Proximal Tibia

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Proximal Tibia

Fractures of the horizontal portion of the physis of the proximal tibial epiphysis are uncommon, but have the highest risk of catastrophic complications. Fractures of the vertical physis of the tibial tuberosity, which is an apophysis, are discussed only briefly here.

Contents

Anatomy and Growth .. . . ..651

Classification ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...655

Tibial.Tubercle. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .658

Epidemiology . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .659

Literature.Review.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .659

Olmsted.County.Study. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .659

Evaluation . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .659

Imaging... . . ..661

Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...661

Types.1,.2,.and.3. .. . . .662

Type.4... . . ..671

Type.5... . . ..677

Type.6... . . .680

General.Considerations.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .680

Complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .681

Complete.Growth.Arrest... . . ..681

Partial.Growth.Arrest.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .681

Vascular.Compromise. ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...681

Compartment.Syndrome.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .685

Neuropathy.... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 685

Irreducibility.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 685

Ligamentous.and.Meniscal.Injury.. .. .. .. .. .. .. .. .. .. .. .. 685

Overgrowth. .. . . 685

Bursitis.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 685

Osteomyelitis. ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 686

Degenerative.Arthrosis.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 686

Author’s Perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 686

A. Proximal Tibial Stress Injury... .. .. .. .. .. .. .. .. .. .. .. .. 686

References . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .691

Anatomy and Growth

The proximal tibial epiphysis is the second largest epiphysis of the body after the distal femur. The shape and contours of the epiphysis remain unchanged throughout growth (Fig. 20.1).

In most newborns the proximal tibial epiphyseal secondary center of ossification (SCO), appears roent- genographically within days following birth. The ear- liest observed ossification is in utero, at 34.0 gesta- tional weeks in girls, and 34.5 weeks in boys [48]. The mean age of appearance in both girls, and boys is 0.1 month postpartum [85]. The SCO is present in 95% of babies by 2 weeks in girls and 5 weeks in boys [48], and in 100% of all children by age 3 months [25, 38, 69]. It is centrally located and spherical. Expan- sion and maturation rapidly changes the center to an elliptical shape. In the coronal plane ossification demarcates the concavity of each tibial plateau and extends into both tibial spines by age 10 years. The physis remains transverse in the coronal projection throughout development [69]. In the sagittal plane the physis is transverse in the posterior 3/4 and angles sharply distalward anteriorly (approximately 80 de- grees) to form the tibial tubercle (Fig. 20.1a).

The tibial tubercle has its own separate ossification

center, which first appears between ages 7 and 12 years

(Fig. 20.1b) [4, 34, 35, 68]. The SCO of the epiphysis is

well developed roentgenographically before the SCO

of the tibial tubercle appears (Fig. 20.2). These two

ossification centers (Fig. 20.1b, c) have separate func-

tions. The major ossification center has all the attri-

butes of an epiphysis (its physis is perpendicular to

the long axis of the bone, it provides growth, and ar-

ticulates with the femur, and there are no major mus-

cle/tendon attachments). The anterior inferior ossifi-

cation center, the tubercle, is an apophysis (its physis

is tangential to the long axis of the bone, it provides

no longitudinal growth, it has no articular function,

and it is the site of the tibial tendon insertion).

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652 Chapter 20 Proximal Tibia

These two secondary centers of ossification unite with each other first (Fig. 20.1c, d). The age at which the conjoined apophysis/epiphysis fuses with the metaphysis varies widely. In girls it ranges from age 12 to 17 years (median 14 years 10 months) and in boys from age 14.5 to 19.5 years (median 16 years 11 months) [4, 34, 35, 38, 68]. Because of these aspects some authors [28, 39, 44] have designated four stages of development: 1) the cartilaginous stage (Fig. 20.1a), 2) the apophyseal stage (Fig. 20.1b, c), 3) the epiphy- seal stage (Fig. 20.1d), and 4) the bony stage (com- pletely fused).

Closure of the conjoined apophyseal-epiphyseal physis begins centrally, proceeds centrifugally and posteriorly first, while the anterior tuberosity is the last to unite with the metaphysis (Fig. 20.1e) [7, 35, 39]. Dvonch and Bunch [26] present a different pat- tern of physeal closure.

The proximal tibial physis accounts for 57–60% of growth of the tibia (Fig. 20.3), 25–28% of the length of the limb, and approximately 0.64 cm (0.25 inch) of growth each year until maturity [4, 25, 67, 83, 84]. The proximal tibia grows between 10 and 15 cm in most children [25]. The proportion of growth occurring at each end of the tibia is neither constant nor average throughout growth (Fig. 20.4). After age 10 years the proximal physis becomes the dominant site of growth.

The growth contribution of the proximal tibia in girls varies from 50% at age 6 to 80% at age 14, and in boys varies from 50% at age 7 to 80% at age 16 [83, 84]. Of

Fig. 20.1

Proximal.tibial.epiphyseal.development,.sagittal.plane .a.Newborn.to.age.6.years .Gradual.enlargement.of.the.epiphyseal.ossification.center .b.Age.7–12.years .First.appearance.of.the.tibial.tubercle.apophyseal.ossification.center .c.Age.

10–14.years .Continuing.growth.and.development.of.both.ossification.centers .There.may.be.a.physis.(not.shown).between.the.two.ossification.centers.[69,.103] .d.The.two.ossification.centers.unite.with.each.other.at.ages.12–13.years.in.

girls.and.13–15.years.in.boys .e.The.conjoined.epiphyses.begin.to.unite.centrally.and.posteriorly.with.the.metaphysis.

at.age.13–15.years.in.girls.and.age.15–19.years.in.boys .The.physis.of.the.tibial.tubercle.is.the.last.to.close .Note:.Wide.

variation.in.ages.of.ossification.exists.among.children

Fig. 20.2

Normal.lateral.roentgenogram. of.a.boy.age.12.years.

5.months . Beginning. ossification. of. the. apophysis.

(apophyseal.stage) .This.roentgenogram.was.taken.for.

comparison.purposes .Normal.position.of.patella

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more practical use in patient management is knowl- edge of the annual increment of growth (Fig. 20.5) and the amount of growth remaining in the proximal tibia at older ages (Fig. 20.6).

As the knee is viewed in the coronal plane, both the lateral and medial collateral ligaments are firmly attached to the distal femoral epiphysis (Fig. 20.7).

There are only minor insertions of these ligaments into the proximal tibial epiphysis. The lateral (fibular) collateral ligament (LCL) attaches primarily to the proximal fibular epiphysis, with some fibers spread- ing out over the lateral side of the tibial epiphysis and metaphysis. The major portion of the medial (tibial) collateral ligament (MCL) attaches to the periosteum of the metaphysis and a lesser portion to the proximal tibial epiphyseal perichondrium [1, 4, 34, 68, 69]. This ligament attachment arrangement, along with the L- shaped physis in the sagittal plane, numerous inter- digitations and undulations of the physis/metaphysis interface, and the presence of the proximal tibiofibu- lar joint, which buttresses the tibial epiphysis, all pro- tect the epiphysis from disruption. The anterior (ACL) and posterior cruciate ligaments (PCL) originate in the distal femoral epiphysis. The ACL inserts into the anterior aspect of the proximal tibial epiphysis, near the tibial eminence, and the PCL inserts into the pos- terior aspect of the epiphysis. Neither seems to be a factor in causation of proximal tibial physeal frac- tures [2, 4, 12, 34].

Viewed in the sagittal plane, the patellar tendon inserts into the tibial tubercle and is an integral component of tibial tubercle fractures, both before (20.1a–c) and after (Fig. 20.1d) the tibial tubercle os- sification center unites with the proximal tibial epiph- ysis proper.

Fig. 20.3

Amount.of.growth.from.each.end.of.the.tibia.at.birth,.

midway.through.growth,.and.at.completion.of.growth . (Adapted.from.Pritchett.[84],.with.permission)

Fig. 20.4

The. percentage. contribution.

of.growth.of.the.tibia.from.the.

proximal.physis .(Adapted.from.

