|
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
Introduction
  • Proximal tibia metaphyseal fractures are significant for their tendency to develop a late valgus deformity  
    • etiology of valgus deformity is unknown
    • known as Cozen's fracture or phenomenon
  • Epidemiology
    • most common in children 3-6 years of age
  • Mechanism
    • typically low-energy with valgus force across the knee creating incomplete fracture of proximal tibia
    • classic mechanism is child going down slide in the lap of an adult with leg extended
  • Prognosis
    • valgus deformity resolves spontaneously
Classification
  • Classification of pediatric proximal tibia metaphyseal fractures is descriptive. 
    • important radiographic parameters include:
      • complete versus incomplete fracture
        • majority are incomplete
      • displaced or nondisplaced
      • presence and location of associated fibula fracture
Presentation
  • Symptoms
    • pain
    • refusal to bear weight
  • Physical exam
    • valgus deformity
    • evaluate carefully for compartment syndrome
Imaging
  • Radiographs
    • recommended views
      • required
        • AP and lateral 
    • findings
      • look for incomplete vs complete and presence of a proximal fibula fracture which may indicate a more unstable fracture pattern
Treatment
  • Nonoperative
    • long leg cast in extension with varus mold (aim for slight overcorrection)
      • indications
        • nondisplaced fracture
      • technique
        • casts are maintained for 6-8 weeks with serial radiographs
        • weight bearing may be allowed after 2-3 weeks.
    • reduction followed by long leg cast in extension with varus mold (aim for slight overcorrection)
      • indications
        • displaced fracture
      • technique
        • requires conscious sedation or general anesthesia
        • cast in near full extension (10 degrees flexion)
        • varus mold at fracture site
  • Operative
    • open reduction
      • indications
        • inability to adequately reduce a displaced fracture
        • secondary to soft tissue interposition
      • technique
        • limited medial approach to proximal tibia
        • periosteum or tendons of pes anserinus may block reduction
        • internal fixation not commonly required
 Complications
  • Valgus deformity (Cozen phenomenon) 
    • may be observed for 12-24 months with expectation of spontaneous correction 
    • parents should be counseled in advance
    • etiology
      • 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
    • typically improves over time
      • may result in S-shaped tibia
      • mechanical axis may remain lateral to the center of the knee
    • treatment
      • if deformity fails to resolve 
        • medial hemi-epiphysiodesis in skeletally immature patient
        • corrective osteotomy in skeletally mature patient
          • osteotomies have significant complications
  • 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
 

Please rate topic.

Average 4.2 of 22 Ratings

Questions (5)

(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? Review Topic

QID: 3270
FIGURES:
1

Recurvatum

3%

(74/2127)

2

Varus

21%

(449/2127)

3

Malrotation

1%

(30/2127)

4

Valgus

65%

(1389/2127)

5

Procurvatum

8%

(179/2127)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase

(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? Review Topic

QID: 1065
FIGURES:
1

Follow-up radiographs in 6 months

66%

(204/311)

2

Ring fixator placement with distraction osteogenesis

2%

(5/311)

3

Hemiepiphyseodesis of the proximal tibia

9%

(29/311)

4

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

14%

(43/311)

5

Closing wedge proximal tibial osteotomy

8%

(24/311)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase
EVIDENCE & REFERENCES (8)
GROUPS (1)
Topic COMMENTS (6)
Private Note