Clinical significance of a classification of epiphyseal injuries at the ankle

Clinical characteristics of 1124 children with epiphyseal fractures

BACKGROUND

In this study, to provide a theoretical basis for understanding the clinical characteristics of epiphyseal fractures in children and improving their management, we explored and analyzed the proportions of different types of epiphyseal fractures in children and evaluated the causes of injury and epidemiological characteristics.

METHODS

We retrospectively analyzed children younger than 18 years with fresh epiphyseal fractures who were admitted to our hospital from July 2015 to February 2020. Demographic information, injury mechanisms, fracture characteristics, fracture classification and surgical information were collected.

RESULTS

A total of 1124 pediatric patients (1147 epiphyseal fractures), including 789 boys and 335 girls, were included in this study. Epiphyseal fractures were classified as Salter-Harris type II (1002 cases), type IV (105 cases), type III (25 cases), Salter-Harris type I (14 cases), and Salter-Harris type V (1 case). The number of fracture sites peaked in the adolescent group (440 cases). The most three common sites of epiphyseal fractures were the distal radius (460 cases) in which Salter-Harris type II fractures were the most common (454 cases) and Salter-Harris type I (3 cases), Salter-Harris type IV (2 cases), Salter-Harris type III was the least common (1 case). Followed by phalanges of fingers (233 cases) in which Salter-Harris type II fractures were the most common (224 cases) and Salter-Harris type IV (4 cases), Salter-Harris type I (3 cases), Salter-Harris type III fractures were the least common (2 cases). Distal humerus (146 cases) in which Salter-Harris type II fractures were the most common (95 cases), followed by Salter-Harris type IV (49 cases), Salter-Harris type I fractures were the least common (2 cases). The most three important causes of fractures were falls (720 patients), car accident injuries (68 patients), and basketball falls (43 patients). Among the 1124 children with epiphyseal fractures, 1058 were treated mainly by surgery and the ratio of open and closed reduction was 1:5.3. Eighty-eight patients showed an interval > 72 h between the injury and the hospital visit. Among these 88 patients, the most common fracture type was distal radial epiphyseal fracture (32 cases), and all fractures were of Salter-Harris type II.

CONCLUSIONS

The epidemiological characteristics of epiphyseal fractures in children indicate the need to strengthen health and safety education and protective measures to prevent the occurrence of these fractures in children. In addition, emergency surgeons and orthopedic surgeons in general hospitals should strengthen their basic knowledge of diagnosing and treating epiphyseal injuries in children to reduce missed diagnoses, misdiagnoses or malpractice.

Risk of premature physeal closure in fractures of distal tibia

The reported incidence of premature physeal closure (PPC) in fractures of the distal tibia has varied between 5 and 36%, but there is no consensus on the cause. We wanted to determine incidence and predictors of PPC in distal tibia physeal fractures in a population-based patient cohort. Two hundred forty-one patients (195 Peterson type I-V fractures and 46 transitional fractures) treated for a physeal fracture of the distal tibia during a 5-year period in two tertiary-level teaching hospitals. Odds ratios (OR) for developing PPC for different parameters (Peterson fracture type, associated fibula fracture, primary and postreduction displacement, number of reductions and the method of treatment) were calculated by binary logistic regression analysis. In 195 children with Peterson type I-V fractures PPC was diagnosed in 21 children (11%), of which 11 (6%) had surgery at mean 14 months from the fracture to correct either angular deformity or leg length discrepancy. The incidence of distal tibia PPC is at least 0.05/1000 children. More than one reduction attempt was the most significant risk factor (OR 7.0) for PPC. Peterson fracture type, associated fibula fracture, initial or post-reduction displacement or type of treatment did not correlate with PPC. The incidence of distal tibia PPC is at least 0.05/1000 children. The number of reductions correlates positively with the risk of PPC.

Physeal injuries of the proximal humerus: long-term results in seventy two patients

PURPOSE

The aim of this study was to evaluate our treatment methods of proximal humeral physeal injuries retrospectively and elucidate the relationship between the trauma mechanism, the radiographic injury pattern, the consequent therapy and the functional outcome, and to further deduct and verify prognostic criteria.

METHODS

At our Department of Trauma Surgery, 303 children and adolescent patients with fractures of the proximal humeral epiphysis were treated from 1992 to 2009. 72 cases were diagnosed as physeal fractures according to the Salter-Harris classification and were included in our study.

RESULTS

15 physeal fractures of the proximal humerus were reconstructed anatomically by open or closed reduction and produced 93.3% excellent results. 57 physeal fractures were treated in a conservative way and produced 94.7% excellent results.

