Classification of proximal tibial epiphysis fractures in children: Four clinical cases

Avulsion Fracture of the Tibial Tuberosity in an Adolescent: Case Report

The present study reports a rare case of avulsion fracture of the tibial tuberosity in an adolescent. A 14-year-old male patient sprained his left knee during a soccer match. At the first emergency-room visit, he presented pain in his left knee, 2 +/4+ edema, and inability to walk and flex the affected knee, but no neurovascular changes or signs of compartment syndrome. Radiographs revealed a physeal fracture at the left proximal tibia, classified by Ogden, Tross and Murphy, and modified by Ryu and Debenham, as type IV, and complemented by Aerts et al. as type IV-B. Immobilization was performed with a plaster cast from the inguinal to malleolar regions, followed by analgesia. The patient was operated on the next day, when open reduction and internal fixation using 4.5-mm cannulated screws were performed. The patient was discharged one day after surgery, with plaster cast immobilization and load restraint for four weeks, and bone consolidation was radiologically confirmed three months after the procedure. The patient evolved with a range of motion similar to that of the contralateral limb, no length discrepancy in the lower limbs, and no complaints after one year of follow-up.

Posterior tibial slope angle is associated with flexion-type Salter-Harris II and Watson-Jones type IV fractures of the proximal tibia

PURPOSE

Flexion-type Salter-Harris (SH) II fractures of the proximal tibia, also described as Watson-Jones (WJ) IV fractures, are rare injuries reported among adolescent athletes who are close to skeletal maturity and remain elusive. Due to this classification disagreement, the various treatments range from nonoperative to operative types, and no previous studies have explained the mechanisms of injury or the source of the fracture forces. This retrospective matched case-control study aimed to identify radiological factors that are associated with the fracture forces and to elucidate the mechanisms of these injuries.

METHODS

Sixteen flexion-type SH II/WJ IV fractures of the proximal tibia in 12 adolescents (12 males, mean age of 14.6 years) were retrospectively reviewed, and knee alignment on plain radiographs was assessed to compare the radiological outcomes of the operated knees (n = 7), nonoperated knees (n = 9), and uninjured contralateral knees (n = 8). The results were compared to healthy age- and sex-matched control subjects (n = 24 knees).

RESULTS

With regard to the radiological outcomes, the posterior tibial slope angle (PTSA) was significantly greater in the nonoperated knees (19.0° ± 1.6°), operated knees (16.8° ± 1.3°), and uninjured knees (13.6° ± 1.3°) than in the healthy knees of the matched control subjects (9.6° ± 0.4°). The anatomical tibiofemoral angle was significantly less in the nonoperated knees (0.7° ± 0.6°) than in the healthy knees of the matched control subjects (3.7° ± 0.4°).

CONCLUSIONS

These findings suggest a relationship between an increased PTSA and flexion-type SH II/WJ IV fractures of the proximal tibia, considering the deteriorating effects of an increased PTSA on knee kinematics. Adolescent active athletes with an increased PTSA and partially closed epiphysis of the proximal tibia are at risk for suffering from flexion-type SH II/WJ IV fractures of the proximal tibia until the closure of the proximal tibial epiphysis.

LEVEL OF EVIDENCE

Case-control study, Level III.

Rehabilitation of simultaneous bilateral epiphysial fracture of proximal tibia in adolescent

Simultaneous and bilateral epiphysial fracture of the proximal tibia is an extremely rare injury, with only 23 cases reported in the literature. In this paper, we present a 15-year-old adolescent with a simultaneous and bilateral epiphysial fracture of the proximal tibia in sport context (trampoline jump). He underwentsurgical repair with bilateral closed reduction and internal fixation, followed by outpatient rehabilitation programme during 4 months. There was a good functional outcome, without limitation in activities of daily living and with resumption of amateur sports activity. Since there are no guidelines described for this pathology, the authors suggest a rehabilitation protocol for bilateral epiphysial fractures of the proximal tibia that underwent surgical treatment previously and in which there were no complications in the acute phase.

Proximal Tibial Epiphysis Fracture in a 13-Year-Old Male Athlete

Fractures of the proximal epiphysis of the tibia are rare, representing 0.5 to 3.0% of all epiphyseal injuries. These injuries can damage the popliteal vessels and their bifurcation, affecting the blood supply of the lower limb, as well as the nerves below the knee. Epiphyseal growth arrest is also a potential complication, leading to various angular deformities. We present a case of a 13-year-old male athlete with a posteriorly displaced Salter-Harris type II fracture of the proximal epiphysis of the left tibia who was treated conservatively with closed reduction and cast immobilization.