate for as long as seventeen months.

Tuten et al then re-reviewed this same cohort at 15 year followup and found that the valgus angulation completely resolved in 100% of cases. However, the affected tibia was longer than the contralateral tibia in 100% of cases with an average limb-length discrepancy of 9 mm.

REFERENCES:

1. Tuten HR, Keeler KA, Gabos PG, Zionts LE, MacKenzie WG. Posttraumatic tibia valga in children. A long-term follow-up note. J Bone Joint Surg Am. 1999 Jun;81(6):799-810. PMID:10391545 (Link to Abstract)

2. Zionts LE, MacEwen GD. Spontaneous improvement of post-traumatic tibia valga. J Bone Joint Surg Am. 1986 Jun;68(5):680-7 PMID:3722224 (Link to Abstract)

3. Herring JA (Ed): Tachdjan's Pediatric Orthopaedics, Ed 3. Philadelphia , PA, WB Saunders, 2002, PP 839-890

Question Authors:

Michael Hughes MD, Eric Shirley MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 12 Ratings

Level of Evidence 4 (Case Series)

Tuten HR, Keeler KA, Gabos PG, Zionts LE, MacKenzie WG. Posttraumatic tibia valga in children. A long-term follow-up note. J Bone Joint Surg Am. 1999 Jun;81(6):799-810. PMID:10391545 (Link to Abstract)
Zionts LE, MacEwen GD. Spontaneous improvement of post-traumatic tibia valga. J Bone Joint Surg Am. 1986 Jun;68(5):680-7 PMID:3722224 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Herring JA (Ed): Tachdjan's Pediatric Orthopaedics, Ed 3. Philadelphia , PA, WB Saunders, 2002, PP 839-890

Undefined

Ogden JA, Ogden DA, Pugh L, Raney EM, Guidera KJ. Tibia valga after proximal metaphyseal fractures in childhood: a normal biologic response. J Pediatr Orthop. 1995 Jul-Aug;15(4):489-94. PMID:7560041 (Link to Abstract)
Tuten HR, Keeler KA, Gabos PG, Zionts LE, MacKenzie WG. Posttraumatic tibia valga in children. A long-term follow-up note. J Bone Joint Surg Am. 1999 Jun;81(6):799-810. PMID:10391545 (Link to Abstract)
Zionts LE, MacEwen GD. Spontaneous improvement of post-traumatic tibia valga. J Bone Joint Surg Am. 1986 Jun;68(5):680-7. PMID:3722224 (Link to Abstract)

Proximal Tibia Metaphyseal Fractures - Pediatric

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