Updated: 6/13/2021

Proximal Tibia Metaphyseal Fractures - Pediatric

0%
Topic
Review Topic
0
0
0%
0%
Flashcards
2
N/A
N/A
Questions
8
0
0
0%
0%
Evidence
11
0
0
Topic
Images
https://upload.orthobullets.com/topic/4025/images/29B_moved.JPG
https://upload.orthobullets.com/topic/4025/images/29A_moved.JPG
https://upload.orthobullets.com/topic/4025/images/proximal tibia fracture cropped.jpg
https://upload.orthobullets.com/topic/4025/images/valgus xr.jpg
https://upload.orthobullets.com/topic/4025/images/screen_shot_2018-10-17_at_6.32.58_am.jpg
  • summary
    • Proximal Tibia Metaphyseal Fractures are fractures of the proximal tibia usually seen in children from 3 to 6 years of age. This fracture is significant for its tendency to develop a late valgus deformity, known as a Cozen's phenomenon, that must be monitored closely.
    • Diagnosis can be confirmed with plain radiographs. 
    • Treatment is usually closed reduction and casting in extension with a varus mold.  Late valgus deformity generally resolves with observation alone. 
  • Epidemiology
    • Demographics
      • most common in children 3-6 years of age
  • Etiology
    • Pathophysiology
      • mechanism
        • typically low-energy with valgus force across the knee creating incomplete fracture of proximal tibia
        • can also result from torsional injury
        • classic mechanism is a child going down a slide in the lap of an adult with leg extended
    • Associated conditions
      • Cozen's phenomenon
        • a late valgus deformity
        • etiology is unknown
        • can occur regardless of treatment
  • Anatomy
    • Osteology
      • tibia
        • triangular shaped bone with apex anteriorly that broadens distally
        • anteromedial border is subcutaneous
      • blood supply
        • posterior tibial a. provides nutrient and periosteal vessels
        • nutrient vessels supply inner 2/3 of the tibial diaphysis
  • Classification
    • Descriptive Classification
      • important radiographic parameters include
        • complete vs incomplete
          • majority are incomplete (greenstick, torus)
        • displaced vs. nondisplaced
        • associated fibula fracture
          • presence of fibula fracture suggests higher energy
  • Presentation
    • Symptoms
      • pain
      • refusal to bear weight
    • Physical exam
      • usually minimal soft tissue swelling or deformity
      • evaluate carefully for compartment syndrome
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
      • findings
        • incomplete vs. complete fracture
        • presence of any angulation, usually valgus
        • presence of proximal fibula fracture, which may indicate a more unstable fracture pattern
  • Treatment
    • Nonoperative
      • long leg cast in extension with varus mold
        • indications
          • nondisplaced fractures
        • technique
          • place cast with varus mold (aim for slight overcorrection)
          • casts are maintained for 4-6 weeks with serial radiographs
          • weight bearing may be allowed after 2-3 weeks.
      • reduction, long leg cast in extension with varus mold
        • indications
          • displaced fractures
        • technique
          • reduction usually done under conscious sedation
          • casting is same as above
    • Operative
      • open reduction
        • indications (rare)
          • inability to adequately reduce a displaced fracture
          • secondary to soft tissue interposition
        • modalities
          • limited open dissection to remove interposed soft tissue
          • casting in near full extension, with or without supplemental k-wire fixation
  • Techniques
    • Closed reduction
      • sedation
        • usually performed under conscious sedation
      • an angulated greenstick fracture is completed
      • cast placed in near full extension with three-point varus mold
    • Open reduction
      • approach
        • small medial incision over fracture site
      • reduction
        • removal of interposed soft tissue (periosteum, pes tendons, MCL)
        • obtain an anatomic reduction under direct visualization
        • may supplement with crossed k-wires
      • postoperative
        • place into well-molded cast
  • Complications
    • Valgus deformity (Cozen phenomenon)
      • incidence
        • as high as 50%-90%
        • develops 5-15 months after injury
        • maximum deformity observed at 12-18 months
      • risk factors
        • incomplete reduction
        • concomitant injury to proximal tibia physis
        • infolded periosteum
        • injury to pes anserinus insertion, with loss of proximal tibia physeal tether, leading to asymmetric physeal growth
      • treatment
        • nonoperative
          • observation
            • may be observed for 12-24 months with expectation of spontaneous correction in most cases although some patients may have a persistant valgus deformity
            • parents should be counseled in advance
            • worst deformity at 18 months with an average valgus deformity of 18 degrees
            • gradually resolves by 3 years, with an average, clinically irrelevant, of 6 degrees
              • can result in S shaped tibia and persistent mechanical axis line that passed lateral to the center of the knee
        • operative
          • guided growth vs. osteotomy
            • reserved for valgus deformities >15-20 degrees near skeletal maturity
            • varus producing proximal tibia and fibula osteotomy
            • medial proximal tibia epiphysiodesis
    • 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
  • Prognosis
    • Valgus deformity usually resolves spontaneously

Please rate this review topic.

You have never rated this topic.

Thank you. You can rate this topic again in 12 months.

Flashcards (2)
Cards
1 of 2
Questions (8)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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 potential deformity?

QID: 3270
FIGURES:

Recurvatum

3%

(134/3849)

Varus

18%

(709/3849)

Malrotation

1%

(45/3849)

Valgus

70%

(2701/3849)

Procurvatum

6%

(239/3849)

L 3 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(SAE07PE.4) A 6-year-old child sustained a closed nondisplaced proximal tibial metaphyseal fracture 1 year ago. She was treated with a long leg cast with a varus mold, and the fracture healed uneventfully. She now has a 15-degree valgus deformity. What is the next step in management?

QID: 6064

Proximal tibial/fibular osteotomy with acute correction and pin fixation

4%

(21/571)

Proximal tibial/fibular osteotomy with gradual correction and external fixation

5%

(26/571)

MRI of the proximal tibial physis

3%

(15/571)

Medial proximal tibial hemiepiphysiodesis

7%

(38/571)

Continued observation

82%

(466/571)

L 2 D

Select Answer to see Preferred Response

(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?

QID: 1065
FIGURES:

Follow-up radiographs in 6 months

74%

(926/1251)

Ring fixator placement with distraction osteogenesis

1%

(11/1251)

Hemiepiphyseodesis of the proximal tibia

9%

(113/1251)

Follow-up radiographs in 3 months and placement of knee-ankle-foot (KAFO) orthosis

9%

(111/1251)

Closing wedge proximal tibial osteotomy

6%

(73/1251)

L 2 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidence (11)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (7)
Private Note