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Triplane fracture of the distal tibia
Injury, Int. J. Care Injured 31 (2000) 729 – 736 www.elsevier.com/locate/injury
Triplane fracture of the distal tibia E. El-Karef *, H.I. Sadek, D.S. Nairn, C.H. Aldam, P.W. Allen Department of Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow, Essex, CM20 1QX, UK Accepted 3 May 2000
Abstract A prospective study of 21 triplane fractures of the distal tibia is presented. Nineteen cases (90.5%) had lateral triplane fractures, while the other two (9.5%) had medial triplane fractures. Two fragment fractures were encountered in 12 cases (57%); three fragment fractures in six cases (29%), and four fragment fractures in the remaining three cases (14%). Fourteen cases (67%) were managed non-operatively, while in seven cases (33%), open reduction and internal fixation was performed. Twenty patients (95%) were pleased with the final outcome. Objectively, 14 cases (67%) achieved excellent results. © 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction The original description of triplane fractures is attributed to Bartl (1957) [1], who presented a fracture with metaphyseal and epiphyseal components. In the same year, Johanson and Fahl described a similar fracture [2]. Gerner-Smidt, in 1963, experimentally produced triplane fracture in cadaveric studies, and described triplane and juvenile Tillaux fractures (Salter and Harris, type III) as different stages of the same injury [3]. Despite these earlier reports, the nature of triplane fractures was not appreciated until Marmor’s report in 1970 [4]. Two years later, Lynn [5] reported additional cases and coined the term triplane fracture. Since then, several authors have reported on these fractures and described several variants and atypical types [6–13]. The triplane fracture is defined as having fractures in the sagittal, coronal and axial anatomical planes [14– 16]. The fracture patterns are combinations of SalterHarris types II, III, and IV. The coronal fracture component, best seen in lateral radiographs, involves the posterior tibial metaphysis and a variably sized portion of the epiphysis [16 – 20]. The sagittal fracture is best visualised in anteroposterior radiographic projec-
tions. It consists of a vertically oriented fracture through the epiphysis, usually, at the mid-portion of the plafond. However, it may start anywhere along the anterior border of the epiphysis and it may extend in various directions. The axial component of the fracture occurs through the physis. This is sometimes difficult to see in ordinary radiographs and usually requires two or three-dimensional imaging [3,7,9,21–23]. Such fractures involve the articular cartilage, epiphysis, physis, and metaphysis and theoretically carry a high risk of complications secondary to premature partial closure of the physis [24–26]. Several anatomical variants have been identified including those with two to four principal fracture fragments, lateral and medial, and intra and extra-articular variants. Nevertheless, all have triplanar geometric configurations. Such a sub-classification is important since each type may require a specific mode of fracture reduction and management [1,9,27–30]. The aim of this study is to identify the relationship between the different types, and configurations of triplane fractures and their prognosis. Attempts were made to determine how far these factors and treatment might affect the risk of premature physeal closure.
2. Material and methods * Corresponding author. Tel.: +44-1279-444455; fax: +44-1279827155.
This prospective study included 21 cases of triplane fracture of the distal tibia, treated in Princess Alexan-
0020-1383/00/$ - see front matter © 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 0 8 6 - 3
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E. El-Karef et al. / Injury, Int. J. Care Injured 31 (2000) 729–736
dra Hospital, Harlow, U.K. Fourteen patients (67%) were male and seven (33%) were female. The age ranged from 10.5 to 15.3 years. The mean age was 13.8 years and 11.6 years for males and females, respectively. The right ankle was involved in nine cases (43%), and left ankle in 12 (57%). The mean follow-up period was 28 months (ranged from 14 to 36 months). All patients gave a history of a twisting injury of the ankle with varying degrees of severity. Radiological examination revealed 19 patients (90.5%) with lateral triplane fractures, 11 (58%) with two-fragment fractures, five (26%) with three-fragment fractures, and three (16%) with four-fragment fractures (Fig. 1a–c). Medial triplane fractures were encountered in only two cases (9.5%); one being a two-fragment fracture, and the other being a three-fragment fracture (Fig. 2a and b). Nineteen fractures (90.5%) were intra-articular involving the tibiotalar joint. While the remaining two patients (9.5%) had sustained transmalleolar (extra-articular) triplane fractures (Fig. 3). Five cases (24%) were associated with a fibular fracture. Four fractures (80%) were obliquely oriented, about 4 – 6 cm proximal to the lateral malleolus and running from the anteroinferior to the posterosuperior cortex, indicating an external rotational injury. In the fifth case the fibula was rather deformed by a green-stick like fracture. In all cases displacement measured 2 mm or more on admission. The lower tibial growth plate was found to be partially fused in 18 cases (86%). In the remaining three children, the growth plates were, completely open, radiologically (14%) (Fig. 4). None of the patients had any other associated injuries.