CONCLUSION

We state that epiphyseal injuries should to be treated depending on the age of the patient. This is the only way to decrease the rate of posttraumatic epiphysiodesis with consequent problems, including limb-length discrepancy and/or angular deformities.

[Traumatic physeal separations of the distal tibia. Occurrence, forms, treatment strategies]

Traumatic physeal separations (SH I/II) of the lower extremities are rare. Complications are reported in 2.2-39.6%. The current study is intended to provide recent data concerning epidemiology and treatment decisions in physeal separation of the distal tibia. All patients who suffered a physeal separation of the distal tibia in a 36-month period were included in a multicenter study. Age, gender, mechanism of injury, classification, therapeutic decision, and early complications were recorded online. There were 150 cases (64.6% male, 35.4% female, average age 11.8 years). The most frequent mechanism of injury was sportive activity (42%); 76% of cases needed reduction. Antecurvation was tolerated up to 10° (p=0.0021) and valgus up to 7° (p=0.0155). Tolerance ranges up to 5° of retrocurvation and varus were not statistically significant. The investigation confirmed epidemiological data of former studies. For the first time data concerning the treatment reality of physeal separations of the distal tibia were recorded. They consistently follow the recommendations of the appropriate literature.

Physeal injuries of the distal tibia: long-term results in 376 patients

The aim of this study was to evaluate our treatment of distal tibial physeal injuries retrospectively and explain the relationship between the trauma mechanism, the radiographic injury pattern, the subsequent therapy and the functional outcome, as well as to further deduce and verify prognostic criteria. At the Department of Trauma Surgery, Vienna Medical University, 419 children and adolescent patients with physeal injuries of the distal tibia were treated from 1993 to 2007, of these 376 were included in our study and evaluated retrospectively. Seventy-seven displaced physeal fractures of the distal tibia were reconstructed anatomically by open or closed reduction and produced 95% excellent results. A perfect anatomical reduction, if necessary by open means, should be achieved to prevent a bone bridge with subsequent epiphysiodesis and post-traumatic deformities due to growth inhibition and/or retardation.

Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure?

INTRODUCTION

The distal tibial physis is the second most commonly injured physis in long bones. Recent reports demonstrate a high rate of premature physeal closure (PPC) in Salter-Harris (SH) type I or II fractures of the distal tibia.

METHODS

At our institution, 137 distal tibial SH type I or II fractures were treated from 1994 to 2002. Reviews were performed on all patients and 91 fractures met inclusion criteria. Patients were categorized according to treatment.

RESULTS

We report a PPC rate of 39.6% in SH type I or II fractures of the distal tibial physis. We found a difference in PPC based on injury mechanism. The rate of PPC in patients with a supination-external-rotation-type injury was 35%, whereas patients with pronation-abduction-type injuries developed PPC in 54% of cases. Type of treatment may prevent PPC in some fractures. The most important determinant of PPC is the fracture displacement following reduction.

DISCUSSION AND CONCLUSION

PPC is a common problem following SH type I or II fractures of the distal tibia. Operative treatment may decrease the frequency of PPC in some fractures. Regardless of treatment method, we recommend anatomic reduction to decrease the risk of PPC.

Pediatric fractures of the foot and ankle

Distal tibial physeal injuries are common in children, accounting for 10% to 40% of all injuries to skeletally immature patients. This article describes the classification, treatment, and complications of distal tibial fractures, fractures of the talus and calcaneus, midfoot and tarsometatarsal injuries, metatarsal fractures, and fractures of the phalanges in children.

Growth disturbances after distal tibial physeal fractures

Twenty-four patients with distal tibial growth disturbance were reviewed. Disturbances were classified as physeal bar (prior to deformity), angular, linear or combined deformities. Treatment consisted of osteotomy in fourteen, epiphyseodesis in seven, excision of bony bar in two, and observation in one patient. Follow up was an average 36.6 months (range 4-129 months) after treatment of growth disturbance. The age at time of injury was 10.4 years of age average (range 3-15 years). There were 12 SH2, 2 SH3, 7 SH4, and 3 SH5 distal tibial physeal fractures. Thirteen of 15 fractures considered high energy and only 1 of 9 fractures considered low energy resulted in angular deformity. Angular and linear deformities presented an average 46 months (range 12-120 months) and physeal bars at an average 14 months (range 6-25 months) after injury. Patients with a delay in presentation of growth disturbance greater than 24 months had angular deformities in 92% compared with 33% in children presenting less than or at 24 months. Treatment based on type of deformity, age at time of injury, and growth remaining was considered successful in 83%. Patients with angular or linear deformities were more likely to present late, have high energy injuries, be male patients and have Salter-Harris types IV and V. Early diagnosis and treatment of growth disturbance can prevent severe deformity.

