Updated: 10/28/2018

Proximal Tibia Metaphyseal Fractures - Pediatric

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https://upload.orthobullets.com/topic/4025/images/proximal tibia fracture cropped.jpg
https://upload.orthobullets.com/topic/4025/images/valgus xr.jpg
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Introduction
  • Overview
    • proximal tibia metaphyseal fractures are a fracture of the proximal tibia usually seen in children from 3 to 6 years of age
      • treatment is usually closed reduction and casting in extension with a varus mold
      • this fracture is significant for their tendency to develop a late valgus deformity, known as a Cozen's phenomenon, that must be monitored closely  
  • Epidemiology
    • demographics
      • most common in children 3-6 years of age
  • 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
      • late valgus deformity
      • etiology is unknown
      • can occur regardless of treatment
  • Prognosis
    • valgus deformity usually resolves spontaneously
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
 

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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

3%

(96/2920)

2

Varus

19%

(567/2920)

3

Malrotation

1%

(38/2920)

4

Valgus

69%

(2008/2920)

5

Procurvatum

7%

(200/2920)

ML 3

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%

(247/369)

2

Ring fixator placement with distraction osteogenesis

1%

(5/369)

3

Hemiepiphyseodesis of the proximal tibia

10%

(38/369)

4

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

13%

(49/369)

5

Closing wedge proximal tibial osteotomy

7%

(24/369)

ML 2

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PREFERRED RESPONSE 1
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