2.1. Treatment The aim of treatment was absolute anatomical reduction after thorough clinical and radiological evaluation. All cases in this study were subjected to a special management protocol. All fractures were manipulated under general anaesthesia, with image intensifier guidance. If an adequate reduction was achieved with no or minimal displacement (less than 2 mm) in all planes cast immobilisation was continued for 6 weeks. A check radiograph was usually obtained seven days after cast application to verify that reduction had been maintained. Partial weight bearing was usually allowed at 4 weeks. If closed reduction was unsuccessful, leaving more than 2 mm of displacement in any plane, operative reduction and internal fixation was contemplated. After surgery, treatment was continued in plaster as for the undisplaced fractures. Radiographic examination was carried out at 6 weeks, 3 months, 6 months and 12 months after injury and at the time of final follow up assessment in all cases. In this series, seven cases (33%) were managed surgically (five lateral triplane fractures, and two medial triplane fractures). The remaining 14 cases (67%) were managed non-operatively. Preoperative CT scans were obtained in order to improve preoperative planning. For lateral triplane fractures an anterolateral approach was used. An additional anteromedial incision was necessary in one case. An anteromedial incision was used for the two medial triplane fractures. Reduction was usually confirmed through direct observation and by image intensification. Most of fractures were initially stabilised with K
Fig. 1. (a) Ap radiograph of a two-fragment lateral triplane fracture. (b) Ap radiograph of a three-fragment lateral triplane fracture. (c) A CT scan showing a four-fragment lateral triplane fracture.
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Fig. 2. (a) Ct scan of a two-fragment medial triplane fracture (Denton and Fissure type) with anterior and medial displacement (a variant of supination adduction injury). (b) Ct scan of a three-fragment medial triplane fracture (Marmor’s type) with avulsed anteolateral part of the distal tibial epiphysis (a variant of supination external rotation injury).
wires, then by two or three screws. No transphyseal screws were inserted in this group of patients.
2.2. Methods of e6aluation At the final assessment and inaddition to physical examination, the patients filled in a questionnaire in order to identify their symptoms and their degree of satisfaction. Radiological examination included lateral view and bilateral A – P orthoradiographic measurement of the tibia. Based on the subjective, objective, and radiological criteria in (Table 1), the results were classified into excellent, good, fair and poor. Statistical analysis was done using SPSS for windows.
3. Results Subjectively, at final follow-up, the results in 16 patients (76.2%) were classified as excellent, four (19%) as good and one (4.8%) as fair. None of the patients complained of pain, swelling or limping or claimed symptoms that interfered with their daily life activities. All patients had unrestricted walking and sport abilities except one (4.8%), who had to modify his favourite sport (Rugby) to a less vigorous one (classified as a fair result). Four patients (19%) had a mild occasional sense of stiffness (classified as a good result). There was no need, in any of the patients to use analgesia or insoles. Fourteen patients (66.7%) had been free of symptoms
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within 6 months after injury. Twenty patients (95.2%) were pleased with the outcome, and one (4.8%) was moderately satisfied. Objectively, the result in 14 patients (66.7%) was classified as excellent, six (29.5%) as good, and one (4.8%) as fair. None of the patients had localised tenderness, swelling or abnormal gait. Three patients (14.3%) had restricted ankle movements by less than 15°. Four (19%) had a mildly reduced subtalar arc of movement (5–10°). There was no clinically apparent deformity in any of the cases. All of the patients had stable ankle joints with negative anterior drawer, and varus and valgus stress tests. Clinically, two patients (9.5%) had shortening of the tibia measuring less than 10 mm. Nevertheless, orthoradiographic measurement revealed length discrepancies of less than 5 mm in three patients (14.3%), and from 5 – 10 mm in two (9.5%). Radiologically all fractures united with smooth regular articular surfaces. In one patient (4.8%) the physis completely closed on the affected side, while the opposite side was still completely open (classified as a fair results). In four patients (19%) the growth plates closed, while the other side was still partially open. Radiographs of two ankles (9.5%) revealed varus deformity of the distal tibia measuring less than 5°. In three cases (14.3%) there was valgus deformity of the distal tibia, which ranged from 3 to 7°. In the remaining 16 patients (76.7%) the growth plates on the affected ankles exactly similar to the opposite uninjured side.
4. Discussion Both patterns and orientations of distal tibial epiphyseal injuries depend on the maturity and degree of fusion of the growth plate, which has a characteristic asymmetric pattern of fusion. In 1984, Feldman and associates [23], showed that fusion begins in the middle of the physis and extends first anteriorly and posteromedially, then later laterally. This process takes about 18 months, during which time triplane fractures have been said to occur [24]. The anterolateral physis, which is the last to fuse, is the most vulnerable, and is at risk of such a fracture. When the medial portion of the distal tibial physis is stabilised by fusion or local irregularities, the forcible external rotation (lateral, outward), of a supinated foot (in planter flexion) at the ankle results in the classical two-fragment triplane fracture. As the external rotation force continues, the tightened, intact anterior tibiofibular ligament avulses the unfused anterolateral corner of the distal tibial epiphysis and separates it together with an attached metaphyseal fragment. Thus, fracture lines and fragments having a triplane configuration are produced. The talus may further force the lateral malleolus laterally and posteriorly producing an oblique fibular fracture. A fibular fracture is not a constant feature but implies that there has been a more severe external rotational force, and this should not be underestimated because of the associated increased incidence of an
Fig. 3. Transmalleolar triplane fracture.
