Rotational displacement of the distal tibial epiphysis without fibular fracture

Pediatric Distal Tibia Physeal Injury Presenting with Acute In-toeing: A Case Report and Literature Review

Ankle fractures are among the most common fractures sustained in the pediatric population. Given the frequency of physeal involvement of the distal fragment, complications including growth arrest, overgrowth, and rotational deformities are not uncommon. This case report describes a 12-year-old adolescent boy who presented after an acute right ankle injury sustained while playing. He noted right ankle pain, swelling, and in-toeing of his foot. Radiographs of the ankle demonstrated a distal tibia Salter-Harris type II fracture that appeared nondisplaced. However, a CT scan of the ankle demonstrated a 60° difference in the rotational profile between the injured and noninjured tibias. The patient's acute rotational deformity was corrected with closed reduction and percutaneous pinning. Pediatric distal tibia physis fractures presenting with in-toeing are rare and difficult to diagnose accurately with radiographs alone. Accordingly, a detailed history, physical examination, comparison radiographs, and CT scans are imperative in making the correct diagnosis and determining the appropriate treatment.

Rotational injuries of the distal tibial growth plate

Nine rotational injuries of the distal tibial growth plate in combination with spiral fracture of the fibula were treated in our department between 1993 and 2000. The average age of the patients was 12 years. The injury was a result of sudden, forceful external rotation of the ankle and foot. Pain and slight swelling of the ankle and external rotation of the distal tibia of 20 degrees -40 degrees were present. Radiologically, irregularity and widening of the growth plate of the distal tibia were obvious. In all these cases we noted, on lateral views, the characteristic sign of an "open fish mouth," due to the changes in the shape of the physeal plate. The spiral fracture of the fibula was not obvious in all radiographic views. The treatment in all eight fresh cases was closed reduction and manipulation by reversing the mechanism of injury and long leg cast application in all nine cases (including the one neglected case) for 6-8 weeks. The final results were either excellent or very good in all nine patients after a mean follow-up of 6 years.

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.