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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
    • 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
 

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