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Fractures involving the distal epiphysis of the tibia and fibula in children
Fractures Involving the Distal Epiphysis of the Tibia and Fibula in Children EINER W. JOHNSON, JR., hi.n.
AND
JAMES C. FAHL,
From the Sections of Orthopedic Surgery and Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. The Mayo Foundation is a part of the Graduate School of the University of Minnesota.
OST of us were taught in medical schoo1 that invoIvement of an epiphysis by a fracturing force before the epiphysis is cIosed wouId invariably produce some deformity. This was emphasized in textbooks, such as those by Magnuson and Stack and Key and ConweII, which show these deformities with regularity. The doctor on Hurst treating such an injury in a chiId is constantIy expecting deformity to appear and is constantIy surprised to see a norma joint after treatment. ReaIization that a11 fractures in chiIdren which invoIve epiphysea1 Iines do not produce disturbances of growth or deformities or both occasioned a review of the cases of fractures of the distal epiphyses of the tibia and fibuIa in chiIdren encountered at the Mayo Clinic, as we11 as a review of the Iiterature on these fractures. It seems that the deformity probabIy is not so much a certainty as we had been Ied to beIieve, certainIy so far as the injury to these epiphyses is concerned. We hoped by our study to settle this question, “Does deformity follow a11 fractures of the dista1 tibia1 epiphysis and dista1 fibular epiphysis, or does it follow only a select few”? Aitken in 1936 analyzed a series of t\ventyone cases treated at the Boston City Hospital. From a study of these cases he was abIe to conclude that of all the forces and strains that couId be applied to an epiphysis, onIy that force which resulted in crushing of the epiphysis would resuIt in deformity. AIthough adequate reposition of an epiphysis was desirabIe, according to Aitken, Iack of good reduction wouId not stop growth but wouId aIIow it to advance in another plane. AIso, he Volume 9). May, 198,
Rochester,
Minnesota
stated that accurate and earIy reduction is most desirabIe but eIaborate operative means shouId not be used to gain absoIute reduction if nearIy perfect apposition can be obtained by manipuIation. GiuIiani, on the other hand, demonstrated to his satisfaction that every one of the traumatic dispIacements of the tibia1 and IibuIar epiphyses is foIIowed by some degree of deformity. He cIaimed that the commonest deformity is a discrepancy in the Iength of the Iegs. He aIso mentioned that varus and vaIgus deformity of the ankIe can occur as a Iate complication of this injury and stressed the advisabiIity of osteotomy for correction. Hohmann, writing in the same year, concurred aImost compIeteIy with GiuIiani’s attitudes, particuIarIy with regard to the need for osteotomy in the correction of any deformity. Carothers and Crenshaw stated that growth deformity usuaIIy occurs in an adduction type of fracture. In our study we anaIyzed the records of cases of injuries in chiIdren in the files of the cIinic. The roentgenograms, taken prior to reduction and those taken foIIowing reduction by either operative or cIosed means, were reviewed as were the records of every other detail of treatment at the cIinic. Whenever possibIe the patients were asked to return to Rochester for another set of roentgenograms and examination which invoIved estimation and measurement of the Iength of the extremity as we11 as the range of motion in the involved joints. By these means we were abIe to anaIyze twenty-seven fractures invoIving the dista1 tibia1 and fibular epiphyses which were treated at the Mayo CIinic during the years 1935 through 1952. None of the patients had received prior treatment and a11 were seen and managed by members of the staff of the Section of Orthopedics.
M
American Journal of Surgery.
