Updated: 6/13/2021

Triplane Fractures

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https://upload.orthobullets.com/topic/4029/images/triplane ap_moved.jpg
https://upload.orthobullets.com/topic/4029/images/preopap.jpg
https://upload.orthobullets.com/topic/4029/images/preoplat.jpg
https://upload.orthobullets.com/topic/4029/images/ctscan.jpg
https://upload.orthobullets.com/topic/4029/images/postop.jpg
  • summary
    • Triplane Fractures are traumatic ankle fractures seen in children 10-17 years of age characterized by a complex salter harris IV fracture pattern in multiple planes.
    • Diagnosis can be made with plain radiographs of the ankle. CT scan may be required to further characterize the fracture pattern and for surgical planning.
    • Treatment is closed reduction and casting or surgical fixation depending on the patient age and degree of fracture displacement.
  • Epidemiology
    • Incidence
      • accounts for 5-15% of pediatric ankle fractures
    • Demographics
      • more common in males
      • occurs in children during physeal closure (average age is 13 years old)
        • juvenile ankle physis ossifies in specific order, which leads to transitional fractures such as triplane and tillaux fractures
        • younger than tillaux fracture age group
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • lateral triplane fractures
          • results from supination-external rotation injury
            • similar to tillaux fractures
        • medial triplane fractures
          • results from adduction injury
      • pathoanatomy
        • a complex SH IV fracture pattern with components in all three planes
          • may be 2, 3, or 4 part fractures
            • sagittal plane - epiphysis is often fractured on the lateral aspect in the sagittal plane (same as tillaux fracture) and is seen on the AP radiograph
            • axial plane - physis is separated
            • coronal plane - metaphysis is fractured on the posterior aspect in the coronal plane and is seen on the lateral radiograph
    • Associated conditions
      • fibular fractures
        • occurs in 50%
        • typically spiral fracture located proximal to the physis in children nearing skeletal maturity
        • remains unstable after fixation of tibia, so fixation of fibula is usually necessary
      • ipsilateral tibial shaft fractures
  • Anatomy
    • Physeal considerations
      • distal tibial physis
        • accounts for 35-40% of overall tibial growth and 15-20% of overall lower extremity growth
        • rate of growth is 3-4 mm/year
        • growth continues until 14 years in girls and 16 years in boys
        • closure occurs during an 18 month transitional period
          • occurs in a predictable pattern: central > anteromedial > posteromedial > lateral
  • Classification
    • Parts
    • Classification by Parts
      2-part
      • Part 1 - anterolateral and posterior epiphysis is connected to the posterior metaphyseal fragment
      • Part 2 - anteromedial epiphysis is connected to the remainder of the distal tibia
      3-part
      • Part 1 - anteriolateral epiphysis
      • Part 2 - posterior epiphysis is connected to the posterior metaphyseal fragment
      • Part 3 - anteromedial epiphysis is connected to the remainder of the distal tibia
      4-part
      • Comminuted variant
      • Can only be distinguished from 3-part fractures via CT
    • Pattern
    • Classification by Pattern
      Lateral triplane fracture
      Most common
      • Epiphyseal fracture occurs in the sagittal plane
      • Physeal fracture occurs in the axial plane
      • Metaphyseal fracture occurs in the coronal plane
      • Similar to tillaux fractures on AP radiographs (distinguish from tillaux fractures by SH II or I fracture on lateral radiograph)
      Medial triplane fracture
      • Epiphyseal fracture occurs in the coronal plane
      • Physeal fracture occurs in the axial plane
      • Metaphyseal fracture occurs in the sagittal plane
      Intramalleolar triplane fracture
      • Type I - intraarticular intramalleolar fracture involving the weight-bearing surface
      • Type II - intraarticular intramalleolar fracture outside of the weight-bearing surface
      • Type III - extraarticular intramalleolar fracture
  • Presentation
    • Symptoms
      • pain
      • inability to bear weight
    • Physical exam
      • inspection
        • swelling
        • focal tenderness
        • deformity
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
        • mortise
          • best view to assess the amount of displacement
      • findings
        • consists of 3 parts
          • anterolateral quadrant of distal tibial epiphysis
          • medial and posterior portions of epiphysis with posterior metaphyseal spike
          • tibial metaphysis
        • AP radiograph shows SH III fracture
        • lateral radiograph shows SH II fracture
    • CT scan
      • indications
        • usually required to delineate fracture pattern and assess articular congruity
        • if closed reduction planned, consider CT after reduction to assess quality of reduction
      • findings
        • fracture involvement seen in all 3 planes
        • Mercedes-Benz sign
  • Treatment
    • Nonoperative
      • closed reduction and casting
        • indications
          • < 2mm displacement
        • techniques
          • ideal for 2-part fractures (difficult to achieve reduction of 3-part or 4-part fractures)
          • reduction maneuvers
            • reduce fibula fracture prior to attempting reduction of tibial fracture
            • for lateral triplane fractures, reduce with internal rotation
            • for medial triplane fractures, reduce with eversion
          • obtain post-reduction CT to assess reduction
          • long leg cast initially for 3-4 weeks to control rotational component of injury
            • follow early with radiographs to assess for displacement
          • immobilize an additional 2-4 weeks in a short leg cast or walking boot (to initiate ankle ROM)
    • Operative
      • CRPP vs. ORIF
        • indications
          • > 2mm displacement
  • Techniques
    • CRPP vs. ORIF
      • approach
        • anterolateral approach for lateral triplane fractures
        • anteromedial approach for medial triplane fractures
      • reduction
        • for lateral triplane fractures, reduce with internal rotation
        • for medial triplane fractures, reduce with external rotation
        • arthroscopically-assisted reduction has been described
      • instrumentation
        • K wires or cannulated screws
        • epiphyseal screws placed parallel to physis
        • metaphyseal fixation if component is large enough
      • post-op
        • long leg cast for 3-4 weeks then short leg walking cast for 2 weeks
      • complications specific to this treatment
        • hardware irritation
        • transient neuropathy
  • Complications
    • Growth arrest
      • occurs in 7-21%
      • risk factors
        • increased risk with pronation-abduction injuries compared to supination-external rotation injuries
        • increased risk with residual fracture displacement following reduction
      • usually insignificant but should closely follow patients with > 2 years of growth remaining
    • Ankle pain and degeneration
      • increased risk with articular step-off > 2mm
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(OBQ06.160) Figures A and B show an AP and lateral radiographs of a 15-year old boy who injured his ankle after skateboarding. What is the mechanism of injury with this type of fracture?

QID: 346
FIGURES:
1

supination - adduction

11%

(345/3274)

2

external rotation

74%

(2420/3274)

3

internal rotation

2%

(78/3274)

4

pronation - abduction

8%

(277/3274)

5

axial load

4%

(130/3274)

L 2 D

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