SLR - May 2012 - Samirah Mohammed
Reference: Duran JA, Dayer R, Kaelin A, Ceroni D (2011). Intraoperative Arthrography for the Evaluation of Closed Reduction and Percutaneous Fixation of Displaced MacFarland Fractures: An Alternative to Open Surgery. Journal of Pediatric Orthopaedics 31(1) e1-e5.
Scientific Literature Review
Reviewed by: Samirah Mohammed, DPM
Residency Program: Yale/DVA Healthcare System
Podiatric Relevance:
The purpose of this retrospective analysis was to assess functional and radiographic results of closed reduction and percutaneous fixation with the aid of arthrography to assess fracture reposition in a MacFarland fracture. A MacFarland fracture is a Salter-Harris type III or type IV of the medial malleolus and the distal fibula that is usually caused by a supination-inversion injury in children between 8 and 15 years of age. The study evaluated 12 (7 boys and 5 girls) patients with MacFarland fractures.
Methods:
Medical records were used for find patients below the age of 16 that had been admitted to the University of Geneva Hospital from January 1993 to December 2006 with the diagnosis of the Salter-Harris type III or IV fracture of the medial malleolus and treated with arthrographic control and percutaneous fixation. The fracture was initially reduced and temporarily stabilized by k-wires, which were inserted parallel to the tibial physis utilizing one or two longitudinal mini incisions measuring approximately 5mm. Arthrographic assessment was used to see if any dye leaked into the fracture line, once there was no dye it was noted that the fracture was in anatomic reduction. The distal fibular fracture was not stabilized. The lower extremity was immobilized in a NWB above the knee cast for three weeks, followed by another three weeks of weight bearing short leg cast. X-rays were performed at six weeks, three months, and six months post-operative, and six month intervals until the end of skeletal growth. The average age was 12.5 years old. Average follow up was 19 months.
Results:
Of the 12 patients, seven had a Salter-Harris Type III and five had a Type IV. The patients also had a concomitant distal fibular fracture; nine had a Salter-Harris I, two had a Salter-Harris II, and one had no fracture present. The average pre operative gap was 2.8mm. The fractures were fixated using partially threaded cannulated screws, nine patients had two screws and three patients had one screw. The post op gap was 0mm in eight patients, 1mm in three patients, and 2mm in one patient. No limb-length discrepancy or varus deformity of the ankle was noted during follow-up. The functional and radiographic result measured by the Gleize classification was a good result for 11 patients, and fair for one child. The child had pain and discomfort for three years due to an intra-articular loose body in the ankle. Once the loose body was removed, the patient’s ankle pain went away.
Conclusions:
The authors in the study wanted to assess the use of percutaneous fixation and arthrography as an alternative treatment method for Salter-Harris type III and type IV fractures. The recommended treatment option for those types of fractures that have greater than 2mm of displacement is open reduction and internal fixation to minimize epiphysiodesis. Although there were some limitations to the study such as: small sample size, information on the any type of rotation, angulation, and translation of fracture fragments, and x-ray exposure time; the study presented an alternative to ORIF with the use of minimal incisions that led to less complications such as wound dehiscence, hypertrophic scars, and ankle stiffness while minimizing limb length discrepancy, or varus deformity of the ankle due to epiphysiodesis.