M.D.,
778
Fractures
FIG. I. Abduction FIG. 2. PIantar
type
of DistaI
Epiphysis
of cpiphysenf
dispkement,
flexion type
FIG. 3. Adduction
of epiphysen1
type of epiphyseal
OF
and FibuIa
anteroposterior
displacement;
dispIacement:
view.
anteroposterior
anteroposterior
and Literal
views.
view.
shaft of the fibula. For fractures which occur in pIantar flexion (Fig. 2), the stress is apphed in a more verticaI direction, so that the fracture appears in the bony epiphysis of the tibia and extends into the cartilaginous plate or if an anteroposterior line of force is added to the above fracture element, the epiphysis will be displaced posteriody. There were ten such fractures in our group, one of which was accompanied by a fracture of the shaft of the Iibula. When the fractures occur in adduction (Fig. 3), the taIus is driven under the medial malleolus of the tibia and the fracture occurs through the epiphyseal cartiIage from the joint and penetrates the shaft. There were five of these fractures in our group, none of which was associated with fractures of the IibuIa. Fractures of the IibuIar epiphysis only are produced by a mechanism simitar to that of the fractures occurring in abduction. They have been considered separately, however, since an entireIy different epiphysis is involved in many instances. However, fracture of the fibuIar epiphysis often accompanies that of the distaI tibia1 epiphysis. Aside from the bony and cartilaginous injury these fractures were remarkabIy uncomplicated. None were compound, but vascular insuffrdue to marked svvelling and bony ciency deformity occurred in one of the fractures of the abduction type. In this instance, however, circuIation to the foot improved rapidIy after manipuIative reduction.
This group of twenty-seven children was composed of sixteen boys and eleven girls. Their ages ranged between eight and sixteen years with the majority, sixteen in all, faIIing m the age group of twelve to fifteen years, inclusive. TYPES
of Tibia
FRACTURE
As far as the mechanism of injury was conit was often impossible from the cerned, patient’s history to reconstruct exactIy what the fracturing force was. Since in many instances the roentgenograms will give a clue to the method of fracturing or the type of force which created the fracture, we made a co-ordinated review of the roentgenograms and the histories. This gave us a good cIue to the mechanism of injury in most instances. The fractures which were seen were of four main types: (I) those which occurred in abduction, (2) those which occurred in plantar Ilexion, (3) those which occurred in adduction and (4) those that occurred in fibular epiphyses only. The fracturing force of the fractures which occur in abduction (Fig. I) passes obliquely through the latera distaI part of the shaft of the tibia to the epiphysis and transversely proxima1 to the epiphyseal plate; thus it separates the epiphysis en masse and dislocates it Iaterally-. There were eight such fractures in our group of cases, all with associated fractures of the distal portion of the 779
Johnson
and
Fahl
reduction ant1 subsequently a stainless steel screlv was used through the fragment and across the epiphyseal line. The screlv \vas removed five weeks later and the end result \vas excellent. In the second case, the fracture occurred in abduction. The anterior tibia1 tendon and a segment of periosteum were interposed between the dispIaced epiphysis anc1 the shaft of the tibia. The reduction kvas helci with two Collison screws and the end result bvas excellent. (Fig. 4.) One year later the patient had grown 3 inches without anv evidence of shortening of the affected extrem-ity. FOLLOW-UP
The immediate results of the treatment outlined were uniformly satisfactory. In no case was any deformity demonstrable immediateI) after removal of the fixation nor was epiphyseal arrest or irregular growth of any of the involved epiphyses apparent within a short foIIow-up period. Subsequently, these chiIdren were al1 contacted by letter, and we either saw and examined or obtained reports on fifteen of them. TweIve of these patients stated that they had no change in the injured ankIe as compared to the norma one and that they had exceIIent range of motion and function in the ankIe with no symptoms. One patient had required further operation which consisted of freeing of adhesions about the tendon of the extensor hallucis Iongus muscle, but he no\\ was asymptomatic and had an excellent range of function and good strength in the ankle. In three cases there were unsatisfactory results. The results in two were rated as unsatisfactory because of shortening and in the third because of cosmetic change. In the two instances in which shortening occurred there was a I inch and 36 inch difference, respectiveIy, from the opposite Ieg. In no instance was the shortening a major disabling factor to the patient, and the second patient’s attention was directed to the shortening only after it was discovered by actual measurements of One of the injuries which rethe extremity. sulted in shortening of the extremity was an abduction type of injury, and the other was a pIantar flexion type. Review of the roentgenograms with the knowIedge that shortening existed failed to revea1 any aspect which could Iead one to predict the degree of shortening which did occur. CertainIy there was no evidence in the
