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Proximal Tibia Metaphyseal Fractures - Pediatric

Topic updated on 05/31/15 2:54pm
Introduction
  • Proximal tibia metaphyseal fractures are significant for their tendency to develop a late valgus deformity  
    • etiology of valgus deformity is unknown
    • known as Cozen's fracture or phenomenon
  • Epidemiology
    • most common in children 3-6 years of age
  • Mechanism
    • typically low-energy with valgus force across the knee
    • classic mechanism is child going down slide in the lap of an adult
  • Prognosis
    • valgus deformity resolves spontaneously
Classification
  • Classification of pediatric proximal tibia metaphyseal fractures is descriptive. 
    • important radiographic parameters include:
      • complete versus incomplete 
        • majority are incomplete
      • displaced or nondisplaced
      • presence and location of associated fibula fracture
Presentation
  • Symptoms
    • pain
    • refusal to bear weight
  • Physical exam
    • valgus deformity
    • evaluate carefully for compartment syndrome
Imaging
  • Radiographs
    • recommended views
      • required
        • AP and lateral 
    • findings
      • look for incomplete vs complete and presence of a proximal fibula fracture which may indicate a more unstable fracture pattern
Treatment
  • Nonoperative
    • long leg cast in extension with varus mold
      • indications
        • nondisplaced fracture
      • technique
        • casts are maintained for 6-8 weeks with serial radiographs
        • weight bearing may be allowed after 2-3 weeks.
    • reduction followed by long leg cast in extension with varus mold 
      • indications
        • displaced fracture
      • technique
        • requires conscious sedation or general anesthesia
        • cast in near full extension (10 degrees flexion)
        • varus mold at fracture site
  • Operative
    • open reduction
      • indications
        • inability to adequately reduce a displaced fracture
        • secondary to soft tissue interposition
      • technique
        • limited medial approach to proximal tibia
        • periosteum or tendons of pes anserinus may block reduction
        • internal fixation not commonly required
 Complications
  • Valgus deformity 
    • may be observed for 12-24 months with expectation of spontaneous correction 
    • parents should be counseled in advance
    • treatment
      • if deformity fails to resolve 
        • medial hemi-epiphysiodesis in skeletally immature patient
        • corrective osteotomy in skeletally mature patient
  • Limb length discrepancy
    • affected tibia is often longer (average 9mm)
    • typically does not require intervention however parents should be counseled that this does not resolve

 

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Qbank (2 Questions)

TAG
(OBQ10.177) A 5-year-old girl falls off of a trampoline and sustains a tibia fracture. The tibia fracture is reduced and placed into a long leg cast in the emergency room. A post-reduction radiograph is provided in Figure A. The parents should be counseled that a temporary tibial deformity may occur. Which of the following best describes the potential deformity? Topic Review Topic
FIGURES: A          

1. Recurvatum
2. Varus
3. Malrotation
4. Valgus
5. Procurvatum

PREFERRED RESPONSE ▶
TAG
(OBQ05.179) A 3-year-old boy sustained a minimally displaced proximal metaphyseal tibia fracture of the left leg 6 months ago that was treated with a molded long leg cast. His current AP radiograph is shown in Figure A. What is the most appropriate management? Topic Review Topic
FIGURES: A          

1. Follow-up radiographs in 6 months
2. Ring fixator placement with distraction osteogenesis
3. Hemiepiphyseodesis of the proximal tibia
4. Follow-up radiographs in 3 months and placement of knee-ankle-foot (KAFO) orthosis
5. Closing wedge proximal tibial osteotomy

PREFERRED RESPONSE ▶




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