No abstract

The incidence and predictors of premature physeal closure (PPC) after pediatric distal tibial fractures were investigated. PPC was defined as evidence of growth plate disturbance on the injured side compared with the uninjured side. Ninety-two fractures were reviewed with at least 1 year of follow-up, or until physiologic closure of the growth plates. Twenty-five fractures (27.2%) were complicated by PPC, as confirmed by CT scan in most cases. Salter-Harris III and IV (medial malleolar type) fractures resulted in the highest percentage of PPC by fracture type (38%). Salter-Harris I and II fractures resulted in PPC in 36% of cases, followed by triplane fractures (21%) and Tillaux fractures (0%). Initial displacement, number of reduction attempts, or treatment method did not significantly affect the incidence of PPC. More anatomic reductions resulted in a statistically significant decrease in PPC rates. Residual physeal gap (>3 mm) following reduction was determined from radiographs in Salter-Harris I and II fractures. If a residual gap was seen on the radiograph, the incidence of PPC increased to 60%; if no gap was present, the incidence decreased to 17%. Open reduction was performed in five Salter-Harris II fractures that had a residual gap. Periosteum was entrapped in the physis in all of these cases. Residual gaps in the physis following closed reduction may represent entrapped periosteum in Salter-Harris I and II fractures. This can lead to a higher incidence of PPC, suggesting that open reduction and removal of the entrapped periosteum may be beneficial.

Flexible intramedullary nail fixation provides excellent fixation in children with unstable tibial shaft fractures, but few published series demonstrate the results and complications with this technique in children. A retrospective review of 19 patients was performed, as well as a biomechanical analysis of two implant configurations. Outcome measures included union rates, residual deformity, and complications. Union occurred in all cases. Five patients (26%) had complications. None required repeat operation. Two (11%) angular deformities (>/=10 degrees) occurred with the medial C and S construct, versus none with the double C. The C and S construct was more stable to mechanical testing with axial and torsional loading. Flexible intramedullary nail fixation is a straightforward technique that reliably produces good results. While the C and S construct was superior in biomechanical testing, the double C construct is more reliable and straightforward and remains by far the authors' preferred technique.

PPC is a common problem following SH type I or II fractures of the distal tibia. Operative treatment may decrease the frequency of PPC in some fractures. Regardless of treatment method, we recommend anatomic reduction to decrease the risk of PPC.

Thoracoscopic anterior release and fusion of the thoracic spine is a safe and effective procedure when combined with posterior instrumentation and fusion. The primary goal of increasing the flexibility of a rigid spine and achieving a solid arthrodesis occurred in the vast majority of cases.