FIG. 4. ((II Abduction type of distal epiphyseal displacement of the tibia, preoperative anteropostrrior view. (b) Position of fragments eleven months after open reduction and internal fixation, anteroposterior view. METHOD
OF TREATMENT
Three main methods of treatment were used to handle the fractures occurring in this group: application of a cast, closed reduction and open reduction. Application qf a Cast. In nine cases there was no sign&ant separation of the fragments and an application of a suitabIe plaster cast was a11 that was required. Of these nine cases one was an abduction type of fracture, six were the pIantar flexion type of injury and two were fractures of the fibular epiphyses. Closed Reduction. Satisfactory anatomic reduction was obtained by cIosed manipulation in sixteen of the twenty-seven cases. These were broken down according to types of fractures as follows: abduction type, six cases; pIantar flexion type, four cases; adduction type, four cases; and fibuIar epiphyses, two cases. Open Reduction. Operative repair was necessary in two cases when anatomic reduction was not possible by cIosed means. In the first of these, the fracture occurred in adduction; the media1 tibia1 fragment couId not be heId in aIignment with the ankIe joint after cIosed 780
Fractures
of DistaI
Epiphysis
roentgenograms to show that compression of the epiphysis had resuIted from the injury. In the third patient in whom the result was rated as’ unsatisfactory there was an enlargement of the medial malleolus following complete union of the displaced epiphysis. This was thought to be due to subperiosteal hematoma arising when the periosteum was stripped at the time of the injury. This injury was an adduction type of strain, and the cosmetic deformity was not of major consequence to the individual.
of Tibia From
and
our study
Fibula of this small series of cases
and our review of the Iiterature, we have been abIe to concIude that accurate reduction of the epiphysis is to be sought most zeaIousIy. However, repeated manipuIations or open operation is seIdom necessary. It is to be expected that growth realignment will occur even late in the growing period, and one is probabIy justified in accepting some minimal degree of deformity earIy rather than subjecting the extremity to considerable closed or open manipuIation. AIso, in our opinion there is no evidence to suggest that massive displacement of the epiphysis by a fracturing force will result in cIinicaIIy discernible change in growth.
COMMENT
Review of these twenty-seven fractures and follow-up data on fifteen patients have emphasized that certainIy not a11 injuries to the dista1 epiphyses of the tibia and fibuIa result in some embarrassment of the function of this epiphysis. As far as our twenty-seven cases are concerned, we have not been able to substantiate the views heId by Aitken that compression of the epiphvsis in an axial plane is the one force which &II result in changes in epiphysea1 growth, since the two patients in our series in whom there were unsatisfactory resuIts because of shortening of the extremity were not necessariIy exposed to such axia1 compression of the epiphysis. However, from review of these cases we aIso were not able to agree with Carothers and Crenshaw that growth deformity usuaIIy occurs in the adduction type and that such growth deformity can be predicted from roentgenograms showing disruption of the epiphysis itseIf.
REFERENCES
I. AITKEN, A. P. The end results of fractured distal tibia1 epiphysis. J. Bone @Y Joint Surg., 18: 685p 691, 1936. 2. CAROTHERS, C. 0. and CRENSHAW, A. H. Clinical significance of a classification of cpiphysea1 injuries at the ankle. Am. J. Surg., 89: 879-889, 1955. K. Spatzustandc nach traumatisch3. GIULIANI, mechanischen Schadigungen der Epiphyse am distalen Tibiaende. Arch. J. orthop. u. UnJall-C&r., 45: 386-394, 1952. 4. HOHMANN, G. Zur Korrektur frischer und veralteter FBlle van Verletzung der distalen Tibiaepiphyse. Arch. J. orthop. u. UnJall-Cbir., 45: 395--399, 1952. 5. KEY, J. A. and CONWELL, H. E. The Management of Fractures, Dislocations and Sprains, 5th ed., pp. rr26-1 134. St. Louis, ,951. C:V. hloiby Co. 6. h~~AGNuSON, P. B. and STACK, J. K. Fractures, 5th ed., p. 375. Philadelphia, 1949. J. B. Lippincott co.
