Clean FRCS notes with inline figures
•AP and lateral Xray of ankle of a skeletally immature patient
•With fracture over distal tibia involving epiphysis
•On AP view it is SH III, on lateral view it is SH II (Thurstan Holland fragment)
•Distal fragment is displaced medial and posterior
•50% associated with fibular fracture
•Triplane fracture (fracture courses through coronal, transverse and sagittal plane)
•Transitional fracture
•This is an intra-articular fracture
•MOI: ER
•Acute: systemically rule out other injuries, locally look for wound, compartment syndrome and document distal NV condition. RICE, slab, analgesics
•Since displacement > 2mm
Definitive: aim at anatomical reduction and stable fixation
•CT
•Lateral (more common) vs medial (judged by distal coronal fragment)
•2 part, 3 part, 4 part
•CR +/- OR, fix with screw (interfragmental compression with screws parallel to physis)
•CR technique: for 2 part - lateral (IR), medial (abduction)
•AL approach, reduce with dorsiflexion + IR +/- pronation, or compression using Weber bone reduction forceps, fixed with 4.0 cannulated screw (transmetaphyseal and transepiphyseal screws)
•Need OT for 3-4 part (sequence: posterior fragment → fibula → AL fragment)
•Advise for removal of transepiphyseal screws. Cadaveric studies (JPO 2005 Charlton) have shown significant increase in peak intraarticular contact pressures over baseline
•Distal tibia physis close at 16yo, distal fibula closes 1 year after
•Contributed to 40% of tibia growth and 20% of LL growth
•All ligaments attach distal to physis
•Distal tibial physis fuse
•Age 11-13 in boys
•Transitional fracture ~ 18 months
•Coronal: cross epiphysis
•Axial: split physis
•Sagittal: exit in metaphysis
•Can be 2, 3, 4 parts
2 parts (named after coronal distal fragment):
•Lateral triplane: supination-external rotation (most common)
•Medial triplane: adduction
3 parts (separate Tillaux fragment):
•SH 3 on AP
•4 part: (Tillaux + AM fragment)
•50% associated with fibular fracture
•Medial os subtibile 20%
•Lateral os subfibulare 1%
•Sequence of distal tibia physis closure: central → anteromedial → posteromedial → anterolateral
•Kump’s bump [radiopedia: superior convexity of the growth plate located in the anteromedial quadrant of the distal tibia physis, which is the first site of physeal fusion. Closure usually occurs at about 12-13 years of age.