Review Question - QID 2191

The images for this child show a distal tibial physeal fracture which may be associated with malrotation of the foot.

Distal tibial physeal injuries commonly occur in the setting of a twisting injury. Although the foot may appear grossly normal and the radiographs show only mild physeal widening, rotational deformity may exist. Healing in this rotated position can lead to changes in foot progression angle, more often resulting in increased external rotation of the foot. The recommended treatment is to evaluate the child for rotational deformity at the time of injury and then perform a closed reduction followed by bent-knee long leg casting.

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

Broock et al. present a case report of a 7-year-old child who sustained an external rotation injury that showed only physeal widening on radiographs. Interestingly, this was associated with a 45-degree external rotation deformity of the foot/ankle that reduced following closed reduction.

Figure A demonstrates anterior widening of the distal tibial physis while Figure B shows widening of the medial aspect of the distal tibial physis. Although clinical malrotation may occur in the setting of distal tibial physeal injuries, it may only show mild physeal widening on plain radiographs.

Incorrect Answers:
Answer 2: According to the article by Phan et al. (see above), an external foot progression angle is far more common than an internal foot progression angle.
Answer 3: An equinus contracture is unlikely given the rotational nature of the injury.
Answer 4: Avascular necrosis is a very rare complication of distal tibia physeal fractures.
Answer 5: Leg compartment syndrome is rare in the distal tibia, but a compartment syndrome of the foot secondary to a tight extensor retinaculum has been described after pediatric ankle fractures.