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Fig. 4. Triplane fracture in a child with completely open physis, a CT scan showing a posteromedial hump described previously by Clement.
unsuccessful closed reduction and an increased likelihood of the need for open reduction. In the presence of axial loading three and four-fragment fractures are to be expected. Our findings are largely compatible with that of Healy et al. [25], Dias et al. [24,26], Cooperman et al. [27], Clement et al. [11], Ertl et al. [28], and others [29 – 32]. In 1985, von Laer [10] reported triplane fractures with completely open growth plates. In 1987 Clement et al. [11] described the presence of a hump or projection of the medial growth plate in six children who had sustained triplane fractures, despite their completely open growth plates. In this study, three cases (14%) were encountered with triplane fracture in the presence of completely open growth plates. The medial hump or projection described previously by Clement [11] was clearly identified in the longitudinal two-dimensional CT reconstruction views in two cases (Fig. 4), while an obvious physeal irregularity was noted in the third case. It would seem that such a hump, or local irregularities stabilise the anteromedial part of the epiphysis, in a manner similar to the partial medial fusion seen in older children. This accounts for the occurrence of triplane fracture in the presence of an open growth plate. Two-transmalleolar (extra-articular) triplane fractures (9.5%) were encountered in our group. In this type the sagittal fracture line extends through the medial malleolus and not into the ankle joint. Feldman et al. proposed that, in such cases, less than an anatomical
reduction could be acceptable. The need for surgical management to restore articular congruity could therefore, often be avoided [33]. Shin et al. [30] and Karrholm [9] also classified this type separately, because of its implications for treatment and prognosis. The medial triplane fracture was originally described by Marmor [4], and Denton and Fisher [34], and reported by others [35–38]. Despite having the same overall special configuration of triplane fractures, it has an altered geometric form, and should be distinguished from the lateral types. Its incidence and prognosis are different from the so-called lateral type. It may have a lower peak age incidence and theoretically may be associated with a higher rate of complications. Nevertheless, its relative rarity makes its analysis difficult. In our series, two medial triplane fracture were encountered. The first case was a two-fragment type (Denton and Fisher type) (Fig. 2), and the second one was three-fragment type (Marmor’s type) (Fig. 2). Both cases were managed operatively. Treatment of the distal tibial triplane fracture is still controversial and addressed with wide variations in the literature. There is still no agreement on management. von Laer [10] used no or open reduction in his cases, whereas several other authors [26,28,31] tried to reduce all of their cases. Wicky et al. [29] and Khouri [38] performed open reduction in a high percentage of their patients. In contrast, Cooperman et al. [27] treated 13 of 15 patients by closed reduction and the application of a cast. Whipple and associates [39] described arthro-
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scopic reduction of two-part triplane fractures. In our series the only indication for surgery was failure to achieve anatomical reduction. However, there was no failure to maintain anatomical reduction in cases treated non-operatively. It is noteable that surgery was commonly indicated in cases with more comminution particularly those associated with a fibular fractures, and also in the medial triplane type of fracture. The theoretical risk of partial premature epiphyseal closure resulting in an angular deformity and/or limblength discrepancy was not realised in our series or in the literature. The prognosis was always surprisingly good [9,10,30] with few reports of complications or unsatisfactory results [9,17,28]. As most of these cases are near to full skeletal maturity at the time of injury the growth pattern usually lasts for a few months with a small risk of growth arrest problems. At final follow-up, five cases (24%) had radiologically measured varus or valgus deformity (ranging from three to seven degrees). Tibial shortening of less than 10 mm was measured clinically in two cases (9.5%) and
detected by orthoradiographic views in five cases (24%) (Fig. 5). However, all patients were unaware of any growth arrest complications. Although it was statistically insignificant there was a tendency for less than excellent results to occur in younger patients (less than 11 years in girls and 12 in boys) (n= 7, P= 0.0585, Fisher’s exact test {one tail} = 0.1333); with fully opened physes (n= 3, P = 0.0764); in presence of more than two fragments (n= 9, P= 0.0932, Fisher’s exact test {one tail} = 0.6263); in association of fibular fractures (n=4, P= 0.0675); and with extra-articular type of triplane fracture (n = 2, P= 0.0904). Very few studies have followed patients up for more then 10 years [9,28]. The length of the followup, in this present study, had no significant effect on the final results. Ertl et al. [28], reported deterioration of results with time. Karrholm [9], also reported a weak tendency in support of this finding. This suggests that the outcome in 10–20 years might be less favourable than reported. This also emphasises the
Table 1 Assessment criteria Symptoms
Excellent
Good
Fair
Poor
Subjecti7ely 1 Pain 2 Swelling 3 Sense of stiffens 4 Limbing 5 Activity at work 6 Return to sport 7 Use of analgesics 8 Use of insols 9 Patient satisfaction
none none none none normal as before injury none none pleased
with violent activity after violent activity mild-occasional mild-occasional mild restriction mild restriction occasionally occasionally moderately satisfied
during ADLa during ADLa moderate moderate modified his work modified his sport often often not sure
at rest sever — constant sever sever unable to work unable to practice always always unsatisfied
Objecti7ely (with comparison to the opposite side) 1 Tenderness none 2 Swelling none 3 Short limb gait none 4 Painful limb gait none 5 Deformity (varus/valgus) none 6 Ankle mobility normal 7 Subtalar mobility normal 8 Ankle stability Drawer test normal Varus stress test normal Valgus stress test normal 9 Tibial length normal
mild mild mild mild up to 5° reduced B15° mildly stiff (B10°)
moderate moderate moderate moderate 5–15° 15–30° moderately stiff
severe severe marked marked \15° \30° very stiff
mild laxity mild laxity mild laxity shortening B5:10 mm
moderate laxity moderate laxity moderate laxity 10:15 mm
marked laxity marked laxity marked laxity \15 mm
Radiologically 1 Fracture healing 2 Articular surface 3 Distal tibial deformity 4 Shortening 5 Development of arthritis
doubtful union B2 mm B5° B10 mm nil
partial union step B2 mm 5:15° 10:15 mm tendency
non-united irregular, step \2 mm \15° \15 mm arthritic
a
ADL = Activity of daily life.
