Triplane fracture


Triplane fracture

Description, Causes and Risk Factors:

The triplane fracture involves the closing physis of the distal tibia in adolescents, with fracture lines occurring in the axial, sagittal, and coronal planes. This complex injury accounts for 6-10% of distal tibial epiphyseal fractures. A triplane fracture of the distal tibia is generally sustained during adolescence and occurs before complete closure of the distal tibial physis (growth plate). It represents 5-10% of pediatric intra-articular ankle injuries and typically presents in children aged 12-15 years of age. The incidence is slightly higher in boys than in girls.

The characteristic asymmetric closure of the distal tibial growth plate occurring over a period of approximately 18 months is the basis for the unique occurrence of this fracture following an ankle injury in this age group.

The classic fracture pattern is multiplanar. The fracture extends through the transverse (growth plate), sagittal (epiphysis), and coronal (distal tibial metaphysis) anatomic planes, disrupting the tibial plafond intra-articularly, resulting in 3 classically described fragments. It has, however, several variations.

Triplane fracture is the result of several factors that exist simultaneously, including the following:

    A partially open distal lateral tibial growth plate, which creates a plane of weakness when a shearing force is applied. This condition is found most commonly during adolescence.

  • External rotation (eversion) of the foot on the tibia (horizontal plane influence), which creates stress along the open distal lateral tibial growth plate, and is the essential force that initiates a triplane fracture.

  • Exact fracture lines that are propagated further through the coronal and sagittal planes as a result of the foot being in plantar flexion (most common) and the varying forces of axial loading.

Some practitioners prefer to call the fracture an adolescent tibial triplane fracture because this term is more descriptive of the age of occurrence, location, and fracture pattern. It is also termed transitional injury because it occurs during the period of transition from skeletal immaturity to skeletal maturity.

Articular congruity at the ankle joint surface, not physeal arrest or growth retardation, is the major concern with triplane fractures. Therefore, nondisplaced fractures and extra-articular fractures can be managed nonoperatively, but displaced fractures require anatomic reduction and internal fixation. Malunited fractures with over 2 mm of intra-articular displacement are associated with poor outcomes.

Symptoms:

    Ankle pain.

  • Inability to bear weight.

  • Swelling.

  • Focal tenderness.

  • Swelling over the anterior aspect of the distal leg and ankle.

  • Presence of bruising or ecchymosis.

  • External rotation deformity of the foot possible in severe injuries.

  • Possible tenderness over the region of the medial malleolus or the deltoid ligament if there is failure of the medial column.

Diagnosis:

Because all triplane fractures involve theepiphysis, physis, and metaphysis, they areSalter-Harris type IV injuries. However,triplane fractures appear to conform to differentSalter-Harris configurations dependingon the location within the distal tibia andthe plane that is being studied, which makesthe evaluation of the anatomy of these complexmultiplanar fractures even more confusing.Radiologic evaluation of triplanefractures is optimally performed on CT, withits excellent spatial resolution. Over the pastdecade, multiplanar reconstruction of CTdata has become routine, greatly enhancingour understanding of this complex injury andfacilitating treatment decisions. Tothe best of our knowledge, multiplanar CThas not been used systematically to evaluatetriplane fractures.

Other x-rays performed in anticipation of the operating room depend on the age of the patient, the extent of all injuries, and other comorbid conditions.

Postreduction CT scans and serial radiographs are needed to assess adequacy of reduction and guard against loss of reduction in the cast.

Treatment:

Nondisplaced triplane fractures (< 2 mm displacement) and extra-articular fractures can be managed with immobilization in a short leg cast for 4-6 weeks. Serial radiographs are obtained at weekly intervals during the first 3 weeks to check for late displacement. For displaced fractures, closed reduction is attempted with general anesthesia. And, at times, skeletal muscle relaxation is required to reduce the displacement. The mechanism of injury or the motion that produced the injury is reversed to obtain realignment. For medial fractures, the foot is positioned in external rotation; for lateral fractures, in internal rotation. Avoid more than 2 attempts at realignment, as each attempt causes additional trauma and bleeding and, possibly, further injury to the distal tibial growth plate. Closed reduction resulting in adequate fracture reduction in all planes is obtained in approximately 30-50% of triplane fractures.

Adequate closed reduction is followed by 4-6 weeks of above-the-knee casting. The cast then is replaced with a below-the-knee cast to allow limited weight bearing with crutches for an additional 4 weeks. Following removal of the final cast, progressive return to normal activity is encouraged with ongoing physical therapy and range-of-motion exercises.

Surgical Option:

Open reduction and internal fixation (ORIF) for any triplane fracture demonstrating 2 mm or more of displacement after attempted closed reduction involves the following:

    The surgical approach depends on the fracture planes and can be anterolateral for lateral fractures or anteromedial for medial fractures. Small stab incisions are often needed for the placement of screws, either solid or cannulated.

  • Reduction and fixation of the metaphyseal spike may be all the surgery that is needed. An alternative is the placement of epiphyseal screws parallel to the joint surface, avoiding the growth plate and the ankle joint. More than 1 screw is needed, and the primary goal is reduction of the physeal fracture and joint surface.

  • Intraoperative radiographs or fluoroscopy are needed to ensure that the fracture is reduced and that screw placement is satisfactory.

  • The anterolateral epiphyseal fragment of a 3-part injury is reduced and held with either a screw or a K-wire. Before the patient leaves the operating room, a final set of postreduction radiographs is completed.

  • Arthroscopic reduction and internal fixation of 2-part triplane fractures has been described to have advantages over traditional open reduction and internal fixation.

NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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