What is the best treatment for displaced Salter–Harris II physeal fractures of the distal tibia?

Abstract

Background and purposeThe optimal treatment of displaced Salter–Harris (SH) II fractures of the distal tibia is controversial. We compared the outcomes of operative and nonoperative treatment of SH II distal tibial fractures with residual gap of >3 mm. Factors that may be associated with the incidence of premature physeal closure (PPC) were analyzed.Patients and methodsWe retrospectively reviewed 95 patients who were treated for SH II distal tibial fractures with residual gap of >3 mm after closed reduction. Patients were assigned to 1 of 2 groups: Group 1 included 25 patients with nonoperative treatment, irrespective of size of residual gap (patients treated primarily at other hospitals). Group 2 included 70 patients with operative treatment. All patients were followed for ≥ 12 months after surgery, with a mean follow-up time of 21 months. Logistic regression analyses were performed to identify risk factors for the occurrence of PPC.ResultsThe incidence of PPC in patients who received nonoperative treatment was 13/52, whereas PPC incidence in patients who received operative treatment was 24/70 (p = 0.1). Multivariable logistic regression analysis determined that significant risk factors for the occurrence of PPC were age at injury, and injury mechanism. The method of treatment, sex, presence of fibular fracture, residual displacement after closed reduction, and implant type were not predictive factors for the occurrence of PPC.InterpretationOperative treatment for displaced SH II distal tibial fractures did not seem to reduce the incidence of PPC compared with nonoperative treatment. We cannot exclude that surgery may be of value in younger children with pronation–abduction or pronation–external rotation injuries.

Salter-Harris type II fractures of the distal tibia

“…SH-II distal tibia fractures account for 30% to 40% of physeal ankle fractures in children. [ 3 , 9 ] The reported mean age at injury ranges from 11.6 to 12.6 years [ 3 , 4 , 6 , 8 , 9 , 12 , 13 ] , with concomitant fibula fracture occurring in 22% to 64% of patients. [ 3 , 4 , 13 ] Although historical data from Dugan et al [ 7 ] suggest that SH-II distal tibia fractures are associated with a low rate of PPC (2% to 5%), more recent studies indicate much higher rates, ranging from 17% to 43%.…”

“…[ 3 , 9 ] The reported mean age at injury ranges from 11.6 to 12.6 years [ 3 , 4 , 6 , 8 , 9 , 12 , 13 ] , with concomitant fibula fracture occurring in 22% to 64% of patients. [ 3 , 4 , 13 ] Although historical data from Dugan et al [ 7 ] suggest that SH-II distal tibia fractures are associated with a low rate of PPC (2% to 5%), more recent studies indicate much higher rates, ranging from 17% to 43%. [ 3 , 4 , 6 , 8 , 9 , 12 , 13 ] SH-II fractures of the distal tibia should be regarded as high-risk fractures, or at least as fractures with unpredictable sequelae.…”

“…[ 3 , 4 , 13 ] Although historical data from Dugan et al [ 7 ] suggest that SH-II distal tibia fractures are associated with a low rate of PPC (2% to 5%), more recent studies indicate much higher rates, ranging from 17% to 43%. [ 3 , 4 , 6 , 8 , 9 , 12 , 13 ] SH-II fractures of the distal tibia should be regarded as high-risk fractures, or at least as fractures with unpredictable sequelae. In 1978, Spiegel et al [ 3 ] described SH-II fractures of the distal tibia as unpredictable because fractures that showed little or no displacement developed complications as readily as those that were considerably displaced.…”

The Mid-term outcomes of ankle Dias-Tachdjian PEER physeal fracture in children treat by ORIF with One-stage medial-lateral combined incision

“…Barmada et al [7] made expectant treatment for distal tibial Salter-Harris I and II fractures nding the premature physeal closure in 60% of patients (14/20) with fracture gap >3mm after reduction and 17% of patients (4/24) with fracture gap <3mm. Yet, Park et al [8] found no signi cantly different effects of operative and nonoperative treatment for Salter-Harris II distal tibial fractures with residual gap of >3 mm. Nevertheless, the authors still considered that surgery might reduce the rate of premature physeal closure for PEER fracture for the high rate of premature physeal closure in this type of fracture, although surgery might not be very effective for patients with residual gap>3mm after reduction [9].…”

“…Salter-Harris classi cation is most widely used for physeal fractures; however, it is limited to ankle fracture. In 1978, DIas and Tachdjian [8] modi ed Lauge-Hansen classi cation and grouped the child ankle fractures into four subtypes comprising the Salter-Harris classi cation. PEER fracture is the typical distal tibial Lauge-Hansen I or II fracture complicated with bular fracture.…”