sound union normal step nil nil nil
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5. Conclusions
1. The complexity of the triplane fractures is often underestimated and its significance overlooked. 2. Triplane fractures are relatively benign, if the correct diagnosis is made and accurate reduction achieved. 3. Growth disturbance has no or only minimal influence on the final subjective results particularly in older children with the lateral type of fracture and partial physeal closure. 4. Open reposition and careful osteosynthesis is recommended, if anatomical reduction cannot be achieved or maintained by non-operative means. 5. Optimum outcome measurement can only be made, some years after complete skeletal maturity and cessation of growth. References
Fig. 5. 1 cm shortening following triplane fracture.
need to achieve an accurate anatomical reduction in the hope of reducing degenerative changes and its consequences in the long term. In this study, the time lapse before management, the accuracy of reduction, associated other injuries, and pre-existing foot or ankle problems did not affect the outcome. Treatment started within hours of injury in all patients. Only a perfect anatomical reduction was accepted. The type of management (non-operative or operative) had no statistically significant influence on outcome (P=0.09806). None of the patients treated operatively had surgically induced problems, such as scars or infection. Karrholm [9] recently analysed the data of 95 cases and also found that, none of the factors, such as age, sex, or treatment had an obvious influence on the outcome. Sub-optimal results reported in the literature have always been associated with inadequate reduction or loss of reduction with a residual displacement of 2 mm or more [28,31]. Nonetheless, the percentages of patients continued to suffer ankle symptoms, when the displacement exceeds 2 mm after reduction, markedly varied, making any definite conclusion difficult [28,14,31].
[1] Bartl R. Die traumatische Epiphysenlosung am distalen ende des Scheinbeines und des Wadenbeines. Heftie Unfalheilk 1957; 54: 228 – 257. Quoted from: Karrholm J, Hansson LI, Laurin S. Computed tomography of intra-articular supination fractures of the ankle in adolescents. J Pediatr Orthop 1981;1:181 –7 [2] Johanson EW, Fahl JC. Fractures involving the distal epiphysis of the tibia and fibula in children. Am J Surg 1957;93:778–81. [3] Gerner-Smidt, M. Ankelbrud hos born. Doctoral thesis. Copenhagen, Nyt Nordisk Forlag, 1963. Quoted from: Karrholm J. The triplane fracture: four years of follow-up of 21 cases and review of the literature. J Pediatr Orthop B, 1997;6(2):91–102 [4] Marmor L. An unusual fracture of the tibial epiphysis. Clin Orthop 1970;73:132 – 5. [5] Lynn MD. The triplane distal tibial epiphyseall fracture. Clin Orthop 1972;86:187 – 90. [6] Kornblatt N, Neese DJ, Azzolini TJ. Triplane fracture of the distal tibia: unusual case presentation and literature review. J Foot Surg 1990;29(5):421– 8. [7] Peterson HA. Extra-articular triplane fracture of the distal tibial epiphysis (letter). J Pediatr Orthop 1996;16(5):679. Comment on: J Pediatr Orthop 1995;15(4):479– 81 [8] van-Laarhoven CJ, van-der-Werken C. Quadriplane fracture of the distal tibia: a triplane fracture with a double metaphyseal fragment. Injury 1992;23(7):497– 9. [9] Karrholm J. The triplane fracture: four years of follow-up of 21 cases and review of the literature. J Pediatr Orthop B 1997;6(2):91 – 102. [10] von Laer LL. Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia. J Bone Joint Surg (Am) 1985;67 A(5):687 – 98. [11] Clement DA, Worlock PH. Triplane fracture of the distal tibia. A variant in cases with an open growth plate. J Bone Joint Surg Br 1987;69(3):412– 5. [12] Karrholm J, Hansson LI, Laurin S. Computed tomography of intra-articular supination fractures of the ankle in adolescents. J Pediatr Orthop 1981;1:181 – 7. [13] Johnson PH. Triplane fracture of the distal tibial epiphysis. J Ark Med Soc 1986;82(9):412– 4. [14] Landin L, Danielsson LG, Jonsson K, Pettersson H. Late results in 65 physeal ankle fractures. Acta Orthop Scand 1986;57(6):530– 4.
