Vol 10 | Issue 1 | January-June 2024 | page: 70-73 | Siddhartha Sablay, Sandeep Patwardhan, Vivek Sodhai, Rahul Jaiswal, Darshan Sonawane, Ashok Shyam, Parag Sancheti

https://doi.org/10.13107/jmt.2024.v10.i01.232

Author: Siddhartha Sablay [1], Sandeep Patwardhan [1], Vivek Sodhai [1], Rahul Jaiswal [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1] 

[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.

Address of Correspondence
Dr. Siddhartha Sablay,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and
Rehabilitation, Pune, Maharashtra, India.
E-mail: siddharthasablay200@gmail.com

Abstract

Background: Fractures through the distal tibial physis in children are important because they can affect future growth and ankle function. This study reviews our experience treating these injuries and reports clinical and radiographic outcomes.
Methods: Fourteen consecutive patients under 16 years were treated between September 2019 and October 2021. Fractures were classified using Salter–Harris and Dias–Tachdjian systems. Treatment included closed reduction with percutaneous fixation or open reduction and internal fixation when necessary; intraoperative arthrography was used selectively. Outcomes were measured with the AOFAS ankle–hindfoot score and VAS for pain at scheduled follow-up visits.
Results: Mean age was 11.86 years. Road-traffic collisions and twisting injuries were the most frequent causes. Eleven patients underwent closed procedures and three required open reduction; fixation used cannulated screws or K-wires according to fragment size. Mean AOFAS score improved markedly to 95.3 at one year. Complications were few and mainly minor.
Conclusion: Careful assessment, timely anatomic reduction and stable fixation — with selective intraoperative arthrography when needed — produced consistently good short-term outcomes in this series. Continued follow-up is recommended to detect late physeal complications.
Keywords: Paediatric ankle fractures, Distal tibial physis, Tillaux fracture, Triplane fracture, Percutaneous fixation.

Introduction

Fractures that involve the distal tibial growth plate deserve careful attention because the physis plays a major role in tibial length and closes unevenly during adolescence. That uneven closure explains transitional patterns such as Tillaux and triplane fractures, where epiphyseal, physeal and metaphyseal components coexist and plain radiographs may not show the full picture [5–7]. When the joint surface is involved, restoring articular congruity is as important as stabilising the bone — failing to do so raises the risk of post-traumatic arthritis and growth disturbance.
Clinically, the aim is straightforward: restore the ankle’s joint surface and alignment while protecting the growth plate to prevent limb-length or angular problems. Classification systems help; Salter–Harris describes the anatomic level of injury while Dias–Tachdjian helps anticipate how the fragments have displaced and what reduction technique will likely succeed [1–2]. For many non-displaced fractures, immobilisation and close radiographic surveillance are sufficient [3]. But when there is displacement within the joint surface, many authors recommend achieving near-anatomic reduction — commonly quoted as ≤2 mm residual step — because smaller gaps tend to give better midterm function [4,17].
Cross-sectional imaging with CT or MRI improves planning for complex or adolescent transitional injuries and guides screw placement [6–7]. Surgical options range from closed reduction and percutaneous screw or K-wire fixation to open reduction when soft-tissue interposition or irreducibility prevents closed alignment [8–11,16]. Intraoperative arthrography can confirm cartilage reduction when fluoroscopy is equivocal and may spare some children an open approach [13–14]. The present retrospective series reports our experience with fourteen consecutive patients managed at a tertiary centre between September 2019 and October 2021, focusing on demographics, fracture patterns, imaging and operative technique — including selective arthrography — and on validated clinical outcomes.

Methods and materials
This was a retro-prospective, non-randomized series of fourteen consecutive children under 16 years with distal tibia–fibula physeal injuries treated at our tertiary centre from September 2019 to October 2021. Institutional approval and guardian consent were obtained. We included closed physeal fractures of the distal tibia; we excluded open fractures, pathological fractures and patients with major polytrauma. Demographic details, mechanism of injury, side involved and time from injury to surgery were recorded. Clinical assessment documented pain, swelling, deformity, range of motion and neurovascular status.
All patients had AP, lateral and mortise radiographs. CT or MRI was obtained selectively when plain films did not clearly define fragment anatomy or suspected intra-articular extension, particularly for triplane or Tillaux patterns [6–7]. Fractures were classified using Salter–Harris and Dias–Tachdjian systems [1–2]. Perioperative care included a single prophylactic dose of a third-generation cephalosporin and standard anaesthetic and aseptic precautions. Closed reduction under fluoroscopy was attempted first; if reduction was maintained, fixation was with percutaneous cannulated cancellous screws or smooth Kirschner wires according to fragment size and the desire to minimise physeal violation [8–11]. Intraoperative arthrography with contrast was used selectively when fluoroscopic detail was inadequate to confirm cartilaginous congruity [13]. Open reduction with an anteromedial approach and direct fixation was reserved for irreducible fragments or soft-tissue interposition [16].
Postoperatively, patients were immobilized in a below-knee cast and kept non-weight bearing for roughly six weeks, then progressed to a walking cast and physiotherapy as healing allowed. Follow-up visits were scheduled at suture removal, six weeks, three months, six months and one year. Functional outcomes were recorded using the AOFAS ankle–hindfoot score and VAS for pain. Data were collected by the treating team and analyzed with standard parametric and categorical tests; significance was set at p<0.05.