Pritchett.[83,.84],.with.permission)

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The epiphysis has a copious blood supply, with ves- sels entering all sides like the spokes of a wheel [64].

No cases of ischemic necrosis have been reported fol- lowing physeal fracture.

The popliteal artery lies adjacent to the posterior capsule of the knee (Fig. 20.8). It passes between the two heads of the gastrocnemius muscle and ends on a level with the distal part of the tibial tubercle by di-

viding into the anterior and posterior tibial arteries. It is anchored by fibrous tissue, the geniculate arteries, the fibrous arch of the soleus muscle, and the anterior and posterior tibial arteries [23, 27, 35, 37]. The space is sufficiently small and tight that a popliteal artery entrapment syndrome has been identified even with- out associated fracture [22].

Fig. 20.5

The. annual. increment. of.

growth. for. the. proximal. tibia.

from. age. 7.years. to. skeletal.

maturity .(Adapted.from.Pritch- ett.[83,.84],.with.permission)

Fig. 20.6

Centimeters.of.growth.remaining. in. the. proximal. tibia. from.

age.7.years.to.skeletal.maturity . The. heavy center lines. repre- sent. the. average . The.second- ary lines. are. one. standard. de- viation. to. each. side. from. the.

average .(Adapted.from.Pritch- ett.[83,.84],.with.permission)

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Classification

Dr. Kay Clawson, in an editorial comment [51], made a plea that a classification of all growth plate fractures of proximal tibia be adopted, rather than separate classifications for fractures of the epiphysis proper and for the apophyseal tibial tubercle. The anatomic six type classification [77] works well for this objec- tive in both the coronal plane (Fig. 3.6) and the sagit-

tal plane (Fig. 20.9). Type 1 fractures [76] are shown (Figs. 20.9 1, 20.10) and a similar case was illustrated by Rogers and Shall [88]. Type 5 fracture of the proxi- mal tibia is rare and has been recorded only in the coronal projection, except for four triplane fractures [20, 73, 81]. A type 6 fracture is shown in Fig. 3F.8, and one has been documented by Mayer and Marchis- elli [57]. When a proximal tibial physeal fracture oc- curs with a femoral fracture it is sometimes classified as one type of a “floating knee” [50, 88].

Fig. 20.7

Ligamentous.attachments.of.the.knee

Fig. 20.8

Popliteal.artery.relationship.to.the.proximal.tibial.with.

a. displaced. type.3. fracture . (Redrawn. from. Burkhart.

and.Peterson.[12],.with.permission)

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Fig. 20.9

Peterson.classification.of.proximal.tibial.physeal.fractures.visualized.in.the.sagittal.plane .Type.1.is.a.compression.fracture:.types.2,.3,.and.4.are.usually.avulsion.fractures .No.type.5.or.6.fractures.have.been.documented.in.the.sagittal.

plane

Fig. 20.10

Proximal.tibia.type.1.fracture .Fourteen.year.6.month.

old. boy. injured. his. left. knee. while. pivoting. on. a. . bicycle .a.AP.roentgenographs.shows.what.appears.to.

be. a. type.2. fracture. with. a. lateral. metaphyseal. fragment.(solid arrows).and.opening.of.the.medial.physis.

(open arrow) .However,.on.close.review.there.is.a.thin.

layer.of.bone.adjacent.to.the.epiphysis.medially.with.

the.fracture.just.distal.to.the.physis.(open arrow) .(Con- tinuation see next page)

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Fig. 20.10 (continued)

b.Lateral.(left).and.oblique.(right).views.show.a.transmetaphy- seal.fracture.distal.to.both.the.epiphysis.and.apophysis.(tibial.

tubercle) .c.A.valgus.stress.confirms.the.fracture.is.across.the.

metaphysis.both.medially.and.laterally,.and.since.it.extends.to.

the.physis.(a.vertical arrow,.b),.this.is.a.type.1.fracture .Closed.

reduction. was. done. under. general. anesthesia .d. Satisfactory.

reduction.in.cast .(Continuation see next page)

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Tibial Tubercle

Fractures which involve primarily the tibial tubercle are best visualized in the sagittal plane and require special mention. In a younger individual before the ossification centers of the tubercle and epiphysis are united (Fig. 20.1b, c) the fracture is a true apophyseal avulsion (Fig. 20.11a). Once these two ossification centers unite (Fig. 20.1d) fractures caused by similar forces may extend into the epiphysis and are incom- plete (Fig. 20.11b), or complete (Fig. 20.11c) type 4 physeal fractures. The force involved in the fractures in drawings in Fig. 20.11a–c is usually an indirect force due to a sudden contraction of the quadriceps muscle when the foot is fixed on the ground, such as

É Fig. 20.10 (continued)

e. Age. 15.years. 5.months,. 11.months. post. injury . The.

patient. is. normally. active. including. football . Scano- grams.showed.the.left.tibia.is.3.mm.shorter.than.the.

right,. and. 8º. genu. valgum. bilaterally . All. physes. are.

closing

Fig. 20.11

Tibial.tubercle.avulsion.fractures .a.Avulsion.of.the.tibial.tubercle.prior.to.its.union.with.the.epiphysis.is.a.true.apophyseal.fracture.separation.and.is.not.discussed.here .b.Incomplete.type.4.fracture .After.union.of.the.tibial.tubercle.and.

epiphyseal. ossification. centers,. fracture. extending. into. the. epiphysis. may. not. cross. the. articular. cartilage. surface . . c.Complete.type.4.fracture .As.with.most.type.4.fractures,.beginning.closure.of.the.physis.is.usually.present .d.Hyper- extension.fracture.may.occur.at.any.age,.with.or.without.union.of.the.tubercle.to.the.epiphysis,.and.may.force.the.

tibia.posteriorly.enough.to.damage.the.popliteal.artery

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in high jumping or jumping in basketball [96]. There is speculation that the apophyseal tubercle avulsion fracture (Fig. 20.11a) may occur with the knee in more extension, while the epiphyseal fractures (Fig. 20.11b, c) occur with the knee in more flexion.

However, age is the more important consideration, since it reflects the state of union of the apophysis, to the epiphysis and of the epiphysis to the metaphysis.

Type 4 fractures can also be caused by an hyperex- tension injury which causes the distal femur to be forced like a wedge onto the proximal tibia (Fig. 20.11d) causing a fracture similar to the avulsion fracture seen in Fig. 20.11c, but with greater potential for dis- placement and vascular impairment by stretching the popliteal artery (Fig. 20.12). Clinically there may be a visible and palpable concavity at the lower level of the tuberosity.

The titles of many of the articles listed in the refer- ences for this chapter include the designation “tibial tubercle.” In each of these articles, however, the illus- trations show and the manuscripts describe, fractures crossing the epiphysis and entering the knee joint.

They are therefore type 4 epiphyseal fractures (Figs. 20.9 4, 20.11b–d). Pre-existing Osgood-Schlat- ter’s disease may predispose to avulsion of a greater portion of the epiphysis [3, 9, 14, 32, 59, 60, 89, 102].

Epidemiology

The proximal tibial physis is one of the least injured of the large long bones. Exclusion of tibial tubercle frac- tures in some series may cause it to be under reported.

The morphology of the proximal tibial epiphysis, the arrangement of ligamentous attachments, and the presence of the proximal fibula protect the physis from fracture.

