SLR- November 2022- Ashley A. Mariano, DPM
Title: Open Reduction and internal fixation for displaced Salter-Harris type II fractures of the distal tibia: a retrospective study of sixty-five cases in childrenReference: Yuan Q, Zhen Y, Guo Z, Zhang F, Fang J, Zhu Z, Zhu L, Shen X, Yin C, Liu Y, Yao F, Wu L, Wang X. Open Reduction and internal fixation for displaced Salter-Harris type II fractures of the distal tibia: a retrospective study of sixty-five cases in children. J Orthop Surg Res. 2021 Mar 27;16(1):224.
Level of Evidence: III
Scientific Literature Review
Reviewed by: Ashley A. Mariano, DPM
Residency Program: Beaumont Wayne Hospital, Wayne, MI
Podiatric Relevance: Purpose of this study was to review Salter-Harris (SH) II distal tibia fractures and evaluate the rate of premature physeal closure (PPC) treated by open reduction internal fixation (ORIF). Premature physeal closure is disruption of normal growth plate at the level of the epiphysis-metaphysis junction. When the growth plate closes early it can alter the normal growth of long bones. SH-II fractures are actually the most frequent ankle injury in children accounting for 32-60%. The treatment for displaced SH-II distal tibia fractures remains controversial.
Methods: This is a retrospective study that was conducted from 2012 to 2019 and included 65 patients, 47 boys and 18 girls. The average age was 11.8 years old (range 3.9 to 14 years). Parameters that were recorded including sex, age, side of injury, mechanism of injury, initial fracture displacement, the interval between the injury and surgery, and length of follow-up. Patients were followed up for a minimum of 6 months. Mean follow-up period was 8.7 months (range, 6-25 months). Exclusion criteria for patients included patients with less than 1 year growth remaining (male > 15 years and female > 13 years), initial fracture displacement < 3 mm, pathological and open fractures or < 6 months of follow up CT scans of injured ankle or contralateral ankle radiograph were obtained if there was any evidence of PPC. Any angular deformity or shortening was documented.
Results: The mean initial displacement was 8.0 mm and all patients but 1 were treated within 7 days after injury and the mean interval was 3.7 days. 42 patients had concomitant fibula fractures and 23 did not. This retrospective study noticed that the early growth plate closure only occurred in those patients that has a fibular fracture as well. Complications included 1 superficial skin infection that was cleared with oral antibiotics and there were no deep infections. All fractures healed within 4-6 weeks. The presence of interposed periosteum was found in all patients but one intraoperatively. At the final visit, 19 patients developed PPC and the rate of PPC was 29.2% (must higher than literature previously described). Out of the 19 patients with PPC, 2 had developed a varus deformity of the ankle (10 and 15 degrees). Previous literature stated that early growth plate closure did not occur very often only 2-5% of the time however this study concluded that 29% of their patients ended up with early growth plate closure.
Conclusion: The incidence of PPC was found to be greater in patients with concomitant fibular fracture as compared with those with intact fibula. Patients with associated fibular fracture had 7 times greater odds of developing PPC. Limitation to the study was a low follow up time. The average length from injury to diagnosis of PPC was 7 months, even 2 years after injury. Overall, PPC is a common complication following ORIF. The presence of associated fibula fracture plays an important role in the fracture outcome.