Review of literature
Pediatric ankle fractures are not just smaller versions of adult injuries — the growth plate behaves differently and is often the weak point around the ankle, producing characteristic physeal and transitional patterns such as Tillaux and triplane fractures [1]. The Salter–Harris scheme gives a helpful anatomic snapshot, but mechanistic classifications like Dias–Tachdjian add value by predicting how the fragments move and what reduction maneuvers will work best [2]. Many low-risk, non-displaced physeal injuries heal well with immobilisation and close radiographic follow-up, yet when the joint surface is involved and displaced, anatomic reduction becomes essential to reduce the risk of premature physeal closure and later arthritis [3–4].
Transitional fractures in adolescents can be complex because they involve epiphysis, physis and metaphysis together, and plain X-rays may underestimate fragment geometry; CT or MRI is therefore often useful for preoperative planning [5–7]. When surgery is needed, the choice of implant depends on fragment size and the desire to protect the physis: cannulated screws give compression for larger epiphyseal fragments, while smooth Kirschner wires are commonly used for small fragments or when crossing the physis should be minimised [8–11]. Bio absorbable implants have been explored as an alternative to metal, showing similar short-term results in selected reports and the practical advantage of avoiding removal procedures [12].
Intraoperative arthrography is a helpful tool when fluoroscopy does not clearly show cartilaginous congruity; several series report that arthrography can allow percutaneous fixation and avoid unnecessary arthrotomy in selected cases [13–14]. Outcome measures such as the AOFAS ankle–hindfoot score and VAS pain scale are widely used and show substantial improvement after anatomic reduction and stable fixation, but the literature cautions that physeal arrest and angular deformity may present months or years later, which is why longer follow-up and standardized outcome reporting are repeatedly recommended [3,15–20].

Results
Fourteen patients were included: nine boys and five girls. The average age was 11.86 years (range 4–14). Time from injury to operation ranged from two hours to 3.5 days (mean 1.2 days). Mechanisms were road-traffic accidents in seven (50%), twisting injuries in six (43%) and a fall in one (7%). According to Salter–Harris classification the distribution was Type IV (n=6), Type II (n=4), Type III (n=3) and Type I (n=1). Eleven patients had closed reduction and percutaneous fixation; three required open reduction because the fragments were irreducible or soft tissue was interposed. Seven patients received cannulated screws and the remainder K-wires.
By three months most children demonstrated radiographic union and improved function. Mean AOFAS score improved from 15.57 preoperatively to 75.71 at three months, 90.07 at six months and 95.29 at one year (p<0.05). Pain and functional sub-scores improved similarly. Complications were uncommon: one child developed a checkrein deformity; three reported persistent ankle pain at intermediate follow-up; isolated minor complaints such as itching or transient sensory change were recorded. There were no wound infections or hardware failures. At latest follow-up half the children had returned to near-normal activity without complications.

Discussion
The strong improvement in function seen in our series supports the core lesson from existing reports: restore the joint surface and achieve stable fixation, but do so while protecting the growth plate [11,17]. When articular congruity is restored to near anatomic alignment, children tend to regain pain-free motion and return to activity, which matches prior cohort findings [4,10]. The selective use of intraoperative arthrography proved useful in cases where fluoroscopic imaging did not clearly show cartilaginous reduction, allowing percutaneous treatment in some displaced injuries and avoiding unnecessary open arthrotomy [13–14].
For fixation, cannulated screws worked well for larger epiphyseal fragments by providing compression and rotational stability; smooth K-wires were a reasonable alternative when the fragment was small or when transphyseal fixation was a concern [8–11]. Bio absorbable implants are an option reported in the literature with comparable short-term results in some series and the benefit of avoiding implant removal in selected situations [12]. Our low complication rate is encouraging, but the key long-term worry remains premature physeal closure, which can show up late and produce limb-length discrepancy or angular deformity — an especially real risk after high-energy mechanisms or large initial displacement [15,18–19].
The study’s limitations are important: small patient numbers, retrospective design and single-center experience limit generalisability and prevent strong comparisons between fixation strategies. Our follow-up is sufficient to document union and early function, but may not be long enough to capture late physeal problems that can appear years after injury [20]. Still, the data support a practical approach: use imaging sensibly for complex patterns, restore the articular surface when displaced, choose fixation that secures reduction while limiting physeal insult, and maintain structured long-term follow-up for cases at higher risk.

Conclusion
Distal tibial physeal fractures in children require treatment that balances joint restoration with protection of the growth plate. In this series timely, anatomic reduction and appropriately chosen fixation — most commonly percutaneous cannulated screws or K-wires — led to marked improvements in pain and function by one year. Selective intraoperative arthrography was a valuable adjunct when fluoroscopic detail was unclear. Complications were few, but the risk of premature physeal closure remains the primary long-term concern and justifies continued surveillance, particularly after high-energy injuries or where initial displacement was large. The retrospective design, small sample size and single-centre setting limit broad application of these results; larger prospective, multicenter studies with standardised outcomes and follow-up until skeletal maturity would better define optimal management and long-term prognosis.

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Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022

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