Literature Review

Fractures of the proximal tibial physis are frequently called “rare” [2, 3, 16, 21, 27, 29, 31, 33–35, 45, 72, 75, 87, 93, 95, 98, 99], and constitute less than 3% of all physeal fractures (Tables 4.5, 4.6). Of all tibial physeal fractures, the proximal physis accounts for 7%, the distal 93% (Table 4.7). Boys predominate [12, 18, 35, 51, 68, 82, 105]. Thirty-seven of 38 patients in the se- ries by Shelton and Canale [93] were male. Most pa- tients are between 10 and 17 years of age, except for a small group age 2–6 years of age involved in lawn- mower accidents [12, 57]. The peak age is 12–14 years [12, 93, 105]. The youngest patient, other than a birth fracture [97], was a 7-month-old victim of child abuse

[99]. The oldest patients were two 19-year-old males [36, 93], one with bone age 17.5 years and a type 3 fracture. Bilateral fractures usually occur simultane- ously [10, 45, 53, 61, 63], but may occur on different dates [42]. The most common fracture is type 2 (Ta- ble 20.1, Fig. 20.9 2). Nine of 14 cases by Aitken [1]

were type 1, which is type 2 in the Salter-Harris [90]

classification. Peterson type 6 fractures are common with lawn mower accidents [57].

Associated injuries are common and include frac- tures (of the fibula, femur, tibial diaphysis, and patel- la), rupture of ligaments (the anterior cruciate and medial collateral), and tendons (patellar and quadri- ceps), meniscus injury, popliteal vascular and nerve damage, peroneal nerve palsy, and hip dislocation [12, 14, 52, 54, 78, 82, 92, 93, 102, 105, 106]. Of these associ- ated injuries, fractures of the proximal fibular me- taphysis or diaphysis [13, 35, 40, 66, 69, 70, 93, 105] are the most common, and often require additional treat- ment. Concomitant physeal fracture of both the prox- imal tibial and the distal femur physes [88] is rare.

Olmsted County Study

Eight fractures of the proximal tibial physis com- prised 1% of all physeal fractures in the Olmsted County study (Table 4.11) [79]. Of all tibial physeal fractures, the proximal physis accounted for 7% (Ta- ble 4.13). There were 6 males, ages 11–15 years, and 2 females, one less than 1 year and one 12 years old.

There were three type 2, three type 3, one type 4, and one type 5 fracture (Peterson classification [77]) (Ta- ble 4.12).

Evaluation

Pain, knee effusion (hemarthrosis), ecchymosis, and

inability to move the knee and to bear weight are

nearly always present. Tenderness is most marked

over the physis, distal to the joint line. Palpation of

bony landmarks, such as the tibial tubercle and me-

dial and lateral tibial plateaus, can be more rewarding

than palpation at other physeal sites due to less ac-

companying soft tissue. Testing the knee for stability

(valgus/varus stress, anterior/posterior drawer, Lach-

man’s, and pivot-shift tests) may be misleading and

should be performed only with the knowledge that

ligamentous rupture may simulate or accompany

physeal fracture. Nowhere is it more essential to pal-

pate distal pulses and assess neurologic status. This

should be performed immediately, documented, and

monitored throughout early treatment.

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Fig. 20.12

Proximal.tibia.hyperextension.type.4.fracture.with.vascular.impairment .This.13.year.0.month.old.girl.was.running. hurdles. in. the. wrong. direction . Her. heel. hit. the.

top.of.the.hurdle.which.would.not.tip.over.easily,.and.

she. fell. with. the. knee. in. forced. hyperextension . . a. There. is. a. type.4. fracture . The. uninjured. posterior.

physis. is. closed . The. treating. physician. manually. reduced.the.fracture.with.thumb.pressure.and.applied.a.

long.leg.cast.with.the.knee.in.full.extension .Over.the.

next.few.days.increasing.pain.was.treated.with.increasing. amounts. of. narcotics. and. splitting. the. cast . The.

cast.was.removed.on.the.fifth.post.injury.day.because.

of. cold. toes. devoid. of. sensation. and. active. motion . . The.entire.lower.leg.was.cold,.mottled,.and.anesthetic ..

b.An.arteriogram.on.the.fifth.post.injury.day.showed.

loss.of.major.vessel.arterial.flow.combined.with.devel- oping.collateral.circulation .Fasciotomies.revealed.posterior.compartment.muscle.infarction .Alcohol.lumbar.

sympathetic.block.improved.the.arterial.flow,.but.muscle.necrosis.resulted.in.below.knee.amputation.on.the.

sixth.post.injury.day .c.Age.13.years.10.months .The.patient.became.a.good.prosthetic.wearer .Note:.It.is.inter- esting.to.speculate.on.the.outcome.of.this.case.had.the.

fracture.been.reduced.and.internally.fixed.(percutaneously.or.openly).and.observed.without.any.external.immobilization

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Imaging

AP and lateral roentgenographs usually reveal the fracture. Fractures of the proximal tibial physis may be in the sagittal, coronal, or transverse plane and are best seen on either the AP or the lateral view, but not both. For example, sagittal fractures are best seen in the AP view and coronal and transverse fractures are best seen in the lateral view (Fig. 20.9).

Epiphyseal displacement with spontaneous reduc- tion or reduction occurring during transport is com- mon, often unrecognized, and sometimes referred to as “concealed epiphyseolysis” [56]. Oblique and com- parison views [29, 95] reveal the fracture less fre- quently than at other sites. When the knee is unstable and the roentgenographs are normal, varus/valgus and occasionally anterior/posterior stress views often reveal an undisplaced physeal fracture and distin- guish it from a ligamentous injury [27, 29, 34, 35, 56, 93, 95, 101]. Stress films can help identify type 1 frac- tures (Fig. 20.10c) and may differentiate a type 4 frac- ture from a tibial spine fracture (Fig. 20.13). Tomog- raphy changed the diagnosis from a type 2 to a type 5 in one case [36].

Occasionally CT scanning and CT reconstruction views may be helpful [4, 35, 73]. MR imaging is usu- ally not necessary to assess acute fractures. As in the distal femur the yield is low. Of 315 knee MR exami-

nations performed on 289 patients with acute trauma, only 2 proximal tibial physeal fractures were identi- fied [18]. MRI may, however, reveal an undisplaced fracture not clearly seen on plain roentgenographs, change the classification type [18, 35, 47], or identify soft tissue interposition when reduction is incomplete [87]. MR imaging also has the advantage of assessing soft tissue structures; ligaments, menisci, and perios- teal elevation [18]. MRI is superior to technetium bone scans for preoperative planning [47]. Arteriog- raphy or magnetic resonance arteriography (MRA) is essential in cases with reduced arterial flow [67] (see Complications).

Management

Because of the propensity for vascular morbidity, fractures of the proximal tibial physis deserve special attention. The amount of displacement present at the moment of fracture may have been significantly greater than that recorded on the initial roentgeno- graph. Even without posterior displacement of the metaphysis, the popliteal arteries, nerves, and veins can be injured by their close proximity to the epiphy- sis and their relatively tight position in the popliteal compartment.

Table 20.1. Proximal.tibial.physeal.fractures.by.type.(Salter-Harris.classification.[90])^a

Year Author^b 1 2 3 4 5 Unclassified Total

1978 Nolan.[68] 1 6 3 4 1^c 15

1979 Burkhart.[12] 3 9 6 8 2^d 28

1979 Shelton.[93] 9 7 10 3 0 39

1983 Bertin.[6] 1 7 4 1 0 13

1987 Mizuta.[62] 1 2 0 0 1^e 4

1989 Poulsen.[82] 0 4 4 6 1^f 15

1990 Mann.[55] 5 8 2 0 0 15

1991 Catarini.[16] 0 2 1 2 0 5

1991 Wozasek.[105] 5 11 4 1 0 9 30

1998 Gautier.[31] 3 0 1 2 0 6

ToTal 28 66 35 27 5 9 170

Percent 16 5 38 8 20 6 15 9 2 9 5 3 100

a.Reports.with.less.than.4.patients.not.included

b.All.reports.have.more.than.one.author;.see.References

c. .This. patient. had. a. femur. fracture. treated. by. femoral. skeletal. traction. 32.days. followed. by. spica. cast. 81.days. (113.days.

