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Introduction
  • Overview
    • proximal tibia epiphyseal fractures are rare injuries seen in adolescents that may be associated with vascular injury 
      • treatment may be nonoperative or operative depending on the Salter-Harris classification, stability, and displacement of fracture
  • Epidemiology
    • incidence
      • < 1% of pediatric fractures
    • demographics
      • more commonly seen in children 12-14 years old
  • Pathophysiology
    • mechanism of injury 
      • high energy trauma
      • varus/valgus force
      • hyperextension
  • Associated conditions
    • fracture
      • may occur as a part of a Type III tibial tubercle fracture  
    • vascular injury
      • most common with hyperextension injuries
      • tethering of popliteal artery (5%)
    • peroneal nerve injury (5%)
    • ligamentous injury
      • seen in up to 40% of Salter-Harris type III and type IV injuries
    • compartment syndrome (3-4%)
Anatomy
  • Physeal considerations
    • general assumptions
      • leg growth continues until 
        • 16 yrs in boys
        • 14 yrs in girls
    • growth contribution
      • leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)
        • proximal femur - 3 mm/yr (1/8 in)
        • distal femur - 9 mm/yr (3/8 in)
        • proximal tibia - 6 mm/yr (1/4 in)
        • distal tibia - 5 mm/yr (3/16 in)
    • closure of proximal tibial epiphysis occurs in a predictable pattern
      • sagittal plane - posterior to anterior
      • coronal plane - medial to lateral
      • axial plane - posteromedial to anterolateral
  • Ligaments
    • medial collateral ligament
      • superficial portion extends distal to physis to insert on medial metaphysis
      • acts as medial buttress
    • lateral collateral ligament
      • inserts on proximal pole of fibula
      • acts as lateral buttress along with fibula
    • patellar ligament
      • inserts on tibial tubercle
      • acts as restraint to posterior displacement
  • Blood supply
    • popliteal artery
      • distal portion lies close to posterior aspect of proximal tibia
        • tethered to proximal tibia by firm connective tissue septa
        • at risk of injury with displaced fractures
      • divides into anterior tibial and posterior tibial branches beneath arch of soleus
    • lateral inferior geniculate artery
      • passes over popliteus, anterior to lateral head of gastrocnemius, and underneath LCL
    • medial inferior geniculate artery
      • passes along proximal border of popliteus, anterior to medial head of gastrocnemius, to anterior proximal tibia
Classification
 
 Salter-Harris Classification 
Type I  • fracture through the physis
 •
mean age 12 yo
 • usually displaced (>50%) due to buttress effect of tibial tubercle and fibula
Type II  • fracture through the physis and exiting through the metaphysis
 •
mean age 14 yo
 • usually displaced (>67%)
 • most common pattern is medial gapping with lateral Thurston-Holland fragment and proximal fibula fracture

Type III  • fracture through the physis and exiting through the epiphysis
 •
usually tibial tubercle fractures

Type IV  • fracture through the physis, metaphysis and epiphysis

 
Presentation
  • Symptoms
    • inability to bear weight
  • Physical exam
    • inspection
      • pain and swelling
      • tenderness along the physis
      • may see deformity or have palpable step-off if displaced
    • motion
      • may see varus or valgus knee instability on exam
    • neurovascular exam
      • important to perform thorough neurovascular exam
        • physis is at same level of trifurcation of vessels and there is a risk of vascular compromise with displacement
Imaging
  • Radiographs 
    • recommended views
      • AP
      • lateral 
    • optional views
      • oblique
      • varus/valgus stress but risk of injury to physis
    • findings  
      • displacement of fracture fragments
      • Salter-Harris classification
  • CT
    • indications
      • assess fracture displacement
      • best modality for SH III or IV fractures
Treatment
  •  Nonoperative
    • immobilization in long leg cast
      • indications
        • non-displaced fractures
        • stable Salter-Harris type I and type II fractures
      • techniques
        • reduce with traction and gentle flexion
        • cast in slight flexion for 6 weeks
      • outcomes
        • redisplacement is common without fixation
  • Operative
    • CRPP
      • indications
        • unstable Salter-Harris type I and type II fractures
        • redisplacement following closed treatment
    • ORIF  
      • indications
        • irreducible fractures
          • usually due to diaphyseal periosteal flap blocking reduction
        • displaced Salter-Harris type III and type IV fractures
        • vascular injury
Techniques
  • CRPP
    • positioning
      • supine on radiolucent table
    • instrumentation
      • crossed smooth pins
        • transphyseal if Salter-Harris type I or type II with small Thurston-Holland fragment
        • extraphyseal if Salter-Harris type III or IV
      • cannulated compression screws parallel to physis
        • useful for Salter-Harris type II with large Thurston-Holland fragment
        • can also be used for Salter-Harris type III or IV
    • post-op
      • univalved or bivalved long leg cast in slight flexion for 4-6 weeks
  • ORIF
    • positioning
      • supine on radiolucent table
    • approach
      • midline anterior longitudinal incision from inferior pole of patella to tibial tubercle
      • consider medial approach if vascular injury
    • instrumentation 
      • crossed smooth pins
        • transphyseal if Salter-Harris type I or type II with small Thurston-Holland fragment
        • extraphyseal if Salter-Harris type III or IV
      • cannulated compression screws parallel to physis
        • useful for Salter-Harris type II with large Thurston-Holland fragment
        • can also be used for Salter-Harris type III or IV
    • post-op
      • univalved or bivalved long leg cast in slight flexion for 4-6 weeks
Complications
  • Loss of reduction
  • Growth disturbances (25%)
    • can lead to limb length discrepancy and/or angular deformities
    • more common in open fractures
  • Compartment syndrome
  • Ligamentous instability
 

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