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Hypertrophic nonunion of the distal fibula after reduced triplane fracture of the distal tibia in a child
Foot and Ankle Surgery 9 (2003) 229–232 www.elsevier.com/locate/fas
Case report
Hypertrophic nonunion of the distal fibula after reduced triplane fracture of the distal tibia in a child Anthony Campbell Maury*, Crispin Southgate, Timothy Owen Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, Mid Glamorgan, Wales CF72 8XR, UK Received 21 January 2003; revised 9 April 2003; accepted 2 September 2003
Abstract Ankle fractures in children are a common injury and most heal uneventfully. Nonunion is unusual in children with otherwise normal bone, particularly following ankle fracture. We report the exceptional case of a hypertrophic fibular nonunion in a healthy 13 year old girl. q 2003 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Nonunion; Pediatric; Fibula; Ankle fracture; Complications
1. Case report A fit and well 13 year old female injured her ankle when falling from her scooter. Plain radiographs demonstrated a displaced triplane fracture of the distal tibia and a comminuted, angulated fracture of the distal fibula as shown in Fig. 1a and b. The patient underwent closed manipulation under general anaesthesia, the tibia was reduced anatomically by internal rotation of the foot, while the fibula had a residual valgus angulation of 48. This position was maintained for 6 weeks in a nonweightbearing, belowknee cast. The patient was then allowed unprotected weight bearing, but required a further 3 weeks immobilisation due to persistent pain. The tibial fracture healed uneventfully, however, chronic pain over the fibula was still a problem on prolonged weight bearing at 6 months, and plain radiographs confirmed evidence of hypertrophic nonunion as illustrated in Fig. 2a and b. The patient underwent open reduction and internal fixation with iliac crest bone graft. There was no soft tissue interposition found at the site of nonunion. The plain radiographs, Fig. 3a and b resulted from surgery, and the fibula was healed and pain free at 3 months postoperatively. * Corresponding author. Address: 60, Hillcrest, Ellesmere, Shropshire SY12 0LJ, UK. Tel.: þ44-787-6252104. E-mail address: [email protected] (A.C. Maury).
The patient remained pain free with an excellent result clinically and radiologically (Fig. 4a and b).
2. Discussion Predisposing factors for nonunion of any fracture are high-energy injuries associated with comminution and soft tissue loss [1]. Nonunion is also commoner in children with abnormal bone, for example osteogenesis imperfecta or neurofibromatosis [2]. However, children with normal bone have the greatest healing potential and heal most rapidly, hence nonunion is rare [4]. Nonunion of the fibula following any ankle injury in children has only previously been reported as a bony avulsion at the tip, successfully treated by fragment excision [3]. The case presented is a pronation– eversion (external rotation) stage 3, according to the extended LaugeHansen classification of indirect ankle fractures. It is to be noted that the Dias-Tachdjian classification of childrens’ ankle fractures has the triplane fracture in a category of its own, although the mechanism of injury was believed to be external rotation [5]. Since then Von Laer has attempted a classification into type I and type II triplane fractures [6]. The Von Laer type I triplane being a combination of a Salter type II physeal injury (with a metaphyseal fragment) with a Salter type III injury of
1268-7731/$ - see front matter q 2003 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S1268-7731(03)00091-2
230
A.C. Maury et al. / Foot and Ankle Surgery 9 (2003) 229–232
Fig. 1. Plain AP and lateral radiographs demonstrating a displaced triplane fracture of the distal tibia and an angulated fracture of the distal fibula.
the epiphysis. A Von Laer type II triplane fracture has a Salter type IV fragment combined with a type III injury [6,7]. The extra-articular nature of the reported case, with the fracture line on the AP radiograph extending into the medial malleolus, a subgroup also reported by
Von Laer, meant that open reduction was not required to restore articular congruity [6]. In this case there was comminution of the fibula shaft, and it may have been the presence of a butterfly fragment that predisposed the fracture to nonunion.
Fig. 2. Plain AP and lateral radiographs illustrating hypertrophic nonunion of the distal fibula.
A.C. Maury et al. / Foot and Ankle Surgery 9 (2003) 229–232
Fig. 3. Plain AP and lateral radiographs of distal fibula following open fixation and bone grafting of nonunion.
Fig. 4. AP and lateral radiographs of the left ankle demonstrating complete union of fibula 18 months after internal fixation and bone grafting.
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This exceptional case highlights an uncommon problem, however, it demonstrates that if fibular nonunion is recognised in a child with chronic pain following an ankle fracture a highly satisfactory outcome can be achieved surgically.
References [1] Dee R, Hurst LC, Gruber MA, Kottmeier SA. Principles of orthopaedic practice, 2nd ed. New York: Mcgraw-Hill; 1997.
[2] Gamble JG, Rinsky LA, Strudwick J, Bleck EE. Non-union of fractures in children who have osteogenesis imperfecta. J Bone Joint Surg 1988; 70A:439. [3] Haramati N, Roye DP, Adler PA, Ruzal-Shapiro C. Non-union of pediatric fibula fractures: easy to overlook, painful to ignore. Pediatr Radiol 1994;24:248–50. [4] Rockwood CA, Green DP, Bucholz RW, Heckman JD. Fractures in children, 4th ed. Philadelphia: Lippincot; 1996. [5] Dias LS, Tachdjian MO. Physeal fractures of the ankle in children. Clin Orthop 1978;136:230–3. [6] Von Laer L. Classification, diagnosis and treatment of transitional fracture of the distal part of the tibia. J Bone Joint Surg 1985;67A:687 –98. [7] Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963;45A:587–622.
