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Periosteum interposed at the compression side of the injury
17%
311/1830
Periosteum interposed at the tension side of the injury
79%
1441/1830
Fracture comminution interposed at the tension side of the injury
1%
18/1830
Fracture comminution interposed at the compression side of the injury
14/1830
Unrecognized fracture line
2%
28/1830
Select Answer to see Preferred Response
Periosteum interposed on the tension side of the injury may impede reduction of pediatric ankle fractures. Physeal fractures of the distal tibia are fairly common injuries. Interposition of periosteum and other soft tissues is occasionally responsible for creating a block to reduction in these injuries. The periosteum becomes entrapped at the tension side of the injury. Entrapped periosteum may also lead to premature physeal closure. Entrapped periosteum has been found to produce bone, cartilage or fibrous tissue within the physis. Barmada et al. performed a retrospective study to determine the incidence and predictors of premature physeal closure after pediatric distal tibial fractures. Out of 92 fractures, 25 were complicated by physeal closure. Salter-Harris III and IV (medial malleolar type) fractures resulted in the highest percentage of PPC by fracture type (38%). They found that if a residual gap was seen on the radiograph, the incidence of PPC increased to 60%; if no gap was present, the incidence decreased to 17%. All cases treated operatively had interposed periosteum which the authors believe can lead to a higher incidence of physeal closure. Rohmiller et al. performed a review on all patients treated with distal tibial fractures. They had a rate of premature physeal closure of 39.6% in Salter-Harris type I or II fractures of the distal tibial physis. They found a difference based on the mechanism of injury with pronation-abduction type injuries having premature physeal closure nearly 54% of the time. They recommend an anatomic reduction in these injuries to avoid premature physeal closure. Figures A and B are AP and lateral radiographs, respectively, demonstrating a Salter-Harris II distal tibial fracture. Illustration A is a photograph demonstrating how periosteum may be interposed at a tension side of a fracture site (Barmada et al.). Incorrect Answers: Answer 1: Periosteum is usually interposed at the tension side of the injury. Answers 3 & 4: There is no fracture comminution visualized in these radiographs. Answer 5: Though an unrecognized fracture line may be present, it is unlikely to create a block to reduction.
4.5
(2)
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