Clinical Outcomes of Triplane Fractures Based on Imaging Modality Utilization and Management: A Systematic Review and Meta-analysis

Diagnosis, Treatment, and Potential Complications of Triplane Ankle Fractures in Pediatric Patients: A Systematic Review

Background/Objectives: Triplane ankle fractures represent a complex fracture type in pediatric patients. These fractures can prove challenging due to the involvement of multiple fracture planes and variations in segment fragmentation. With increasing literature pertaining to the treatment of triplane fractures and the limitations of previous systematic reviews, the aim of this review is to summarize recent data on the diagnosis, treatment, and complications of pediatric triplane ankle fractures. Methods: This systematic review was conducted following PRISMA guidelines and searched five major databases up to July 2024. The inclusion criteria focused on observational studies and randomized controlled trials in pediatric triplane fractures. Case reports, cadaveric studies, and systematic reviews were excluded. Articles were screened and graded using the MINORS tool for quality assessment. Data were extracted on demographics, fracture types, treatment approaches, and outcomes. Results: A total of 34 studies met the inclusion criteria. The use of CT scans in combination with radiographs was common, and two-part fractures were the most frequently observed type. Surgical treatment, particularly open reduction with internal fixation, was preferred, while conservative surgical treatment remains under-reported. Complications were minimal, with limb length discrepancy being the most common. Conclusions: This review highlights the increased use of CT for diagnosing triplane fractures and the preference of certain surgical interventions. Conservative treatment approaches, though less studied, may offer alternatives in moderate cases. This review emphasizes the need for further research on conservative treatment outcomes, longer follow-ups, and randomized controlled trials to refine treatment strategies for this complex fracture pattern.

Triplane ankle fracture patterns in paediatric patients

Aims

Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

Methods

A fracture mapping study was performed in 83 paediatric patients with a triplane ankle fracture treated in three trauma centres between January 2010 and June 2020. Patients aged younger than 18 years who had CT scans available were included. An independent Paediatric Orthopaedic Trauma Surgeon assessed all CT scans and classified the injuries as n-part triplane fractures. Qualitative analysis of the fracture pattern was performed using the modified Cole fracture mapping technique. The maps were assessed for both patterns and correlation with the closing of the physis until consensus was reached by a panel of six surgeons.

Results

Fracture map grouped by age demonstrates that, regardless of age (even at the extremes of the spectrum), the fracture lines consolidate in a characteristic Y-pattern, and no shift with closure of the physis was observed. A second fracture map with two years added to female age also did not show a shift. The fracture map, grouped by both age and sex, shows a Y-pattern in all different groups. The fracture lines appear to occur between the anterior and posterior inferior tibiofibular ligaments, and the medially fused physis or deltoid ligament.

Conclusion

This fracture mapping study reveals that triplane ankle fractures have a characteristic Y-pattern, and acknowledges the weakness created by the physis, however it also challenges classic teaching that the specific fracture pattern at the level of the joint of these injuries relies on advancing closure of the physis with age. Instead, this study observes the importance of ligament attachment in the fracture patterns of these injuries.

Analysis of Clinical Outcomes in Pediatric Distal Tibia Triplanar Fractures Treated Surgically and Conservatively

Purpose

We aimed to analyze the clinical and functional outcomes of patients who underwent surgery or received conservative treatment to look into the impact of treatment methods on clinical outcomes.

Methods

A retrospective study was performed on 25 patients with a minimum one-year follow-up. Patients were divided into two groups based on joint and physis displacement measured on preop CT images. Patients with a displacement of > 2 mm underwent surgery, while those with a displacement of < 2 mm received conservative treatment. The clinical results were assessed using the Ankle-Hindfoot Scale developed by the American Orthopedic Foot and Ankle Society (AOFAS) and the Modified Weber Protocol (MWP).

Results

The sample consisted of 14 patients who underwent surgery and 11 patients who received conservative treatment. The surgical group had a mean follow-up of 36.79±14.43 months, while the conservative group had a mean follow-up of 31.82±13.55 months. The surgical and conservative groups had a postop 1st-year AOFAS score of 96.64±3.54 and 93.64 ± 4.69, respectively. The difference was statistically insignificant (p > 0.05), but the surgical group had higher scores numerically. The surgical and conservative groups had a postop 6th-month AOFAS score of 84.64±1.64 and 80.82±2.85, respectively. The difference was statistically significant (p < 0.05).

Conclusion

The results of both surgical treatment and conservative treatment are satisfactory. Especially, surgical treatment should not be avoided in patients requiring surgery with a displacement of more than 2 mm and surgeons may consider surgery for better clinical outcomes and earlier rehabilitation in the treatment of triplane fractures.