.immobilization)

d.These.2.cases.were.re-evaluated,.noted.to.be.other.than.type.5.fractures,.and.re-reported.[78]

e.No.details.of.this.case.were.given

f. .This. patient. had. an. ipsilateral. ACL. rupture. and. fractures. of. the. femoral. and. tibial. shafts. and. of. the. hindfoot,. resulting..

in.amputation.of.the.foot

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The key to successful management of these frac- tures, regardless of type, is prompt and continued neurovascular assessment by competent personnel.

This nearly always requires hospital admission. No cast should be applied during the first 12 hours. If the fracture is undisplaced a knee immobilizing splint will suffice and allow ongoing vascular assessment. If the fracture is comminuted or otherwise in jeopardy of displacement, a large bulky cotton and ace wrap dressing with a posterior plaster splint (called a Rob- ert Jones compression dressing at our institution) can be applied without much “compression” and allows access to the ankle and pedal pulses. Skeletal traction, with the pin in the distal femur, distal tibia, or os cal- cis, may be appropriate in poly trauma cases [105].

When it is safe to apply a cast, a long leg cast including the foot with mild knee flexion (20–45 degrees) to re- lieve popliteal tension and allow the foot to clear the floor using crutches is most commonly used.

Significantly displaced fractures, regardless of type require prompt careful assessment and treatment to avoid catastrophic results.

Types 1, 2, and 3

Type 1, 2, or 3 fractures that are minimally or undis- placed can be treated with casting or closed reduction and casting [7, 12, 15, 27, 35, 45, 68–70, 88, 93, 105].

Type 1 fractures usually do well (Fig. 20.10), but can result in premature physeal closure requiring long follow-up and additional treatment (Fig. 20.14). Un- displaced type 2 fractures typically do well with brief cast immobilization (Fig. 20.15). Reduced type 1 and 2 fractures are usually stable (Figs. 20.10, 20.15), but if unstable internal fixation can be used [33].

Type 3 fractures are usually due to flexion or ex- tension forces on the lower leg. The flexion injury, in which the metaphysis is displaced anteriorly [7, 9, 89], is more common in older boys, ages 15–17 years (Fig. 20.16). Severe anterior or lateral displacement of the metaphysis is blocked by the tibial tubercle anteri- orly and the head of the fibular laterally. These frac- tures are treated by extending the tibia.

Fig. 20.13

Proximal.tibia.type.4.fracture.distinguished.from.a.tibial.spine.fracture.by.a.stress.film .The.right.knee.of.this.12.year.

9.month.old.girl.struck.a.tree.while.sledding .There.was.grade.4.effusion.and.no.instability .a.The.routine.AP.view.sug- gests.a.tibial.spine.fracture.(arrows) .b.A.valgus.stress.test.(lateral arrow).reveals.a.type.4.physeal.fracture.(medial white and vertical black arrows) .Treatment.was.a.long.leg.cast.(4.weeks).followed.by.a.knee.immobilizer.and.progressive.

weightbearing.an.additional.three.weeks

(13)

Fig. 20.14

Proximal.tibia.type.1.fracture.with.premature.arrest .This.9.year.3.month.old.girl.injured.her.left.knee.while.sledding ..

a.Transmetaphyseal.fracture.with.central.extension.to.the.physis,.best.seen.on.the.AP.view.(left) .On.the.lateral.view.

(right).there.is.transmetaphyseal.fracture.with.forward.tilt.of.epiphysis .Since.the.anterior.tubercle.is.unossified.the.

anterior.extent.of.the.metaphyseal.fracture.cannot.be.determined,.but.extends.at.least.to.the.physis.of.the.tubercle ..

b.Treatment.was.closed.reduction.and.long.leg.cast.with.knee.flexed.35º .(Continuation see next page)

(14)

c.Three.years.post.fracture.at.age.12.years.3.months,.the.left.knee.

(right).shows.physeal.bar.anteriorly.with.25.degrees.forward.tilt.

of.epiphysis .The.normal.right.knee.(left).shows.normal.backward.

tilt.of.5.degrees.of.the.articular.surface .There.is.30.degrees.dif- ference. in. the. sagittal. tilt. of. the. articular. surface. between. the.

two.tibiae .d.Photograph.of.the.left.leg.at.same.time.as.c .Since.

the.joint.is.articulating.normally,.this.anterior.angulation.of.the.

tibia.is.a.proximal.tibial.physeal.recurvatum.rather.than.true.genu.

recurvatum .The.skeletal.age.was.12.years .Although.the.patient.

had.little.growth.remaining,.a.bar.excision.could.help,.as.noted.in.

a.similar.case.by.Langenskiöld.[49] .(Continuation see next page)

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e.The.bar.excision.at.age.12.years.3.months.was.filled.with.cranioplast .The.metal.markers.were.14.mm.apart .A.com- pression.bandage.was.removed.after.18.hours.and.the.patient.allowed.to.ambulate .f.Age.13.years.0.months,.9.months.

post.operation .The.forward.angulation.has.corrected.10.degrees.(to.–15.degrees).and.the.metal.markers.are.23.mm.

apart .g.Photograph.of.left.leg.at.age.13.years.8.months .The.forward.angulation.of.the.tibia.is.improved,.but.not.fully.

corrected .Persistence.of.this.articular.tilt.allows.excessive.tension.on.the.posterior.cruciate.ligament.and.predisposes.

to.degenerative.arthrosis .(Continuation see next page)

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h.At.age.13.years.8.months,.an.

open. wedge. osteotomy. using.

iliac. crest. bone. [91]. proximal. . to. the. insertion. of. the. tibial.

tendon. provided. 19°. of. recurvatum.correction .i.AP.both.

knees.standing.at.age.14.years.

0.months . The. left. tibia. is.

15.mm. shorter. than. the. right . (Continuation see next page)

(17)

j. Lateral. both. knees. at. same.

time.as.i.show.a.backward.tilt.

of.4.degrees.on.the.left.(right).

and. 3°. on. the. normal. right.

(left) . The. combined. bar. exci- sion.and.open.wedge.osteotomy. resulted. in. 29.degrees. of.

forward. tilt. correction .k. Pho- tograph. of. both. legs. at. same.

time.as.i.and.j .The.anterior.angulation.is.corrected .Compare.

with.d . Note:. After. osteotomy.

the.position.of.the.left.patella.

is.relatively.lower.on.the.femur.

than. the. right. (compare.f. and.

j) .This.is.due.to.the.space.oc- cupied.by.the.iliac.graft .Does.

this. predispose. to. degenerative.arthrosis.or.will.the.patellar.tendon.elongate.with.time?.

The.bar.excision.was.successful.

in. reducing. the. amount. of.

wedge. required . A. 30-degree.

wedge. would. have. cause. the.

patella. to. be. even. lower. relative.to.the.femoral.condyles

(18)

Fig. 20.15

Proximal. tibia. type.2. fracture,. undisplaced . This.

12.year. 4.month. old. boy. injured. his. right. knee. in. a.

motorcycle.accident .a.There.is.a.nondisplaced.type.2.

fracture .A.long.leg.nonweightbearing.cast.was.worn.

four. weeks. followed. by. progressive. weightbearing.

with.crutches .b.One.year.later.(age.13.years.4.months).

the.patient.was.normally.active.and.asymptomatic . All.physes.were.open .The.right.tibia.was.1.mm.shorter.than.the.left

(19)

Fig. 20.16

Proximal.tibia.type.3.flexion.fracture .This.15.year.5.month.old.boy.initiated.a.jump.from.his.left.leg.while.playing..

basketball.and.noted.a.“pop”.in.his.left.leg.on.the.way.up .a.The.AP.view.(left).shows.only.mild.widening.of.the.physis . The.lateral.view.(right).confirms.type.3.fracture.with.mild.posterior.displacement.of.the.epiphysis .b.Reduction.under.

general.anesthesia.was.stable .A.long.leg.cast.was.applied.with.the.knee.in.extension .Case.contributed.by.Dr .Scott.

