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Introduction
  • Salter-Harris III fx of the distal tibia epiphysis
    • caused by an avulsion of the anterior inferior tibiofibular ligament   
  • Mechanism
    • mechanism of injury is thought to be due to an external rotation force
  • Epidemiology
    • typically occur within one year of complete distal tibia physeal closure.
      • older than triplane fracture age group
  • Pathoanatomy
    • lack of fracture in the posterior distal tibial metaphysis in the coronal plane distinguishes this fracture from a triplane injury
    • transitional fractures (tillaux and triplane) occur in older children at the end of growth
      • variability in fracture pattern due to progression of physeal closure
      • a period of time exists when the lateral physis is the only portion not fused
      • leads to Tillaux and Triplane fractures
      • often associated with external rotation deformity of the ankle/foot
Anatomy
  • Ossification
    • the distal tibial physis closes in the following order
      • central (first)
      • posterior
      • medial
      • anterolateral (last)
Imaging 
  • Radiographs 
    • recommended views
      • AP
      • lateral
      • mortise
    • findings
    •  
      • SH III fx of the anterolateral distal tibia epiphysis 
  • CT scan  
    • delineate the fracture pattern  
    • determine degree of displacement
    • identify intramalleolar or medial fracture variant patterns
Treatment
  • Nonoperative
    • closed reduction, long leg cast x 4 weeks (control rotation), SLC x 2-3 weeks
      • indications
        •  if  < 2 mm of displacement (rare) following closed reduction
      • technique
        • reduction technique by internally rotating foot
        • CT scans sometimes needed to determine residual displacement (confirm < 2mm) 
        • long leg cast initially to control rotational component of injury
  • Operative
    • open reduction and internal fixation 
      • indications
        • if  >2 mm of displacement remains after reduction attempt 
      • technique
        • closed reduction (by internal rotation) can be attempted under general anesthesia first
          • percutaneous screws can be placed if adequate reduction obtained
        • visualize joint line to optimize reduction
        • intra-epiphyseal screws 
          • transphyseal screws can also be used as most patients are approaching skeletal maturity
        • arthroscopically-assisted reduction has been described
Complications
  • Premature growth arrest
    • rare as little physis remaining as closure is already occuring
    • decrease risk with anatomic reduction
  • Early arthritis
    • increase risk with articular displacement
 

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(OBQ12.223) A 12-year-old sustains a twisting injury to his ankle while playing soccer. His skin is intact and he has no evidence of neurovascular compromise. An injury radiograph is shown in Figure A. A closed reduction is attempted to improve alignment. What is the next best step after reduction to optimize this patient’s outcome? Review Topic

QID: 4583
FIGURES:
1

Splinting and admit for observation for compartment syndrome

1%

(35/3086)

2

Short leg cast and discharge with outpatient follow up

3%

(90/3086)

3

Long leg cast and discharge with outpatient follow up

2%

(71/3086)

4

Percutaneous pinning with casting immobilization

14%

(418/3086)

5

CT scan of the ankle

80%

(2459/3086)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ08.102) A juvenile Tillaux ankle fracture is caused by an avulsion injury involving which of the following structures? Review Topic

QID: 488
1

Anterior-inferior tibiofibular ligament

89%

(1548/1738)

2

Posterior-inferior tibiofibular ligament

4%

(66/1738)

3

Anterior talofibular ligament

5%

(91/1738)

4

Posterior talofibular ligament

1%

(12/1738)

5

Calcaneofibular ligament

1%

(11/1738)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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