781
AND
JAMES C. FAHL,
From the Sections of Orthopedic Surgery and Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. The Mayo Foundation is a part of the Graduate School of the University of Minnesota.
OST of us were taught in medical schoo1 that invoIvement of an epiphysis by a fracturing force before the epiphysis is cIosed wouId invariably produce some deformity. This was emphasized in textbooks, such as those by Magnuson and Stack and Key and ConweII, which show these deformities with regularity. The doctor on Hurst treating such an injury in a chiId is constantIy expecting deformity to appear and is constantIy surprised to see a norma joint after treatment. ReaIization that a11 fractures in chiIdren which invoIve epiphysea1 Iines do not produce disturbances of growth or deformities or both occasioned a review of the cases of fractures of the distal epiphyses of the tibia and fibuIa in chiIdren encountered at the Mayo Clinic, as we11 as a review of the Iiterature on these fractures. It seems that the deformity probabIy is not so much a certainty as we had been Ied to beIieve, certainIy so far as the injury to these epiphyses is concerned. We hoped by our study to settle this question, “Does deformity follow a11 fractures of the dista1 tibia1 epiphysis and dista1 fibular epiphysis, or does it follow only a select few”? Aitken in 1936 analyzed a series of t\ventyone cases treated at the Boston City Hospital. From a study of these cases he was abIe to conclude that of all the forces and strains that couId be applied to an epiphysis, onIy that force which resulted in crushing of the epiphysis would resuIt in deformity. AIthough adequate reposition of an epiphysis was desirabIe, according to Aitken, Iack of good reduction wouId not stop growth but wouId aIIow it to advance in another plane. AIso, he Volume 9). May, 198,
Rochester,
Minnesota
stated that accurate and earIy reduction is most desirabIe but eIaborate operative means shouId not be used to gain absoIute reduction if nearIy perfect apposition can be obtained by manipuIation. GiuIiani, on the other hand, demonstrated to his satisfaction that every one of the traumatic dispIacements of the tibia1 and IibuIar epiphyses is foIIowed by some degree of deformity. He cIaimed that the commonest deformity is a discrepancy in the Iength of the Iegs. He aIso mentioned that varus and vaIgus deformity of the ankIe can occur as a Iate complication of this injury and stressed the advisabiIity of osteotomy for correction. Hohmann, writing in the same year, concurred aImost compIeteIy with GiuIiani’s attitudes, particuIarIy with regard to the need for osteotomy in the correction of any deformity. Carothers and Crenshaw stated that growth deformity usuaIIy occurs in an adduction type of fracture. In our study we anaIyzed the records of cases of injuries in chiIdren in the files of the cIinic. The roentgenograms, taken prior to reduction and those taken foIIowing reduction by either operative or cIosed means, were reviewed as were the records of every other detail of treatment at the cIinic. Whenever possibIe the patients were asked to return to Rochester for another set of roentgenograms and examination which invoIved estimation and measurement of the Iength of the extremity as we11 as the range of motion in the involved joints. By these means we were abIe to anaIyze twenty-seven fractures invoIving the dista1 tibia1 and fibular epiphyses which were treated at the Mayo CIinic during the years 1935 through 1952. None of the patients had received prior treatment and a11 were seen and managed by members of the staff of the Section of Orthopedics.
M
American Journal of Surgery.
M.D.,
778
Fractures
FIG. I. Abduction FIG. 2. PIantar
type
of DistaI
Epiphysis
of cpiphysenf
dispkement,
flexion type
FIG. 3. Adduction
of epiphysen1
type of epiphyseal
OF
and FibuIa
anteroposterior
displacement;
dispIacement:
view.
anteroposterior
anteroposterior
and Literal
views.
view.