Cameron,.Marshfield,.WI

(20)

Fig. 20.17

Proximal.tibia.type.3.fracture .This.13.year.6.month.old.

boy.sustained.a.right.knee.injury.in.a.bicycle/automobile.collision .a.There.is.a.type.3.fracture.with.posterior.

displacement. of. the. metaphysis . The. neurovascular.

status.was.normal .The.fracture.reduced.easily.under.

general. anesthesia. by. flexion. and. was. stable . The. . leg.was.observed.and.two.days.later.a.cylinder.cast.applied. with. the. knee. flexed. 25° . The. cylinder. cast. allowed.continued.monitoring.of.ankle.pulses.and.foot.

sensation .b. Reduction. was. stable. at. time. of. cast. removal.5.weeks.later .Patient.was.encouraged.in.active.

motion.and.was.started.on.progressive.weight.bearing.

with. crutches .c. Five. years. 5.months. post. injury,. age.

18.years.11.months,.the.knee.was.normal

(21)

Displacement of the metaphysis posteriorly (Figs. 8A.1, 20.8, 20.17) or posteromedially (Fig. 20.23) is usually a hyperextension injury. Closed reduction is accomplished by the physician placing his/her fore- arm in the popliteal space followed by maximal flex- ion of the knee [105]. The reduction may be more stable in 90 degrees flexion. In this case, a long leg cast may be applied with the knee in 90 degrees flex- ion and changed to more extension in 2 weeks. An over-the-opposite-shoulder strap attached to the proximal portion of the cast improves patient mobil- ity. Occasionally soft tissue will be interposed at the fracture site preventing reduction (see Complica- tions). Multiple attempts at reduction risks further physeal damage [31]. Open extraction of the inter- posed tissue is necessary.

If the fracture is unstable after reduction, percuta- neous pins can be added [105]. In a young child the pins should avoid transversing the physis. If the me- taphyseal fragment of a type 2 fracture is too small to

accept pins it is treated like a type 3 fracture. Pins crossing the physis should be smooth, small in diam- eter, and removed in 3 weeks in an effort to avoid pre- mature closure. An alternative to pins across the phy- sis is insertion of pins transversely in the epiphysis and diaphysis, without crossing the physis, secured to an external fixator [31]. External fixation across the knee joint [73] is rarely indicated, and internal fixa- tion across the knee joint should be avoided (Fig. 30.7).

After pinning, the status of the ligamentous struc- tures and menisci can be well visualized by concomi- tant arthroscopy [70].

Type 4

Sagittal plane type 4 fractures that are undisplaced may be treated nonoperatively (Fig. 20.13). Displaced type 4 fractures must be reduced to achieve articular congruity. Internal fixation prevents redisplacement and is best done epiphysis to epiphysis (Fig. 20.18).

Fig. 20.18

Proximal.tibia.type.4.fracture.with.ORIF .This.16.year.0.month.old.boy.injured.his.left.knee.in.a.motorcycle.accident ..

a.AP.and.lateral.roentgenographs.show.a.mildly.displaced.type.4.fracture.of.the.proximal.tibial.epiphysis .(Continua- tion see next page)

(22)

b.An.oblique.tomogram.shows.greater.articular.separation.and.physeal.undulation.incongruity.than.appreciated.on.

the.plain.AP.(a) .Attempted.closed.reduction.was.unsuccessful .c.One-centimeter.skin.incisions.were.made.medially.

and.laterally.to.allow.entry.of.the.tynes.of.a.large.bone.holding.clamp .The.fracture.was.not.opened .Excellent.reduction.was.achieved .d.A.single.partially.threaded.4 5-mm.diameter.68-mm.screw.was.placed.over.a.guide.wire.across.the.

epiphysis.through.the.medial.incision .Arthroscopy.revealed.no.ligamentous.injury.or.intra-articular.fragments .The.

lateral.meniscus.was.contused,.but.not.lacerated .The.articular.cartilage.fracture.offset.was.<1.mm .A.long.leg.cast.was.

applied.2.days.later.and.worn.6.weeks .(Continuation see next page)

(23)

e.Six.months.post.fracture.(age.16.years.6.months).the.

patient.was.normally.active.and.asymptomatic .There.

is. subperiosteal. new. bone. on. the. medial. metaphysis.

indicative.of.periosteal.stripping.at.the.time.of.fracture . All.physes.are.closing .f.The.screw.was.removed.as.an.

outpatient. seven. months. after. fracture. (age. 16.years.

7.months)

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Coronal plane type 4 fractures (Figs. 20.4, 20.11b–

d) may be minimally displaced or easily reduced closed. However, the pull of the quadriceps mecha- nism predisposes to redisplacement. Maintenance of reduction cannot be assured by cast alone. Therefore, internal fixation is often performed [2, 46, 87]. In–

ternal fixation may be inserted percutaneously (Fig. 20.19), particularly if the fracture is incomplete (Fig. 20.11B), or more commonly, by open surgery (Fig. 20.20). If the distal portion of the tubercle frag- ment has periosteum attached it may be possible to

suture the fragment in place, avoiding internal metal- lic fixation [30, 50, 92, 100].

Fractures that enter the joint should be inspected, either directly or arthroscopically, to ensure articular congruity and absence of cartilage/bone fragments or meniscal/ligamentous damage. In those patients nearing maturity, metal fixation crossing the physis usually causes no growth problem. Fixation with crossed smooth wires (Fig. 20.19) facilitates metal removal.

Fig. 20.19

Proximal.tibia.type.4.fracture .This.14.year.9.month.old.boy.felt.a.“snap”.in.his.left.knee.while.taking.off.for.a.high.jump . a.Lateral.view.left.knee.shows.displaced.fragment.of.conjoined.anterior.portion.of.the.epiphysis.and.the.anterior.tu- bercle .The.central.and.posterior.portions.of.the.physis.are.essentially.closed .b.The.fracture.was.reduced.closed.and.

held.with.2.percutaneous.crossed.Steinmann.pins .Cast.applied .The.pins.were.removed.6.weeks.post.fracture .A.knee.

immobilizing.splint.was.applied.and.worn.2.weeks .c.Six.months.later.the.patient.was.normally.active.and.asymptomatic .Right.knee.(left).and.left.knee.(right).comparison.views .(Continuation see next page)

(25)

(26)

Fig. 20.20

Proximal.tibia.type.4.fracture .This.16.year.1.month.old.boy.jumped.up.for.a.dunk.playing.basketball.and.felt.like.a.brick.

hit.his.left.knee .a.AP.left.knee.is.normal .The.central.portion.of.the.proximal.tibial.physis.is.obscure,.and.appears.

closed .The.lateral.shows.avulsion.of.the.tibial.tubercle.which.is.united.with.the.anterior.tibial.epiphysis .There.is.closure.of.the.central.portion.of.the.physis .Compare.with.Fig .20 9.4 .The.treatment.was.ORIF.with.two.screws .b.At.time.

of.cast.removal.5.weeks.after.fracture,.all.of.the.physis.except.the.tubercle.is.closed .(Continuation see next page)

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Type 5

Type 5 fractures visualized in the AP plane are often two part and easy to reduce. Anatomic reduction is essential (but not a guarantee) in avoiding physeal ar- rest. Joint inspection visually (by open reduction or arthroscopy) helps to remove small bone fragments, assess ligamentous and meniscal damage, and ensure reduction. Internal fixation enhances maintenance of reduction and should avoid crossing the physes if pos- sible (Fig. 20.21). Fixation above and below the physis helps to control rotation of the fragment in the sagit-

tal plane. The incision should be planned to visualize and achieve both articular and physeal cartilage con- gruity. Smooth Kirschner wires and Steinmann pins, and cannulated screws are appropriate and depend on the size of the bone structure and the particular frac- ture.

