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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
    • 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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