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Proximal Tibial Physeal Injury

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Other Names

  • Proximal Tibial Physeal Injury
  • Proximal Tibial Physeal Fracture
  • Proximal Tibia Epiphyseal Fractures

Background

  • This page refers to proximal tibial epiphyseal and physeal fractures seen in pediatric patients

History
Epidemiology

  • Account for less than 1% of all pediatric fractures[1]
  • Peak incidence between 10 and 16 years old[2]

Introduction

Stress induced chronic salter harris 1 growth plate fracture of the proximal tibia[3]

General

  • Rare fracture pattern seen in skeletally immature patients
  • Diagnosis can be made with standard radiographs
  • Note: Can mimic knee dislocation, develop peroneal nerve or popliteal injuries

Mechanism of Injury

  • About 50% of these occur in sporting events
  • Often due to indirect injury with hyperextension force on the knee
    • Example is emergent breaking of a bicycle with leg in hyperextension, forcefully striking the ground with forward momentum
  • Less commonly, high energy direct trauma such as being struck by a car bumper

Associated Conditions


Risk Factors

  • Unknown

Differential Diagnosis

Differential Diagnosis Knee Pain


Clinical Features

History

  • Inability to bear weight following injury

Physical Exam: Physical Exam Knee

  • Pain, swelling
  • Tenderness along the physis
  • Visible deformity or palpable step off if displaced
  • Carefully evaluate for varus and valgus instability
  • Though neurovascular exam

Evaluation

Coronal view of knee CT showing salter harris II fracture of the proximal tibial epiphysis[4]

Radiographs

  • Standard Radiographs Knee
    • Sufficient to make the diagnosis
  • Findings
    • Displacement of fracture fragments
    • Use salter harris classification

CT

  • Can help better assess fracture displacement
  • Especially useful for SH III, IV fractures

Ankle Brachial Index

  • Consider obtaining ABIs since proximal tibial physeal injuries can mimic knee dislocation
  • Can reduce the need for unnecessary CTs in pedaitric patients

Classification


Management

Nonoperative

  • Indications
    • Nondisplaced fractures (< 2mm)
    • Stable SH type I, II fractures
  • Reduce with traction, gentle flexion
  • Long Leg Cast
    • In slight flexion for 6 weeks

Operative

  • Indications
    • Unstable SH I, II fractures
    • Redisplacement following closed treatment
    • Irreducible fractures
    • Displaced SH III, IV fractures
    • Vascular injuries
  • Technique
    • CRPP
    • ORIF

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Needs to be updated

Complications

  • Mimic of Knee Dislocation
    • Can have peroneal nerve or popliteal injuries
    • Occurs in about 7% of cases[5]
  • Acute Compartment Syndrome
  • Loss of reduction
    • Following closed reduction, non op management
  • Growth disturbance
    • Leg length discrepancy or angular deformities
    • More common in open fractures
  • Ligamentous instability

See Also

Internal

External


References

  1. Little, Rhianna M., and Matthew D. Milewski. "Physeal fractures about the knee." Current reviews in musculoskeletal medicine 9 (2016): 478-486.
  2. Mubarak, Scott J., et al. "Classification of proximal tibial fractures in children." Journal of children's orthopaedics 3.3 (2009): 191-197.
  3. Nanni, M., et al. "Stress-induced Salter-Harris I growth plate injury of the proximal tibia: first report." Skeletal radiology 34 (2005): 405-410.
  4. Image courtesy of orthobullets, "proximal tibial epiphyseal injury
  5. Guled, Uday, et al. "Proximal tibial and fibular physeal fracture causing popliteal artery injury and peroneal nerve injury: A case report and review of literature." Chinese Journal of Traumatology 18.04 (2015): 238-240.
Created by:
John Kiel on 22 March 2023 15:26:26
Authors:
Last edited:
22 March 2023 16:16:31
Categories:
Knee | Lower Extremity | Trauma | Pediatrics | Fractures | Acute