Type 5 fractures visualized in the lateral projection may have three parts and may resemble a triplane fracture [20, 41, 73, 81]. The force required to produce a type 5 fracture often results in comminution (Fig. 20.22) and/or ligamentous and meniscal damage [35], which is more likely to require ORIF.

c.Eight.months.post.fracture.(age.16.years.9.months).the.patient.is.asymptomatic.and.normally.active.including.orga- nized.softball .All.physes.are.closed

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Fig. 20.21a,b

Proximal. tibia. type.5. fracture.

with.screw.fixation.above.and.

below.the.physes

Fig. 20.22

Proximal.tibia.comminuted.type.5.fracture,.with.soft.tissue.interposition .The.left.leg.of.this.15.year.8.month.old.was.

caught.between.the.handle.bars.and.the.gas.tank.during.a.motorcycle.accident .a.The.AP.view.shows.what.appears.to.

be.a.type.2.fracture.with.a.small.metaphyseal.fragment.(Holland.sign).attached.to.the.epiphysis.laterally.(arrow) .How- ever,.there.is.also.an.oblique.fracture.line.in.the.direction.of.the.arrow.from.the.lateral.edge.of.the.physis.to.the.tibial.

spines .In.addition,.the.articular.surfaces.of.the.two.tibial.condyles.are.not.in.the.same.plane.(one.or.the.other.is.tilted.

in.the.sagittal.plane) .b.The.lateral.view.shows.a.forward.tilted.type.3.fracture .However,.there.is.a.faint.rounded.osse- ous.shadow.superimposed.on.the.epiphysis.and.metaphysis.posteriorly.(arrow),.and.the.tibial.tubercle.apophysis.may.

be.detached.from.the.epiphysis .(Continuation see next page)

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c.At.the.time.of.closed.reduction.an.interosseous.Steinmann.pin.in.the.proximal.tibia.was.used.for.leverage.and.to.

.facilitate.cast.application .Note.persistence.of.the.medial.and.lateral.articular.surface.being.on.separate.planes.and.

persistent.widening.of.the.medial.portion.of.the.physis .d.Lateral.at.same.time.as.c .The.large.condylar.fragment.(arrow).

as.seen.on.b.is.displaced.posteriorly .A.long.leg.cast.incorporating.the.pin.was.applied .e.Eleven.days.post.fracture.the.

cast.and.pin.were.removed .An.oblique.view.shows.the.lateral.condyle.tilted.in.both.sagittal.and.coronal.planes.con- firming.a.type.5.fracture.(arrows),.in.addition.to.persistent.widening.of.the.medial.physis .This.fracture.does.not.have.

all.elements.of.a.triplane.fracture.and.is.best.classified.as.a.comminuted.type.5.fracture .Another.cast.was.applied.and.

removed.4.weeks.post.fracture,.followed.by.a.knee.immobilizer .f.At.6.weeks.post.fracture.(age.15.years.10.months).

there.is.persistent.widening.medial.physis.and.a.more.well.defined.metaphyseal.fracture.(between.the.arrows) .(Con- tinuation see next page)

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Type 6

Type 6 fractures all require initial debridement and eventual wound closure. All those with some growth remaining will require reconstructive surgery for angular deformity or length discrepancy [57]. Bar for- mation is inevitable and excision of the bar is unlikely to re-establish growth. These patients need repeat corrective osteotomies, physeal arrests, lengthenings, and on occasion cadaveric partial joint replacement (Fig. 3F.8).

General Considerations

In general, pins which cross the physis should be re- moved in three weeks followed by additional immobi- lization as appropriate. At six weeks the cast can be removed, a knee immobilizer applied, and exercises begun. Because of the high incidence of growth dis- turbance all cases should be followed a minimum of two years, unless all physes close earlier. A young child whose physis is not entirely normal should be followed until all physes are closed [12, 72]. Scano- grams every six months along with occasional bone age films will detect most problems.

g. An. AP. tomogram. shows. step-off. of. the. articular. surfaces . There. was.

10.degrees.genu.valgum.clinically.on.the.left .h.Open.reduction.revealed.

periosteum.rolled.between.the.medial.epiphysis.and.metaphysis .After.removal.of.the.periosteum.the.valgus.corrected.and.all.fragments.reduced . Two.staples.were.placed .Note.congruence.of.medial.and.lateral.condyle.

articular.surfaces .i.Scanogram,.age.17.years.1.month,.one.year.5.months.

post. fracture . The. patient. is. normally. active,. asymptomatic. and. has. returned. to. motocross. racing . All. physes. are. closed . The. left. tibia. is. 7.mm.

shorter.than.the.right .Clinical.genu.valgum.standing;.left.7.degrees,.right.

2.degrees

(31)

The implantation of metal markers in bone on each side of the physis at the time of fracture permit future determination of longitudinal growth and early de- tection of growth impairment. Spherical 0.5-mm balls of tantalum have been used [13]. Guidelines for the use of this technique, such as age of patient and type of fracture, have not been offered.

Complications

In the Olmsted County study, of 8 patients there were 3 patients (37.5%, Table 8.6) with 5 complications: 3 growth arrests, 1 angular deformity, and 1 length dis- crepancy (Table 8.1).

Complete Growth Arrest

Limb length discrepancy without angular deformity occurred in 14 of 97 total patients (14%) in the 3 larg- est series [12, 93, 105]. Relative tibial shortening is treated by contralateral tibial epiphysiodesis or ipsi- lateral tibial lengthening, or both, depending upon the amount of discrepancy. If tibial lengthening is not appropriate, arrest of the ipsilateral proximal fibula should be considered [94]. Shortening of the normal contralateral tibia is contraindicated because of the high likelihood of postoperative permanent anterior tibial weakness and footdrop.

Partial Growth Arrest

Bar formation with subsequent angular deformity oc- curred in 25% of 110 cases in a literature review by Gautier et al. [31] and in 24% of 67 patients in the combined series of Burkhart and Peterson [12] and Shelton and Canale [93]. Valgus is the most common deformity, followed by recurvatum [31]. Although most angular deformities occurred after type 5 frac- tures [1, 12, 21, 93], they have also been reported with type 2 and 4 fractures [12]. Also note the anterior angulation deformity after a type 1 fracture on Figs.

20.9 1, 20.14. Partial physeal arrest is always accom- panied by some amount of relative shortening [12].

When genu recurvatum occurs following minor trauma to the anterior knee in which no roentgeno- graphs are taken [98], it is not possible to determine the fracture type. Treatment is usually by bar excision (Fig. 20.9, 20.14e) if enough growth remains, with or without corrective osteotomy. An open wedge osteo- tomy [8, 12, 91] adds some length (Fig. 20.14h). Phy- seal arrest of the contralateral tibia is frequently nec- essary to prevent increasing length discrepancy.

Occasionally, physeal arrest of the remaining ipsilat- eral proximal tibia and the ipsilateral fibula is useful in preventing increasing angular deformity. Long- standing gradually progressive genu recurvatum may result in atrophy of the thigh and leg [8]. If the arrest is isolated to the anterior tibial tubercle, excision of the bar and limited corticotomy (instead of complete osteotomy) can be combined with application of an external lengthener to obtain gradual correction [74].

In cases of longstanding varus or valgus angula- tion the distal femur may develop a compensatory an- gular deformity in the opposite direction [5]. Since corrective osteotomy of the tibia alone would align the tibia oblique to the ground, it may be necessary to osteotomize both the tibia and the femur in order to achieve proper longitudinal alignment and a knee joint parallel with the floor.

Vascular Compromise

Posterior displacement of the metaphysis (Fig. 20.8) can cause mechanical obstruction (Fig. 20.23), arte- rial spasm, contusion, or stretching of the artery, or tearing of the intimal layer which invaginates, any of which may cause immediate or delayed thrombosis [11, 37, 43, 86, 105]. Complete severance of the artery is rare; two cases have been reported [19, 66]. Vessel repair with suture did not prevent subsequent gan- grene and amputation. Amputation is not an infre- quent occurrence (Figs. 8A.1, 20.12, 20.23) [2, 12, 23, 66, 93, 105]. The only way this can be prevented is by immediate vascular assessment and appropriate treat- ment, nearly always including surgery.