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[15] Jarvis JG. Tibial triplane fractures. In: Letts RM, editor. Management of paediatric fractures. London: Churchill-Livingstone, 1994:735 – 49. [16] Izant TH, Davidson RS. The four-part triplane fracture: a case report of a new pattern. Foot-Ankle 1989;10(3):170–5. [17] Toupin JM, Lechevallier J. Post-traumatic epiphysiodesis of the distal end of the tibia. Rev Chir Orthop Reparatrice Appar Mot 1997;83(2):112– 22. [18] Erlemann R, Wuisman P, Just A, Peters PE. Deformities and trauma sequelae of the ankle joint in children and adolescents. Radiologe 1991;31(12):601–8. [19] Cass JR, Peterson HA. Salter-Harris type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg (Am) 1983;65(8):1059– 70. [20] Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of 237 cases in children. J Bone Joint Surg (Am) 1978;60 A:1046 – 50. [21] MacNearly GA, Rogers LF, Hernandez R, Poznanski AK. Injuries of the distal tibial epiphysis: systemic evaluation. AJR (Am) Roentgenol 1982;138(4):683–9. [22] Cone RO 3d, Nguyen V, Flournoy JG, Guerra J, Jr. Triplane fracture of the distal tibial epiphysis: radiographic and CT studies. Radiology 1984;153(3):763–77. [23] Feldman F, Singson RD, Rosenberg ZS, et al. Distal tibial triplane fractures: diagnosis with CT. Radiology 1987;164:429 – 35. [24] Dias LS. Triplane fracture. In: Rockwood CA, Wilkins KE, King RE, editors. Fractures in children, 3rd ed. Philadelphia: JB Lippincott, 1991:1341–8. [25] Healy WA 3rd, Starkweather KD, Meyer J, Teplitz GA. Triplane fracture associated with a proximal third fibula fracture. Am J Orthop 1996;25(6):449–51. [26] Dias LS, Giegerich CR. Fractures of the distal tibial epiphysis in adolescence. J Bone Joint Surg (Am) 1983;65(4):438–44.
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[27] Cooperman DR, Spiegel PG, Laros GS. Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture. J Bone Joint Surg (Am) 1978;60 A:1040 – 6. [28] Ertl JP, Barrack RL, Alexander AH, VanBuecken K. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg (Am) 1988;70(7):967– 76. [29] Wicky B, Stauffer UG. Triplane fractures of the distal tibia. Z Kinderchir 1983;38:51 – 5. [30] Shin AY, Moran ME, Wenger DR. Intramalleolar triplane fractures of the distal tibial epiphysis. J Pediatr Orthop 1997;17(3):352– 5. [31] Rapariz JM, Ocete G, Gonzalez Herranz P, Lopez Mondejar JA, Domenech J, Burgos J, Amaya S. Distal tibial triplane fractures: long-term follow-up. J Pediatr Orthop 1996;16(1):113–8. [32] Tinnemans JR, Severijnen RS. The triplane fracture of the distal tibial epiphysis in children. Injury 1981;12(5):393– 6. [33] Feldman DS, Otsuka NY, Hedden DM. Extra-articular triplane fracture of the distal tibial epiphysis. J Pediatr Orthop 1995;15(4):479– 81. Comment in: J Pediatr Orthop 1996;16(5):679 [34] Denton JR, Fisher SJ. The medial triplane fracture: report of an unusual injury. J Trauma 1981;21(11):991– 5. [35] Seitz WH, Jr., LaPorte J. Medial triplane fracture delineated by computerised axial tomography. J Pediatr Orthop 1988;8(1):65– 6. [36] Canale TS. Fractures and dislocations in children. In: Crenshow AH, editor. Campbell’s operative Orthopaedics. St Louis, MO: Mosby, 1987. [37] Peiro A, Aracil J, Martos F, Mut T. Triplane distal tibial epiphyseal fracture. Clin Orthop 1981;160:196 – 200. [38] Khouri N, Ducloyer P, Karlioz H. Fractures triplans de la cheville. A props de 25 cas et rreveue generale (distal tibial triplane fractures). Riv Chir Orthop 1989;75(6):394– 404. [39] Whipple TL, Dale RM, McIntyre LF, Meyers JF. Arthroscopic treatment of triplane fractures of the ankle. Arthroscopy 1993;9:456 – 63.
Triplane fracture of the distal tibia E. El-Karef *, H.I. Sadek, D.S. Nairn, C.H. Aldam, P.W. Allen Department of Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow, Essex, CM20 1QX, UK Accepted 3 May 2000
Abstract A prospective study of 21 triplane fractures of the distal tibia is presented. Nineteen cases (90.5%) had lateral triplane fractures, while the other two (9.5%) had medial triplane fractures. Two fragment fractures were encountered in 12 cases (57%); three fragment fractures in six cases (29%), and four fragment fractures in the remaining three cases (14%). Fourteen cases (67%) were managed non-operatively, while in seven cases (33%), open reduction and internal fixation was performed. Twenty patients (95%) were pleased with the final outcome. Objectively, 14 cases (67%) achieved excellent results. © 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction The original description of triplane fractures is attributed to Bartl (1957) [1], who presented a fracture with metaphyseal and epiphyseal components. In the same year, Johanson and Fahl described a similar fracture [2]. Gerner-Smidt, in 1963, experimentally produced triplane fracture in cadaveric studies, and described triplane and juvenile Tillaux fractures (Salter and Harris, type III) as different stages of the same injury [3]. Despite these earlier reports, the nature of triplane fractures was not appreciated until Marmor’s report in 1970 [4]. Two years later, Lynn [5] reported additional cases and coined the term triplane fracture. Since then, several authors have reported on these fractures and described several variants and atypical types [6–13]. The triplane fracture is defined as having fractures in the sagittal, coronal and axial anatomical planes [14– 16]. The fracture patterns are combinations of SalterHarris types II, III, and IV. The coronal fracture component, best seen in lateral radiographs, involves the posterior tibial metaphysis and a variably sized portion of the epiphysis [16 – 20]. The sagittal fracture is best visualised in anteroposterior radiographic projec-
tions. It consists of a vertically oriented fracture through the epiphysis, usually, at the mid-portion of the plafond. However, it may start anywhere along the anterior border of the epiphysis and it may extend in various directions. The axial component of the fracture occurs through the physis. This is sometimes difficult to see in ordinary radiographs and usually requires two or three-dimensional imaging [3,7,9,21–23]. Such fractures involve the articular cartilage, epiphysis, physis, and metaphysis and theoretically carry a high risk of complications secondary to premature partial closure of the physis [24–26]. Several anatomical variants have been identified including those with two to four principal fracture fragments, lateral and medial, and intra and extra-articular variants. Nevertheless, all have triplanar geometric configurations. Such a sub-classification is important since each type may require a specific mode of fracture reduction and management [1,9,27–30]. The aim of this study is to identify the relationship between the different types, and configurations of triplane fractures and their prognosis. Attempts were made to determine how far these factors and treatment might affect the risk of premature physeal closure.
