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Updated: Mar 7 2024

Proximal Tibia Metaphyseal Fractures - Pediatric

Images tibia fracture cropped.jpg xr.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
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