Vascular impairment may be subtle. The presence of pedal pulses is the most reliable physical finding of a patent arterial system. This does not exclude, how- ever, the possibility of damage to the arterial wall with delayed thrombosis, false aneurysm, or arterio- venous fistula. Normal skin capillary filling should not be equated with circulatory adequacy. Massive edema may make palpation of pulses impossible. The Doppler flowmeter may help determine the arterial status [37].

If distal pulses are absent fracture reduction should be performed immediately. If vascular deficit persists despite reduction, arteriography must be performed as soon as possible. Arteriography most accurately de- fines the arterial injury. It can be performed in the operating room and should not delay the surgery.

Magnetic resonance arteriography (MRA) [67] per-

formed with IV gadolinium is equally as revealing as

intraarterial iodine arteriography, has fewer side ef-

fects, and displays the opposite extremity for compar-

(32)

ison at no additional cost (financial or morbidity). To be useful in this situation, however, it must be avail- able in or near the emergency or operating room.

When vascular occlusion is present on arteriogra- phy surgical exploration is mandatory. Discussion of the use of vasodilators, catheters, and operative cor- rection of the occlusion are beyond the scope of this book. However, internal fixation of the fracture be- fore the arterial repair will help to prevent reinjury of the artery. In this instance operating time is impor- tant and internal fixation across the physis can be done quickly. Secure fixation will delay or negate cast application which also facilitates postoperative evalu- ations. Increased collateral circulation which devel- ops with an occluded popliteal artery may be suffi- cient to maintain physeal growth [11].

Without adequate management the amputation rate is 75–100% [37]. Vascular impairment was found in 4 of the 67 patients (6%) in the combined series of

Burkhart and Peterson [12] and Shelton and Canale [93], and these 4 ended in amputation. The injury to repair time interval and surgical management are the most important factors. After 6–12 hours limb sur- vival is greatly diminished [37]. In 1969, Haas and Staple [37] stated that no limb has been salvaged with more than a 40 hour interval from injury to repair.

However, in 1984 one limb with popliteal artery thrombosis was salvaged by arterectomy and throm- bectomy 96 hours post fracture [58]. This patient de- veloped permanent clawing of the toes, anesthesia of the lateral side of the foot, pronounced loss of calf muscle, and his athletic career was finished.

An attempt to restore arterial continuity is the best way to save the extremity of any patient with associ- ated popliteal artery damage. Anything less than nor- mal circulation demands immediate attention, usu- ally surgical. “Do not elevate, do not heat, do not refrigerate, do not delay” [43].

Fig. 20.23

Proximal.tibia.type.3.fracture .This.12.year.6.month.old.girl.was.critically,.and.originally.thought.to.be.mortally,.injured.

in.an.automobile.accident .Among.other.injuries.there.were.bilateral.type.3.physeal.fractures.of.the.proximal.tibiae.

with.posterior.displacement.of.the.metaphysis.on.the.left .The.left.leg.was.pale,.cold,.insensate,.and.pulseless.below.

the.knee .a.The.left.metaphysis.was.displaced.posteriorly.and.the.epiphysis.may.be.comminuted .(Continuation see next page)

(33)

b. After. reduction,. the. fracture. was. noted. to. extend.

vertically.through.the.epiphysis.making.it.a.“double”.

type.2.fracture.(Poland.type.4) .Exploration.of.the.left.

popliteal.artery.under.spinal.anesthesia.revealed.occlusion.of.the.popliteal.artery.by.direct.pressure.(mechanical.obstruction) .After.fracture.reduction.the.ankle.pulses.returned .The.toes.and.the.sole.of.the.foot.

remained.“cold ”.c.Six.weeks.post.injury.there.was.dry.

gangrene. of. toes,. sole,. and. heel. of. the. foot .d. In. an.

.attempt. to. save. some. length. a. subtalar. amputation.

was.combined.with.a.cross.leg.pedicle.graft.to.the.sole.

of.the.stump .(Continuation see next page)

(34)

e.This.was.unsuccessful.as.evidenced.by.subsequent.ischemic.necrosis.of.the.talus.and.skin.breakdown .f.Ankle.disar- ticulation.was.accomplished.and.the.stump.healed.for.successful.weightbearing.prosthetic.wear .g.The.proximal.tibial.

physeal.fracture.healed.with.anterior.angulation.which.normally.would.have.required.treatment,.but.which.was.not.

detrimental.for.prosthetic.wear.and.function

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Compartment Syndrome

Compartment syndrome may occur following any proximal tibial physeal fracture, even from tibial tu- bercle “avulsion” fractures (Figs. 20.11d, 20.12) [24, 65, 71, 102].

Differentiation between compartment syndrome and vascular compromise may be difficult. They may occur concomitantly [35, 106]. Pain upon hyperex- tension of the toes may be an early symptom of the onset of compartment syndrome. The diagnosis is confirmed by measuring soft tissue pressures. A con- firmed compartment syndrome requires immediate fasciotomy [65, 94].

Neuropathy

Damage to the peroneal nerve can occur with proxi- mal tibial physeal fracture alone, but is more likely to occur with an associated fracture of the head or neck of the fibula [35] or it may be due to a tight cast [94, 106]. Tibial nerve neuropathy is unusual and presents with clawing and insensate toes [34].

Combined injuries involving popliteal artery and nerves presents a special problem. Sensory distur- bance and paralysis may result from concomitant in- jury of the tibial and peroneal nerves, or as a result of ischemia. The popliteal nerves are not as anatomically fixed as the arteries, and therefore are less likely to be injured. Hence, nerve injuries are usually due to con- tusion or traction. Since the nerves are in continuity, recovery usually occurs. Any needed surgical nerve repair may await determination of spontaneous re- covery [43].

Irreducibility

Soft tissue interposition preventing reduction is not uncommon. It is most likely to occur with displaced type 2 fractures and has been noted with a type 3 fracture [80]. The tissue most commonly entrapped is the periosteum alone (Fig. 20.22h) [17, 27, 67, 73, 80], periosteum and pes anserine [99, 104], periosteum and MCL [87], and the infrapatellar fat pad. Multiple attempts at reduction may further damage the physis.

Open reduction is necessary [31], but internal fixation is optional [101]. If left untreated, permanent angular deformity may require osteotomy (Fig. 8C.1c) [87].

Ligamentous and Meniscal Injury

Since the physis is weaker than the ligaments, usually the physis alone is injured. However, physeal fracture does not exclude ligament damage and, in fact, is as- sociated with a significant incidence of ligament in- jury. Soft tissue structures that participate in knee stability and function that have been injured include rupture of the anterior cruciate and medial collateral ligaments (ACL and MCL), the patellar and quadri- ceps tendons, and tearing of menisci [6, 14, 34, 35, 52, 54, 82, 92, 93, 102, 105]. Tear of the medial meniscus apparently occurs only in association with ACL tear [6]. These patients are typically boys. These injuries are similar to distal femoral physeal fractures with ligamentous injury (Chapter 18).

In the series by Poulsen et al. [82], 8 of 12 patients had concomitant ligamentous injuries. In the series by Bertin and Goble [6], 8 of 13 had an “unstable”

ligament, defined as significant laxity with a definite endpoint. Of these 8 cases the ACL was involved in 4, the MCL in 3, and both the ACL and MCL in one case.

Avulsion of the ACL is most likely with type 4 and 5 fractures. Both ACL and MCL injuries may be over- looked at the time of injury because attention is di- rected to fracture management. When these injuries are recognized they should be repaired primarily [6, 82]. If these injuries are not treated promptly and ad- equately, degenerative arthrosis is likely [6, 35].

Overgrowth

Overgrowth is uncommon and usually minimal [93].

It can be troublesome in type 2 fractures with the metaphyseal fragment medially [21, 99]. The medial overgrowth, produces valgus deformity. In one case [99] the overgrowth was not improved by a brace and recurred after corrective osteotomy of the tibia and fibula. This phenomenon occurs only in very young children, similar to overgrowth following proximal tibial medial metaphyseal fracture and distal humeral lateral condyle fracture.