Recurrent medial ankle instability: the result of distal fibular growth arrest

Recurrent medial ankle instability is an uncommon clinical entity. A case that resulted from a distal fibular physeal arrest is described. Symptoms resolved after a one-stage fibular lengthening.

[Reparative processes of experimental Aitken III lesion. An animal experiment study]

This present study describes the fine structural aspects of experimentally induced defects of the proximal growth plate of the tibia in rabbits as simulation of epi-/methaphyseal fractures. We evaluated two different defect sizes. As important result we find in narrow defects of 0.5 mm no osseous bridging of the epiphyseal plate whereas with 2 mm defects there is partial transphyseal closure. Growth plate cartilage is thus capable of repairing spontaneously smaller defects.

The classification and prognosis of epiphyseal injuries

Because of the difficulty of assessing prognosis, a clinical and radiological review of 103 injuries of growth plates was performed. Thirteen patients showed retardation of growth and in 4 it was clinically obvious. In addition, external deformity occurred because of failure of remodelling in 1 case. In 9 cases there appeared to be slight stimulation of growth. The correlation between the Salter-Harris classification and retardation of growth was not always clear, especially in Salter-Harris type IV injuries, wherein prognosis varied with site. At the distal end of the tibia two groups of type IV injury were identified having respectively a 0 and 62.5 per cent incidence of retardation of growth. A new classification of distal injuries of the tibia is proposed, with superior predictive value for retardation of growth than that of Salter and Harris. This is valuable as a guide to prognosis and may facilitate treatment.

Late results in 65 physeal ankle fractures

Fifty-nine Salter-Harris III and IV lesions of the medial malleolus, Tillaux fractures, and triplane fractures were examined after 9 (3-32) years to assess the frequency of late symptoms, deformity, joint incongruity, and secondary arthrosis. Six out of 18 Salter-Harris III and IV lesions of the medial malleolus were reduced open, none of which had any signs of growth disturbance, whereas 1 case, left with a 3-mm residual dislocation, had 5 degrees of anterior angulation. Of the 17 Tillaux fractures, ten were not reduced and two of these gave slight symptoms, whereas five openly reduced fractures were asymptomatic at follow-up. Out of 18 triplane fractures, not reduced, two gave slight ankle pain and another had 6 degrees of anterior angulation, whereas three of ten reduced fractures were symptomatic. The overall results were good and no case of arthrosis, defined as reduction of the joint space, was found in any of the fracture groups despite a follow-up of 12 or more years in one third of the cases.

Children's ankle fractures. Classification and epidemiology

In an investigation of childhood and adolescence fractures (age groups 0-16) occurring in Malmö during 1950, 1955, 1960, 1965, 1970 and 1975-79, a total of 8682 were found. Four per cent or 373 ankle fractures were classified according to their roentgenological appearance. Avulsion fractures of the tip of the lateral malleolus were the most frequent, followed by fractures involving the distal fibular physis. Triplane and Tillaux fractures were the third and fourth most common fracture groups. Tillaux fractures were more common in girls (0.01 greater than P greater than 0.001). There was no statistically significant difference between the sexes in the other fracture groups or in the whole series. Most injuries were caused by low energy trauma. A foot caught in a bicycle wheel resulted more often in an epiphyseal fracture of the lateral malleolus than any other type of fracture. Otherwise no other etiological factor caused a significant number of cases in any fracture group. There was a seasonal variation with twice as many fractures during April and September as compared with July and December. The incidence showed a steady increase during growth which ceased after the early teens due to a lower incidence among girls in the age groups 15-16. The incidence increased significantly during the 30 years covered by this study.

Supination-adduction injuries of the ankle in children--radiographical classification and treatment

Diagnostical and therapeutical problems associated with supination-adduction injuries are presented. 457 ankle fractures were collected from a retrospective material of 919 children aged 0-18 years with fractures of the tibio-fibular shaft or the ankle. The ankle fractures were classified anatomically according to Salter and Harris and traumatologically according to Gerner-Smidt. 147 fractures were classified as due to supination-adduction, of which 128 had open growth plates. The first stage, a Salter-Harris type I, II, or III fracture through the lateral malleolus or only epiphyseal fracture without fracture through the growth plate, is easily overlooked and is probably more common than earlier registered. The stage II injury with, an addition, a vertical or oblique fracture of the medial malleolus sometimes continuing through the physis and metaphysis is often more easily recognized at the radiographical examination. The mean age of supination-adduction injuries is lower than for supination-eversion injuries. The supination-adduction injuries are the second most common type of ankle fractures in children (32%) only exceeded by injuries due to supination-eversion (39%). Early recognition of the fracture pattern of supination-adduction injuries is important as growth disturbance and joint problems are not uncommon when there is fracture through the medial malleolus. The need for correct diagnosis and treatment is stressed by the risk for late problems.