shaft of the fibula. For fractures which occur in pIantar flexion (Fig. 2), the stress is apphed in a more verticaI direction, so that the fracture appears in the bony epiphysis of the tibia and extends into the cartilaginous plate or if an anteroposterior line of force is added to the above fracture element, the epiphysis will be displaced posteriody. There were ten such fractures in our group, one of which was accompanied by a fracture of the shaft of the Iibula. When the fractures occur in adduction (Fig. 3), the taIus is driven under the medial malleolus of the tibia and the fracture occurs through the epiphyseal cartiIage from the joint and penetrates the shaft. There were five of these fractures in our group, none of which was associated with fractures of the IibuIa. Fractures of the IibuIar epiphysis only are produced by a mechanism simitar to that of the fractures occurring in abduction. They have been considered separately, however, since an entireIy different epiphysis is involved in many instances. However, fracture of the fibuIar epiphysis often accompanies that of the distaI tibia1 epiphysis. Aside from the bony and cartilaginous injury these fractures were remarkabIy uncomplicated. None were compound, but vascular insuffrdue to marked svvelling and bony ciency deformity occurred in one of the fractures of the abduction type. In this instance, however, circuIation to the foot improved rapidIy after manipuIative reduction.
This group of twenty-seven children was composed of sixteen boys and eleven girls. Their ages ranged between eight and sixteen years with the majority, sixteen in all, faIIing m the age group of twelve to fifteen years, inclusive. TYPES
of Tibia
FRACTURE
As far as the mechanism of injury was conit was often impossible from the cerned, patient’s history to reconstruct exactIy what the fracturing force was. Since in many instances the roentgenograms will give a clue to the method of fracturing or the type of force which created the fracture, we made a co-ordinated review of the roentgenograms and the histories. This gave us a good cIue to the mechanism of injury in most instances. The fractures which were seen were of four main types: (I) those which occurred in abduction, (2) those which occurred in plantar Ilexion, (3) those which occurred in adduction and (4) those that occurred in fibular epiphyses only. The fracturing force of the fractures which occur in abduction (Fig. I) passes obliquely through the latera distaI part of the shaft of the tibia to the epiphysis and transversely proxima1 to the epiphyseal plate; thus it separates the epiphysis en masse and dislocates it Iaterally-. There were eight such fractures in our group of cases, all with associated fractures of the distal portion of the 779
Johnson
and
Fahl
reduction ant1 subsequently a stainless steel screlv was used through the fragment and across the epiphyseal line. The screlv \vas removed five weeks later and the end result \vas excellent. In the second case, the fracture occurred in abduction. The anterior tibia1 tendon and a segment of periosteum were interposed between the dispIaced epiphysis anc1 the shaft of the tibia. The reduction kvas helci with two Collison screws and the end result bvas excellent. (Fig. 4.) One year later the patient had grown 3 inches without anv evidence of shortening of the affected extrem-ity. FOLLOW-UP
The immediate results of the treatment outlined were uniformly satisfactory. In no case was any deformity demonstrable immediateI) after removal of the fixation nor was epiphyseal arrest or irregular growth of any of the involved epiphyses apparent within a short foIIow-up period. Subsequently, these chiIdren were al1 contacted by letter, and we either saw and examined or obtained reports on fifteen of them. TweIve of these patients stated that they had no change in the injured ankIe as compared to the norma one and that they had exceIIent range of motion and function in the ankIe with no symptoms. One patient had required further operation which consisted of freeing of adhesions about the tendon of the extensor hallucis Iongus muscle, but he no\\ was asymptomatic and had an excellent range of function and good strength in the ankle. In three cases there were unsatisfactory results. The results in two were rated as unsatisfactory because of shortening and in the third because of cosmetic change. In the two instances in which shortening occurred there was a I inch and 36 inch difference, respectiveIy, from the opposite Ieg. In no instance was the shortening a major disabling factor to the patient, and the second patient’s attention was directed to the shortening only after it was discovered by actual measurements of One of the injuries which rethe extremity. sulted in shortening of the extremity was an abduction type of injury, and the other was a pIantar flexion type. Review of the roentgenograms with the knowIedge that shortening existed failed to revea1 any aspect which could Iead one to predict the degree of shortening which did occur. CertainIy there was no evidence in the