Bursitis

A paucity of soft tissue about the proximal tibia pre-

disposes to bursitis over prominent screw heads, cor-

rectible by screw removal [102].

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Osteomyelitis

Infection associated with a physeal fracture typically occurs only with an open fracture, such as a type 5 or 6 due to lawnmower injury [12]. Popliteal vascular occlusion associated with any type fracture may lead to ischemia followed by infection. If an amputation for limb gangrene is delayed too long, the amputation stump may become infected (Fig. 8A.1d).

Degenerative Arthrosis

This complication is underreported because most pediatric orthopedists do not follow their patients into adulthood. It is, however, common after type 4, 5, and 6 fractures [1, 82, 93] and may be more com- mon with associated ligamentous laxity [6, 93].

Author’s Perspective

Although distal tibial physeal fractures may have more frequent complications, serious morbidity from complications is greater at the proximal tibial physis.

Remember that the amount of displacement may be significantly greater at the time of fracture than on the initial roentgenograph. Careful and ongoing vascular assessment frequently precludes early cast application. Residents under my direction were in- structed that each and every patient with a fracture of the proximal tibial physis be admitted to the hospital for observation and treatment.

A. Proximal Tibial Stress Injury

In contradistinction to the very common stress injury of the proximal tibial apophysis (Osgood-Schlatter’s Disease), stress injury of the physis of the proximal tibial epiphysis is exceedingly rare. Two possible cases have been reported. One [107] was in a 15-year-old male long distance runner and the etiology was thought to be repetitive rotational or sheer stress.

Temporary cessation of activity allowed eventual re- turn to running. The second case [108] was a 13-year- old baseball catcher which the authors felt was due to prolonged, repetitive compression loading forces and called it “catcher’s knee.”

To these two cases, a third case is added (Fig. 20A.1).

In this case the condition was initiated by a direct

blow resulting in subperiosteal bleeding of the proxi-

mal medial tibia. This brings up the possibility of im-

pairment of the metaphyseal blood supply allowing

increased thickness of the physis similar to that illus-

trated in Fig. 2.8. This patient had the same symptoms

and clinical course as patients with stress injury at all

other sites.

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Fig. 20A.1

Stress.injury,.proximal.tibia .This.12.year.0.month.old.boy.was.kicked.by.another.soccer.player.on.the.right.knee.just.

medial.to.the.tibial.tubercle.and.inferior.to.the.“joint.line ”.There.was.immediate.pain.and.he.was.carried.from.the.field . a.Roentgenographs.were.reported.normal.and.a.diagnosis.of.“sprain”.of.the.knee.was.made .A.knee.immobilizer.was.

applied.and.crutches.given .Four.days.later.an.orthopedist.noted.swelling.and.tenderness.well.localized.medial.to.the.

tibial. tubercle . The. diagnosis. was. “contusion,”. proximal. right. tibia . The. immobilizer. and. crutches. were. continued . . b.Three.week.post.injury,.age.12.years.1.month,.the.pain.was.gone.and.the.immobilizer.and.crutches.had.been.discon- tinued .Other.than.a.smooth,.non-tender.raised.area.medial.to.the.tibial.tubercle.the.examination.was.normal .Roent- genographs.showed.widening.of.the.medial.half.of.the.tibial.physis.and.faint.subperiosteal.new.bone.formation.of.the.

metaphysis.medially.regarded.as.a.sequela.of.the.previous.“contusion ”.He.was.allowed.to.return.to.soccer.(Continua- tion see next page)

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Fig. 20A.1 (continued)

c.Eleven.weeks.post.injury,.age.12.years.2.months,.the.

patient.noted.limp.and.pain.on.the.medial.side.of.the.

proximal. right. tibia. after. running. 5–10.minutes. and.

while. using. a. skateboard . The. proximal. medial. tibia.

was.“more.full”.and.slightly.tender .The.physeal.width.

medially. continued. to. increase .d. A. PA. view. showed.

the. subperiosteal. new. bone. extending. down. to. the.

diaphysis.was.more.mature .There.is.unrelated.osteo- chondritis. dissecans. of. the. medial. femoral. condyle . Activity. curtailment. was. advised .(Continuation see next page)

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e.Twelve.weeks.after.injury.MR.images.confirmed.widening.of.the.medial.physis .f.Fourteen.weeks.post.injury,.age.

12.years.3.months,.the.pain.was.less .There.was.nontender.fullness.on.the.medial.side.of.the.proximal.tibial.diaphysis . There.was.discomfort.in.the.area.of.the.medial.tibial.physis.with.valgus.stress,.but.not.with.varus.stress .Curtailed.

.activities.were.reemphasized .(Continuation see next page)

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References

1. Aitken AP: Fractures of the proximal tibial epiphyseal cartilage. Clin Orthop 41:92-97, 1965

2. Aitken AP, Ingersoll RE: Fractures of the proximal tibial epiphyseal cartilage. J Bone Joint Surg 38A:787-796, 1956 3. Bak K: Separation of the proximal tibial epiphysis in a

gymnast. Acta Orthop Scand 62:293-294, 1991

4. Beaty JH, Kumar A: Fractures about the knee in children.

J Bone Joint Surg 76A:1870-1880, 1994

5. Beck A, Kundel K, Rüter A: Significance of corrective growth of opposite physes in the surgical correction of deformity following epiphyseal injury around the knee joint.

Knee Surg Sports Traumatol Arthroscopy 5:38-41, 1997 6. Bertin KC, Goble EM: Ligament injuries associated with

physeal fractures about the knee. Clin Orthop 177:188-195, 7. Blanks RH, Lester K, Shaw BA: Flexion-type Salter II frac-1983

ture of the proximal tibia. Proposed mechanism of injury and two case studies. Clin Orthop 301:256-259, 1994

8. Bohn CLS: The treatment of traumatic genu recurvatum by corrective, subarticular osteotomy on the tibia and by bone transplantation. Acta Orthop Scand 25:310-317, 1955-1956 9. Bolesta MJ, Fitch RD: Tibial tubercle avulsions. J Pediatr

Orthop 6:186-192, 1986

10. Borch-Madsen P: On symmetrical bilateral fracture of the tuberositas tibiae and eminentia intercondyloidea. Acta Orthop Scand 24:44-49, 1955

11. Bovill EG: Arteriographic visualization of the juxta-epiphyseal vascular bed following epiphyseal separation. A case report. J Bone Joint Surg 45A:1260-1262, 1963

12. Burkhart SS, Peterson HA: Fractures of the proximal tibial epiphysis. J Bone Joint Surg 61A:996-1002, 1979

13. Bylander B, Aronson S, Egund N, Hansson LJ, Selvik G:

Growth disturbance after physeal injury of the distal femur and proximal tibia studied by roentgen stereophoto- grammetry. Arch Orthop Trauma Surg 98:225-235, 1981 14. Carro LP: Avulsion of the patellar ligament with combined

fracture luxation of the proximal tibial epiphysis: Case report and review of the literature. J Orthop Trauma 10:355- 358, 1996

g.Five.months.post.injury,.age.12.years.5.months .The.patient.had.curtailed.his.activities .Examination.of.the.knee.was.

normal .There.is.beginning.ossification.within.the.widened.portion.of.the.physis .h.Six.months.post.injury,.age.12.years.

8.months .The.patient.had.remained.relatively.inactive.and.was.asymptomatic .Knee.examination.was.normal .The.

proximal.tibial.physis.is.returning.to.normal.and.the.subperiosteal.new.bone.was.incorporated.into.the.diaphysis .i.At.

age.14.years.6.months,.2.years.6.months.post.injury,.the.patient.was.normally.active.and.asymptomatic .Roentgeno- graphs.were.normal.for.his.age .This.case.was.contributed.by.Dr .Thomas.Schmidt,.Overland.Park,.Kansas