2. Material and methods * Corresponding author. Tel.: +44-1279-444455; fax: +44-1279827155.
This prospective study included 21 cases of triplane fracture of the distal tibia, treated in Princess Alexan-
0020-1383/00/$ - see front matter © 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 0 8 6 - 3
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dra Hospital, Harlow, U.K. Fourteen patients (67%) were male and seven (33%) were female. The age ranged from 10.5 to 15.3 years. The mean age was 13.8 years and 11.6 years for males and females, respectively. The right ankle was involved in nine cases (43%), and left ankle in 12 (57%). The mean follow-up period was 28 months (ranged from 14 to 36 months). All patients gave a history of a twisting injury of the ankle with varying degrees of severity. Radiological examination revealed 19 patients (90.5%) with lateral triplane fractures, 11 (58%) with two-fragment fractures, five (26%) with three-fragment fractures, and three (16%) with four-fragment fractures (Fig. 1a–c). Medial triplane fractures were encountered in only two cases (9.5%); one being a two-fragment fracture, and the other being a three-fragment fracture (Fig. 2a and b). Nineteen fractures (90.5%) were intra-articular involving the tibiotalar joint. While the remaining two patients (9.5%) had sustained transmalleolar (extra-articular) triplane fractures (Fig. 3). Five cases (24%) were associated with a fibular fracture. Four fractures (80%) were obliquely oriented, about 4 – 6 cm proximal to the lateral malleolus and running from the anteroinferior to the posterosuperior cortex, indicating an external rotational injury. In the fifth case the fibula was rather deformed by a green-stick like fracture. In all cases displacement measured 2 mm or more on admission. The lower tibial growth plate was found to be partially fused in 18 cases (86%). In the remaining three children, the growth plates were, completely open, radiologically (14%) (Fig. 4). None of the patients had any other associated injuries.
2.1. Treatment The aim of treatment was absolute anatomical reduction after thorough clinical and radiological evaluation. All cases in this study were subjected to a special management protocol. All fractures were manipulated under general anaesthesia, with image intensifier guidance. If an adequate reduction was achieved with no or minimal displacement (less than 2 mm) in all planes cast immobilisation was continued for 6 weeks. A check radiograph was usually obtained seven days after cast application to verify that reduction had been maintained. Partial weight bearing was usually allowed at 4 weeks. If closed reduction was unsuccessful, leaving more than 2 mm of displacement in any plane, operative reduction and internal fixation was contemplated. After surgery, treatment was continued in plaster as for the undisplaced fractures. Radiographic examination was carried out at 6 weeks, 3 months, 6 months and 12 months after injury and at the time of final follow up assessment in all cases. In this series, seven cases (33%) were managed surgically (five lateral triplane fractures, and two medial triplane fractures). The remaining 14 cases (67%) were managed non-operatively. Preoperative CT scans were obtained in order to improve preoperative planning. For lateral triplane fractures an anterolateral approach was used. An additional anteromedial incision was necessary in one case. An anteromedial incision was used for the two medial triplane fractures. Reduction was usually confirmed through direct observation and by image intensification. Most of fractures were initially stabilised with K
Fig. 1. (a) Ap radiograph of a two-fragment lateral triplane fracture. (b) Ap radiograph of a three-fragment lateral triplane fracture. (c) A CT scan showing a four-fragment lateral triplane fracture.
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Fig. 2. (a) Ct scan of a two-fragment medial triplane fracture (Denton and Fissure type) with anterior and medial displacement (a variant of supination adduction injury). (b) Ct scan of a three-fragment medial triplane fracture (Marmor’s type) with avulsed anteolateral part of the distal tibial epiphysis (a variant of supination external rotation injury).
wires, then by two or three screws. No transphyseal screws were inserted in this group of patients.
2.2. Methods of e6aluation At the final assessment and inaddition to physical examination, the patients filled in a questionnaire in order to identify their symptoms and their degree of satisfaction. Radiological examination included lateral view and bilateral A – P orthoradiographic measurement of the tibia. Based on the subjective, objective, and radiological criteria in (Table 1), the results were classified into excellent, good, fair and poor. Statistical analysis was done using SPSS for windows.
