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Pure rotational displacement of the distal tibial epiphysis: a case report and a review of the literature
Case reports
495
Pure rotational displacement of the distal tibia1 epiphysis: a case report and a review of the literature A. C. Fairbank, P. Lynch and R. H. Jinnah Department
of Orthopaedic
Surgery, St Agnes Hospital, and The Johns Hopkins University,
Case report An II-year-old boy fell and injured his left ankle. Radiographs were taken. A diagnosis of a fracture of the fibula was made. The seventy of his pain led to a request for orthopaedic assessment. In addition to his obvious discomfort, clinical examination revealed one salient finding. With patellae facing anteriorly, his right foot was resting in a position of 80” of external rotation. The ankle was not swollen, his skin was not excessively taut and there was no neurovascular deficit. Radiographs (F&re I) revealed the fracture of the fibula as well as incongruence of the distal tibial epiphysis. Contralateral radiographs were taken for comparison and confirmed the pure external rotation displacement of the distal tibia1 epiphysis with an associated spiral fracture of the fibula above the level of the syndesmosis. Once the fracture was recognized, gentle traction from the calcaneum, with the foot in neutral version and the ankle at 90”, accompanied by gentle internal rotation, resulted in apparent anatomical reduction without the need for a general anaesthetic. The reduction was accompanied by a ‘click’ and appeared to be relatively stable; the patient’s pain resolved almost instantaneously. The limb was placed in an above knee-cast for 5 weeks. He made an uncomplicated recovery.
Discussion Salter-Harris type I injuries of the distal tibia1 epiphysis are rare. Love11 (1968) reported a case of a l&year-old boy who sustained a similar injury with posterior dislocation of the
Baltimore, MD, USA
fibula, without fracture. He perhaps incorrectly attributed the first report of this kind of injury to Bosworth (1947), who had reported five cases of rotational injury in adult fracturedislocation of the ankle. Broock and Greer (1970) described a Salter-Harris type II rotational injury of the epiphysis ina 7-year-old as a result of external rotation of the foot, and followed this with an experimental study that suggested rotation of the epiphysis could occur without injury to supporting ligaments but did require stripping of the periosteum and perichondrium from the cartilage plate. Nevelos and Colton (1977) described a Salter-Harris type 1 rotational injury in an II-year-old and gained satisfactory reduction under general anaesthesia. No evidence of periosteal new bone formation was seen on follow-up, and they suggested that the perichondrium tears circurnferentially with no injury to the periosteum. They also feel that the ‘fibula seems elastic enough to twist without breaking’. In our case, the fibula did indeed break, and much as in the case of Broock and Greer, reduction did not require general anaesthesia. Our purpose in reporting this case is to draw attention to a fractured fibula occurring with a pure rotational Salter-Harris type I injury of the distal tibia1 epiphysis; this injury may be missed on radiographs.
References Bosworth D. M. (1947) Fracture-dislocation of the ankle with fixed displacement of the fibula behind the tibia. 1, Bone joint Sttrg.29, 130. Broock G. J. and Greer R. 8. (1970) Traumatic rotational displacements of the distal tibial growth plate. J. Bone JointSwg. 52A, 1666. Love11 E. S. (1968) An unusual rotatory injury to the ankle. J. Bone ]oinf Surg.5OA, 163. Nevelos A. B. and Colton C. L. (1977) Rotational displacement of the lower tibia1 epiphysis due to trauma. J Bone JointSurg.59B, 331.
Paper accepted I March 1993.
Figure I. Radiographs showing fracture of the fibula and incongruence of the distal tibia1 epiphysis. 0 1993 Butterworth-Heinemann 0020-1383/93/070495-01
Ltd
Requestsfor reprintsshould be addressedto: Mr A. C. Fairbank, Department of Orthopaedics, St George’s Hospital, Blackshaw Road, London SW17 OQT, UK.
495
Pure rotational displacement of the distal tibia1 epiphysis: a case report and a review of the literature A. C. Fairbank, P. Lynch and R. H. Jinnah Department
of Orthopaedic
Surgery, St Agnes Hospital, and The Johns Hopkins University,
Case report An II-year-old boy fell and injured his left ankle. Radiographs were taken. A diagnosis of a fracture of the fibula was made. The seventy of his pain led to a request for orthopaedic assessment. In addition to his obvious discomfort, clinical examination revealed one salient finding. With patellae facing anteriorly, his right foot was resting in a position of 80” of external rotation. The ankle was not swollen, his skin was not excessively taut and there was no neurovascular deficit. Radiographs (F&re I) revealed the fracture of the fibula as well as incongruence of the distal tibial epiphysis. Contralateral radiographs were taken for comparison and confirmed the pure external rotation displacement of the distal tibia1 epiphysis with an associated spiral fracture of the fibula above the level of the syndesmosis. Once the fracture was recognized, gentle traction from the calcaneum, with the foot in neutral version and the ankle at 90”, accompanied by gentle internal rotation, resulted in apparent anatomical reduction without the need for a general anaesthetic. The reduction was accompanied by a ‘click’ and appeared to be relatively stable; the patient’s pain resolved almost instantaneously. The limb was placed in an above knee-cast for 5 weeks. He made an uncomplicated recovery.
Discussion Salter-Harris type I injuries of the distal tibia1 epiphysis are rare. Love11 (1968) reported a case of a l&year-old boy who sustained a similar injury with posterior dislocation of the
Baltimore, MD, USA
fibula, without fracture. He perhaps incorrectly attributed the first report of this kind of injury to Bosworth (1947), who had reported five cases of rotational injury in adult fracturedislocation of the ankle. Broock and Greer (1970) described a Salter-Harris type II rotational injury of the epiphysis ina 7-year-old as a result of external rotation of the foot, and followed this with an experimental study that suggested rotation of the epiphysis could occur without injury to supporting ligaments but did require stripping of the periosteum and perichondrium from the cartilage plate. Nevelos and Colton (1977) described a Salter-Harris type 1 rotational injury in an II-year-old and gained satisfactory reduction under general anaesthesia. No evidence of periosteal new bone formation was seen on follow-up, and they suggested that the perichondrium tears circurnferentially with no injury to the periosteum. They also feel that the ‘fibula seems elastic enough to twist without breaking’. In our case, the fibula did indeed break, and much as in the case of Broock and Greer, reduction did not require general anaesthesia. Our purpose in reporting this case is to draw attention to a fractured fibula occurring with a pure rotational Salter-Harris type I injury of the distal tibia1 epiphysis; this injury may be missed on radiographs.
References Bosworth D. M. (1947) Fracture-dislocation of the ankle with fixed displacement of the fibula behind the tibia. 1, Bone joint Sttrg.29, 130. Broock G. J. and Greer R. 8. (1970) Traumatic rotational displacements of the distal tibial growth plate. J. Bone JointSwg. 52A, 1666. Love11 E. S. (1968) An unusual rotatory injury to the ankle. J. Bone ]oinf Surg.5OA, 163. Nevelos A. B. and Colton C. L. (1977) Rotational displacement of the lower tibia1 epiphysis due to trauma. J Bone JointSurg.59B, 331.
Paper accepted I March 1993.
Figure I. Radiographs showing fracture of the fibula and incongruence of the distal tibia1 epiphysis. 0 1993 Butterworth-Heinemann 0020-1383/93/070495-01
Ltd
Requestsfor reprintsshould be addressedto: Mr A. C. Fairbank, Department of Orthopaedics, St George’s Hospital, Blackshaw Road, London SW17 OQT, UK.