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Updated: Jun 13 2021

Proximal Tibia Epiphyseal Fractures - Pediatric

3.1

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Images
https://upload.orthobullets.com/topic/4024/images/lower-extremity-growth-plate-fractures1.jpg
https://upload.orthobullets.com/topic/4024/images/tibial_tuburcle_fracture_type_iii.jpg
https://upload.orthobullets.com/topic/4024/images/tibia.jpg
https://upload.orthobullets.com/topic/4024/images/orif.jpg
https://upload.orthobullets.com/topic/4024/images/xr_ap.jpg
https://upload.orthobullets.com/topic/4024/images/ct_coronal_2.jpg
  • summary
    • Proximal Tibia Epiphyseal Fractures are rare injuries seen in adolescents that may be associated with vascular injury.
    • Diagnosis can be confirmed with plain radiographs of the knee. 
    • 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
  • Etiology
    • 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 years
      • 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 years
      • 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 (< 2mm) 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 (> 2mm) 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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