3. Results Subjectively, at final follow-up, the results in 16 patients (76.2%) were classified as excellent, four (19%) as good and one (4.8%) as fair. None of the patients complained of pain, swelling or limping or claimed symptoms that interfered with their daily life activities. All patients had unrestricted walking and sport abilities except one (4.8%), who had to modify his favourite sport (Rugby) to a less vigorous one (classified as a fair result). Four patients (19%) had a mild occasional sense of stiffness (classified as a good result). There was no need, in any of the patients to use analgesia or insoles. Fourteen patients (66.7%) had been free of symptoms
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within 6 months after injury. Twenty patients (95.2%) were pleased with the outcome, and one (4.8%) was moderately satisfied. Objectively, the result in 14 patients (66.7%) was classified as excellent, six (29.5%) as good, and one (4.8%) as fair. None of the patients had localised tenderness, swelling or abnormal gait. Three patients (14.3%) had restricted ankle movements by less than 15°. Four (19%) had a mildly reduced subtalar arc of movement (5–10°). There was no clinically apparent deformity in any of the cases. All of the patients had stable ankle joints with negative anterior drawer, and varus and valgus stress tests. Clinically, two patients (9.5%) had shortening of the tibia measuring less than 10 mm. Nevertheless, orthoradiographic measurement revealed length discrepancies of less than 5 mm in three patients (14.3%), and from 5 – 10 mm in two (9.5%). Radiologically all fractures united with smooth regular articular surfaces. In one patient (4.8%) the physis completely closed on the affected side, while the opposite side was still completely open (classified as a fair results). In four patients (19%) the growth plates closed, while the other side was still partially open. Radiographs of two ankles (9.5%) revealed varus deformity of the distal tibia measuring less than 5°. In three cases (14.3%) there was valgus deformity of the distal tibia, which ranged from 3 to 7°. In the remaining 16 patients (76.7%) the growth plates on the affected ankles exactly similar to the opposite uninjured side.
4. Discussion Both patterns and orientations of distal tibial epiphyseal injuries depend on the maturity and degree of fusion of the growth plate, which has a characteristic asymmetric pattern of fusion. In 1984, Feldman and associates [23], showed that fusion begins in the middle of the physis and extends first anteriorly and posteromedially, then later laterally. This process takes about 18 months, during which time triplane fractures have been said to occur [24]. The anterolateral physis, which is the last to fuse, is the most vulnerable, and is at risk of such a fracture. When the medial portion of the distal tibial physis is stabilised by fusion or local irregularities, the forcible external rotation (lateral, outward), of a supinated foot (in planter flexion) at the ankle results in the classical two-fragment triplane fracture. As the external rotation force continues, the tightened, intact anterior tibiofibular ligament avulses the unfused anterolateral corner of the distal tibial epiphysis and separates it together with an attached metaphyseal fragment. Thus, fracture lines and fragments having a triplane configuration are produced. The talus may further force the lateral malleolus laterally and posteriorly producing an oblique fibular fracture. A fibular fracture is not a constant feature but implies that there has been a more severe external rotational force, and this should not be underestimated because of the associated increased incidence of an
Fig. 3. Transmalleolar triplane fracture.
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Fig. 4. Triplane fracture in a child with completely open physis, a CT scan showing a posteromedial hump described previously by Clement.
unsuccessful closed reduction and an increased likelihood of the need for open reduction. In the presence of axial loading three and four-fragment fractures are to be expected. Our findings are largely compatible with that of Healy et al. [25], Dias et al. [24,26], Cooperman et al. [27], Clement et al. [11], Ertl et al. [28], and others [29 – 32]. In 1985, von Laer [10] reported triplane fractures with completely open growth plates. In 1987 Clement et al. [11] described the presence of a hump or projection of the medial growth plate in six children who had sustained triplane fractures, despite their completely open growth plates. In this study, three cases (14%) were encountered with triplane fracture in the presence of completely open growth plates. The medial hump or projection described previously by Clement [11] was clearly identified in the longitudinal two-dimensional CT reconstruction views in two cases (Fig. 4), while an obvious physeal irregularity was noted in the third case. It would seem that such a hump, or local irregularities stabilise the anteromedial part of the epiphysis, in a manner similar to the partial medial fusion seen in older children. This accounts for the occurrence of triplane fracture in the presence of an open growth plate. Two-transmalleolar (extra-articular) triplane fractures (9.5%) were encountered in our group. In this type the sagittal fracture line extends through the medial malleolus and not into the ankle joint. Feldman et al. proposed that, in such cases, less than an anatomical
reduction could be acceptable. The need for surgical management to restore articular congruity could therefore, often be avoided [33]. Shin et al. [30] and Karrholm [9] also classified this type separately, because of its implications for treatment and prognosis. The medial triplane fracture was originally described by Marmor [4], and Denton and Fisher [34], and reported by others [35–38]. Despite having the same overall special configuration of triplane fractures, it has an altered geometric form, and should be distinguished from the lateral types. Its incidence and prognosis are different from the so-called lateral type. It may have a lower peak age incidence and theoretically may be associated with a higher rate of complications. Nevertheless, its relative rarity makes its analysis difficult. In our series, two medial triplane fracture were encountered. The first case was a two-fragment type (Denton and Fisher type) (Fig. 2), and the second one was three-fragment type (Marmor’s type) (Fig. 2). Both cases were managed operatively. Treatment of the distal tibial triplane fracture is still controversial and addressed with wide variations in the literature. There is still no agreement on management. von Laer [10] used no or open reduction in his cases, whereas several other authors [26,28,31] tried to reduce all of their cases. Wicky et al. [29] and Khouri [38] performed open reduction in a high percentage of their patients. In contrast, Cooperman et al. [27] treated 13 of 15 patients by closed reduction and the application of a cast. Whipple and associates [39] described arthro-
