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Proximal Tibia Epiphyseal Fractures - Pediatric

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Topic updated on 12/15/15 1:22am
Introduction
  • Type 4 Tibial Tubercle FractureEpidemiology
    • incidence
      • <1% of pediatric fractures
  • Pathophysiology
    • mechanism of injury
      • high energy trauma
      • varus/valgus force
      • hyperextension
  • Associated conditions
    • fracture
      • may occur as a part of a Type III tibial tubercle fracture   
    • vascular injury
      • most commone with hyperextension injuries
      • tethering of popliteal artery (5%)
    • peroneal nerve injury (5%)
    • knee ligamentous injury
    • compartment syndrome (3%-4%)
Anatomy
  • Physeal considerations of the knee
    • general assumptions
      • leg growth continues until 
        • 16 yrs in boys
        • 14 yrs in girls
    • growth contribution
      • leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)
        • proximal femur - 3 mm / yr (1/8 in)
        • distal femur - 9 mm / yr (3/8 in)
        • proximal tibia - 6 mm / yr (1/4 in)
        • distal tibia - 5 mm / yr (3/16 in)
Presentation
  • Symptoms
    • unable to bear weight
  • Physical exam
    • inspection
      • pain and swelling
      • tenderness along the physis in the presence of a knee effusion
    • motion
      • may see varus or valgus knee instability on exam
    • neurovascular exam
      • physis is at same level of trifurcation of vessels and there is a risk of vascular compromise with displacement
Imaging
  • Radiographs 
    • recommended views
      • AP and lateral 
    • optional views
      • oblique views
      • varus/valgus stress views
    • findings  
      • displacement of fracture fragments
      • Salter Harris classification
  • CT
    • indications
      • assess fracture displacement
    • findings
      • best modality for SH III or IV fractures
Treatment
  •  Nonoperative
    • immobilization in long leg cast
      • indications
        • non-displaced fracture
        • stable Salter-Harris Type I and Type II fractures
      • modalities
        • traction for fracture reduction
        • cast in slight flexion for 6 weeks
      • outcomes
        • redisplacement is common without internal fixation
  • Operative
    • anatomic reduction and fixation with percutaneous pinning
      • indications
        • displaced fractures
        • unstable Salter-Harris Type I and Type II fractures
        • redisplacement following closed treatment
      • modalities
        • percutaneous pins parallel to physis
        • pins crossing perpendicular to physis if extra-articular fixation needed
      • outcomes
        • avoid displacement to affect trifurcation
    • open reduction internal fixation  
      • indications
        • displaced fractures
        • Salter-Harris Type III and Type IV fractures
      • modalities
        • screw parallel to physis
        • cast in slight flexion for 4-6 weeks
Complications
  • Loss of reduction
  • Growth disturbances (25%)
    • can lead to limb length discrepancy and/or angular deformities
  • Compartment syndrome
  • Ligamentous instability

 

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