FIG. 4. ((II Abduction type of distal epiphyseal displacement of the tibia, preoperative anteropostrrior view. (b) Position of fragments eleven months after open reduction and internal fixation, anteroposterior view. METHOD
OF TREATMENT
Three main methods of treatment were used to handle the fractures occurring in this group: application of a cast, closed reduction and open reduction. Application qf a Cast. In nine cases there was no sign&ant separation of the fragments and an application of a suitabIe plaster cast was a11 that was required. Of these nine cases one was an abduction type of fracture, six were the pIantar flexion type of injury and two were fractures of the fibular epiphyses. Closed Reduction. Satisfactory anatomic reduction was obtained by cIosed manipulation in sixteen of the twenty-seven cases. These were broken down according to types of fractures as follows: abduction type, six cases; pIantar flexion type, four cases; adduction type, four cases; and fibuIar epiphyses, two cases. Open Reduction. Operative repair was necessary in two cases when anatomic reduction was not possible by cIosed means. In the first of these, the fracture occurred in adduction; the media1 tibia1 fragment couId not be heId in aIignment with the ankIe joint after cIosed 780
Fractures
of DistaI
Epiphysis
roentgenograms to show that compression of the epiphysis had resuIted from the injury. In the third patient in whom the result was rated as’ unsatisfactory there was an enlargement of the medial malleolus following complete union of the displaced epiphysis. This was thought to be due to subperiosteal hematoma arising when the periosteum was stripped at the time of the injury. This injury was an adduction type of strain, and the cosmetic deformity was not of major consequence to the individual.
of Tibia From
and
our study
Fibula of this small series of cases
and our review of the Iiterature, we have been abIe to concIude that accurate reduction of the epiphysis is to be sought most zeaIousIy. However, repeated manipuIations or open operation is seIdom necessary. It is to be expected that growth realignment will occur even late in the growing period, and one is probabIy justified in accepting some minimal degree of deformity earIy rather than subjecting the extremity to considerable closed or open manipuIation. AIso, in our opinion there is no evidence to suggest that massive displacement of the epiphysis by a fracturing force will result in cIinicaIIy discernible change in growth.
COMMENT
Review of these twenty-seven fractures and follow-up data on fifteen patients have emphasized that certainIy not a11 injuries to the dista1 epiphyses of the tibia and fibuIa result in some embarrassment of the function of this epiphysis. As far as our twenty-seven cases are concerned, we have not been able to substantiate the views heId by Aitken that compression of the epiphvsis in an axial plane is the one force which &II result in changes in epiphysea1 growth, since the two patients in our series in whom there were unsatisfactory resuIts because of shortening of the extremity were not necessariIy exposed to such axia1 compression of the epiphysis. However, from review of these cases we aIso were not able to agree with Carothers and Crenshaw that growth deformity usuaIIy occurs in the adduction type and that such growth deformity can be predicted from roentgenograms showing disruption of the epiphysis itseIf.
REFERENCES
I. AITKEN, A. P. The end results of fractured distal tibia1 epiphysis. J. Bone @Y Joint Surg., 18: 685p 691, 1936. 2. CAROTHERS, C. 0. and CRENSHAW, A. H. Clinical significance of a classification of cpiphysea1 injuries at the ankle. Am. J. Surg., 89: 879-889, 1955. K. Spatzustandc nach traumatisch3. GIULIANI, mechanischen Schadigungen der Epiphyse am distalen Tibiaende. Arch. J. orthop. u. UnJall-C&r., 45: 386-394, 1952. 4. HOHMANN, G. Zur Korrektur frischer und veralteter FBlle van Verletzung der distalen Tibiaepiphyse. Arch. J. orthop. u. UnJall-Cbir., 45: 395--399, 1952. 5. KEY, J. A. and CONWELL, H. E. The Management of Fractures, Dislocations and Sprains, 5th ed., pp. rr26-1 134. St. Louis, ,951. C:V. hloiby Co. 6. h~~AGNuSON, P. B. and STACK, J. K. Fractures, 5th ed., p. 375. Philadelphia, 1949. J. B. Lippincott co.
781