Pronation injuries of the ankle in children. Retrospective study of radiographical classification and treatment

In a retrospective study in children aged 0-18 years, 457 ankle fractures in children were classified traumatologically according to Gerner-Smidt or Lauge-Hansen. Anatomically, ankle fractures with open growth plates were classified according to the Salter-Harris classification. Pronation injuries constituted 18% of the ankle injuries and showed different fracture patterns. In total 83 pronation injuries were found. Of these, 52 showed open growth plates: 25 pronation-abduction, 23 pronation-eversion, and 4 pronation-dorsal flexion injuries. The pronation-abduction injuries were classified into two groups. In 15, a detachment of the deltoid ligament at the medial malleolus, visible on radiographs as a minimal fragment or transverse fracture of the medial malleolus, was found; seven showed in addition a fracture through the growth plate (Salter-Harris type I or II) or a metaphyseal fracture of the distal fibula. In 10, a physeal fracture through the distal tibia (Salter-Harris type I) was found. Of these, seven had in addition a metaphyseal fibular fracture. Pronation-eversion injuries showed in 21 cases a physeal-metaphyseal fracture (Salter-Harris type II) with an antero-lateral metaphyseal fragment (Stage I-II); 17 had in addition a metaphyseal fibular fracture (Stage III). A minimal posterolateral metaphyseal fragment of the distal tibia represents the fourth stage but could not adequately be separated from the third, so Stages III and IV were combined. Pronation-dorsal flexion showed a physeal-metaphyseal fracture in four cases with an anteriorly situated metaphyseal fragment (Stages I-II); one case also had a metaphyseal fracture of the distal fibula (Stage III). Pronation-eversion injuries showed frequently displacement and were more commonly treated by reduction than pronation-abduction and supination injuries including supination-eversion injuries of intra-articular type. However, complete reduction of pronation-eversion injuries with closed methods often proved difficult.

Roentgen stereophotogrammetric analysis of growth pattern after pronation ankle injuries in children

In a prospective study of ankle fractures in children, the posttraumatic growth pattern was registered with a roentgen stereophotogrammetric technique. This method allows determination of growth rates within 3 months after fracture, and the prognosis for future growth can be determined within 6-8 months after fracture. The ankle fractures were classified anatomically according to Salter-Harris and traumatologically according to Gerner-Smidt. Nine cases were classified as due to pronation: two pronation-abduction injuries and seven pronation-eversion injuries. The pronation-abduction injuries had Salter-Harris type I injury in distal fibula and tibia, respectively, and showed initial growth stimulation and symmetric growth. The pronation-eversion injuries had a Salter-Harris type II injury in distal tibia and showed three types of growth pattern: initial growth stimulation (3 cases), growth arrest (2 cases), and progressive growth retardation (1 case), besides one case with no significant growth registered bilaterally. Asymmetric growth within the growth region was found in four cases; in three mainly as a varus position, in one mainly as antecurvation of the ankle joint. In conclusion, the pronation-abduction injuries showed growth stimulation, whereas the older showed progressive growth retardation or growth arrest.

Classification of ankle fractures in children

The roentgenograms of 310 children treated for ankle fractures were evaluated for grouping according to the classifications of Ashhurst-Bromer-Weber, Lauge-Hansen, and Salter-Harris. The mean age of the children at the time of injury was 11.1 years (range 2-14 years). Two hundred twenty-one (71.3%) children had malleolar fractures, 71 (22.9%) had tibial epiphyseal fractures, and 18 (5.8%) had syndesmotic lesions. The age distribution of fractures was typical: malleolar fractures predominated among the younger children, epiphyseal fractures among the older. Only the oldest children had avulsion fractures of the syndesmosis. Grouping of the fractures according to Lauge-Hansen and Ashhurst-Bromer-Weber, classifications suited to adults was largely unsuccessful. Epiphyseal fractures, moreover, were easily classified according to Salter-Harris. In spite of their complexity, ankle fractures in children can be roughly divided into avulsional and epiphyseal fractures. Adequately reduced avulsional fractures can be expected to heal well; epiphyseal fractures, however, may five rise to late complications. We propose, therefore, that ankle fractures in children be classified on the basis of roentgenological findings with respect primarily to epiphyseal lesions as well as on an additional simple grouping as to risk for clinical purposes: Group I, low risk, avulsional fractures and epiphyseal separations; Group II, high risk, fractures through the epiphyseal plate.