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scopic reduction of two-part triplane fractures. In our series the only indication for surgery was failure to achieve anatomical reduction. However, there was no failure to maintain anatomical reduction in cases treated non-operatively. It is noteable that surgery was commonly indicated in cases with more comminution particularly those associated with a fibular fractures, and also in the medial triplane type of fracture. The theoretical risk of partial premature epiphyseal closure resulting in an angular deformity and/or limblength discrepancy was not realised in our series or in the literature. The prognosis was always surprisingly good [9,10,30] with few reports of complications or unsatisfactory results [9,17,28]. As most of these cases are near to full skeletal maturity at the time of injury the growth pattern usually lasts for a few months with a small risk of growth arrest problems. At final follow-up, five cases (24%) had radiologically measured varus or valgus deformity (ranging from three to seven degrees). Tibial shortening of less than 10 mm was measured clinically in two cases (9.5%) and
detected by orthoradiographic views in five cases (24%) (Fig. 5). However, all patients were unaware of any growth arrest complications. Although it was statistically insignificant there was a tendency for less than excellent results to occur in younger patients (less than 11 years in girls and 12 in boys) (n= 7, P= 0.0585, Fisher’s exact test {one tail} = 0.1333); with fully opened physes (n= 3, P = 0.0764); in presence of more than two fragments (n= 9, P= 0.0932, Fisher’s exact test {one tail} = 0.6263); in association of fibular fractures (n=4, P= 0.0675); and with extra-articular type of triplane fracture (n = 2, P= 0.0904). Very few studies have followed patients up for more then 10 years [9,28]. The length of the followup, in this present study, had no significant effect on the final results. Ertl et al. [28], reported deterioration of results with time. Karrholm [9], also reported a weak tendency in support of this finding. This suggests that the outcome in 10–20 years might be less favourable than reported. This also emphasises the
Table 1 Assessment criteria Symptoms
Excellent
Good
Fair
Poor
Subjecti7ely 1 Pain 2 Swelling 3 Sense of stiffens 4 Limbing 5 Activity at work 6 Return to sport 7 Use of analgesics 8 Use of insols 9 Patient satisfaction
none none none none normal as before injury none none pleased
with violent activity after violent activity mild-occasional mild-occasional mild restriction mild restriction occasionally occasionally moderately satisfied
during ADLa during ADLa moderate moderate modified his work modified his sport often often not sure
at rest sever — constant sever sever unable to work unable to practice always always unsatisfied
Objecti7ely (with comparison to the opposite side) 1 Tenderness none 2 Swelling none 3 Short limb gait none 4 Painful limb gait none 5 Deformity (varus/valgus) none 6 Ankle mobility normal 7 Subtalar mobility normal 8 Ankle stability Drawer test normal Varus stress test normal Valgus stress test normal 9 Tibial length normal
mild mild mild mild up to 5° reduced B15° mildly stiff (B10°)
moderate moderate moderate moderate 5–15° 15–30° moderately stiff
severe severe marked marked \15° \30° very stiff
mild laxity mild laxity mild laxity shortening B5:10 mm
moderate laxity moderate laxity moderate laxity 10:15 mm
marked laxity marked laxity marked laxity \15 mm
Radiologically 1 Fracture healing 2 Articular surface 3 Distal tibial deformity 4 Shortening 5 Development of arthritis
doubtful union B2 mm B5° B10 mm nil
partial union step B2 mm 5:15° 10:15 mm tendency
non-united irregular, step \2 mm \15° \15 mm arthritic
a
ADL = Activity of daily life.
sound union normal step nil nil nil
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5. Conclusions
1. The complexity of the triplane fractures is often underestimated and its significance overlooked. 2. Triplane fractures are relatively benign, if the correct diagnosis is made and accurate reduction achieved. 3. Growth disturbance has no or only minimal influence on the final subjective results particularly in older children with the lateral type of fracture and partial physeal closure. 4. Open reposition and careful osteosynthesis is recommended, if anatomical reduction cannot be achieved or maintained by non-operative means. 5. Optimum outcome measurement can only be made, some years after complete skeletal maturity and cessation of growth. References
Fig. 5. 1 cm shortening following triplane fracture.
need to achieve an accurate anatomical reduction in the hope of reducing degenerative changes and its consequences in the long term. In this study, the time lapse before management, the accuracy of reduction, associated other injuries, and pre-existing foot or ankle problems did not affect the outcome. Treatment started within hours of injury in all patients. Only a perfect anatomical reduction was accepted. The type of management (non-operative or operative) had no statistically significant influence on outcome (P=0.09806). None of the patients treated operatively had surgically induced problems, such as scars or infection. Karrholm [9] recently analysed the data of 95 cases and also found that, none of the factors, such as age, sex, or treatment had an obvious influence on the outcome. Sub-optimal results reported in the literature have always been associated with inadequate reduction or loss of reduction with a residual displacement of 2 mm or more [28,31]. Nonetheless, the percentages of patients continued to suffer ankle symptoms, when the displacement exceeds 2 mm after reduction, markedly varied, making any definite conclusion difficult [28,14,31].
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