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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
    • can also result from torsional injury 
    • classic mechanism is child going down slide in the lap of an adult with leg extended
  • Prognosis
    • valgus deformity resolves spontaneously
Anatomy
  • Osteology 
    • Tibia
      • triangular shaped bone with apex anteriorly that broadens distally 
      • anteromedial boarder is subcutaneous 
    • Blood supply
      • posterior tibial a. provides nutrient and periosteal vessels 
      • nutrient vessels supply inner 2/3 of tibial diaphysis 
 
Classification
  • Classification of pediatric proximal tibia metaphyseal fractures is descriptive. 
    • important radiographic parameters include:
      • Three main fracture patterns: torus, greenstick, and complete
        • complete versus incomplete fracture
        • majority are incomplete (greenstick)
      • displaced or nondisplaced
      • presence and location of 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 (aim for slight overcorrection)
      • indications
        • nondisplaced fracture
      • modalities
        • 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
      • modalities
        • closed reduction and casting
  • Operative
    • open reduction (rare)
      • indications
        • 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
    • Usually performed under conscious sedation 
    • an angulated greenstick fracture is completed 
    • cast placed in near full extension with three point mold
  • Open reduction
    • small medial incision over fracture site
    • removal of interposed soft tissue (periosteum, pes tendons, MCL)
    • obtain anatomic reduction under direct visualization 
    • Place into well molded cast
      • may supplement with crossed k-wires 
 

 Complications
  • Valgus deformity (Cozen phenomenon) 
    • Incidence
      • as high as 90% 
      • 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
      • Observation
        • may be observed for 12-24 months with expectation of spontaneous correction  
        • 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 
        • 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
 
 

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Questions (6)
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(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

4%

(80/2279)

2

Varus

21%

(468/2279)

3

Malrotation

1%

(31/2279)

4

Valgus

66%

(1510/2279)

5

Procurvatum

8%

(184/2279)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(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

67%

(246/367)

2

Ring fixator placement with distraction osteogenesis

1%

(5/367)

3

Hemiepiphyseodesis of the proximal tibia

10%

(37/367)

4

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

13%

(49/367)

5

Closing wedge proximal tibial osteotomy

7%

(24/367)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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