Case report
Hypertrophic nonunion of the distal fibula after reduced triplane fracture of the distal tibia in a child Anthony Campbell Maury*, Crispin Southgate, Timothy Owen Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, Mid Glamorgan, Wales CF72 8XR, UK Received 21 January 2003; revised 9 April 2003; accepted 2 September 2003
Abstract Ankle fractures in children are a common injury and most heal uneventfully. Nonunion is unusual in children with otherwise normal bone, particularly following ankle fracture. We report the exceptional case of a hypertrophic fibular nonunion in a healthy 13 year old girl. q 2003 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Nonunion; Pediatric; Fibula; Ankle fracture; Complications
1. Case report A fit and well 13 year old female injured her ankle when falling from her scooter. Plain radiographs demonstrated a displaced triplane fracture of the distal tibia and a comminuted, angulated fracture of the distal fibula as shown in Fig. 1a and b. The patient underwent closed manipulation under general anaesthesia, the tibia was reduced anatomically by internal rotation of the foot, while the fibula had a residual valgus angulation of 48. This position was maintained for 6 weeks in a nonweightbearing, belowknee cast. The patient was then allowed unprotected weight bearing, but required a further 3 weeks immobilisation due to persistent pain. The tibial fracture healed uneventfully, however, chronic pain over the fibula was still a problem on prolonged weight bearing at 6 months, and plain radiographs confirmed evidence of hypertrophic nonunion as illustrated in Fig. 2a and b. The patient underwent open reduction and internal fixation with iliac crest bone graft. There was no soft tissue interposition found at the site of nonunion. The plain radiographs, Fig. 3a and b resulted from surgery, and the fibula was healed and pain free at 3 months postoperatively. * Corresponding author. Address: 60, Hillcrest, Ellesmere, Shropshire SY12 0LJ, UK. Tel.: þ44-787-6252104. E-mail address: [email protected] (A.C. Maury).
The patient remained pain free with an excellent result clinically and radiologically (Fig. 4a and b).
2. Discussion Predisposing factors for nonunion of any fracture are high-energy injuries associated with comminution and soft tissue loss [1]. Nonunion is also commoner in children with abnormal bone, for example osteogenesis imperfecta or neurofibromatosis [2]. However, children with normal bone have the greatest healing potential and heal most rapidly, hence nonunion is rare [4]. Nonunion of the fibula following any ankle injury in children has only previously been reported as a bony avulsion at the tip, successfully treated by fragment excision [3]. The case presented is a pronation– eversion (external rotation) stage 3, according to the extended LaugeHansen classification of indirect ankle fractures. It is to be noted that the Dias-Tachdjian classification of childrens’ ankle fractures has the triplane fracture in a category of its own, although the mechanism of injury was believed to be external rotation [5]. Since then Von Laer has attempted a classification into type I and type II triplane fractures [6]. The Von Laer type I triplane being a combination of a Salter type II physeal injury (with a metaphyseal fragment) with a Salter type III injury of
1268-7731/$ - see front matter q 2003 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S1268-7731(03)00091-2
230
A.C. Maury et al. / Foot and Ankle Surgery 9 (2003) 229–232
Fig. 1. Plain AP and lateral radiographs demonstrating a displaced triplane fracture of the distal tibia and an angulated fracture of the distal fibula.
the epiphysis. A Von Laer type II triplane fracture has a Salter type IV fragment combined with a type III injury [6,7]. The extra-articular nature of the reported case, with the fracture line on the AP radiograph extending into the medial malleolus, a subgroup also reported by
Von Laer, meant that open reduction was not required to restore articular congruity [6]. In this case there was comminution of the fibula shaft, and it may have been the presence of a butterfly fragment that predisposed the fracture to nonunion.
Fig. 2. Plain AP and lateral radiographs illustrating hypertrophic nonunion of the distal fibula.
A.C. Maury et al. / Foot and Ankle Surgery 9 (2003) 229–232
Fig. 3. Plain AP and lateral radiographs of distal fibula following open fixation and bone grafting of nonunion.
Fig. 4. AP and lateral radiographs of the left ankle demonstrating complete union of fibula 18 months after internal fixation and bone grafting.
231
232
A.C. Maury et al. / Foot and Ankle Surgery 9 (2003) 229–232
This exceptional case highlights an uncommon problem, however, it demonstrates that if fibular nonunion is recognised in a child with chronic pain following an ankle fracture a highly satisfactory outcome can be achieved surgically.
References [1] Dee R, Hurst LC, Gruber MA, Kottmeier SA. Principles of orthopaedic practice, 2nd ed. New York: Mcgraw-Hill; 1997.
[2] Gamble JG, Rinsky LA, Strudwick J, Bleck EE. Non-union of fractures in children who have osteogenesis imperfecta. J Bone Joint Surg 1988; 70A:439. [3] Haramati N, Roye DP, Adler PA, Ruzal-Shapiro C. Non-union of pediatric fibula fractures: easy to overlook, painful to ignore. Pediatr Radiol 1994;24:248–50. [4] Rockwood CA, Green DP, Bucholz RW, Heckman JD. Fractures in children, 4th ed. Philadelphia: Lippincot; 1996. [5] Dias LS, Tachdjian MO. Physeal fractures of the ankle in children. Clin Orthop 1978;136:230–3. [6] Von Laer L. Classification, diagnosis and treatment of transitional fracture of the distal part of the tibia. J Bone Joint Surg 1985;67A:687 –98. [7] Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963;45A:587–622.