Salter-Harris I Injury of the Proximal Tibial Physis with Vascular Compromise: A Case Report and Review of Literature

Abstract

Introduction: Physeal injuries of proximal tibia are uncommon and constitute only 1% of all physeal injuries. Major vessel injuries are also rare in children and occur in 0.6% trauma cases, out of which, injuries of popliteal artery comprise only 5%. The combination of these is an extremely rare injury pattern but is potentially limb threatening. Most of the cases of physeal injuries of proximal tibia along with popliteal artery compromise, reported in the literature include Salter Harris (SH) type II, III, and IV patterns (type II being most common) with pure type I being extremely rare. Case Report: We describe a rare posteriorly displaced pure SH I injury of proximal tibial physis with compromised vascularity of the limb. Immediate closed reduction and stabilization with Kirschner wires (K-wires) restored the vascularity of the limb and the patient went on to have a good functional recovery at the last follow-up of 1 year. Conclusion: Vascular injuries occurring in SH 1 proximal tibial physeal fractures are often overlooked or missed due to the relatively benign appearance of slip with no sharp fragments to injure major vessels. Close monitoring of neurovascular status and a low threshold for fixation, for example, with K-wires, are important to prevent limb threatening ischemia in these relatively simple appearing injuries. Keywords: Hyperextension injury, physeal injury, proximal tibia, Salter-Harris 1, vascular injury.

Clinical characteristics of 1124 children with epiphyseal fractures

“…In addition, for children with clinical manifestations of suspected epiphyseal injury (swelling, pain, and mobility impairment), radiographs of the uninjured wrist joint can be taken for comparison, or MRI can be performed when necessary to clarify the site and type of epiphyseal injury [39][40][41].…”

Physeal separation leading to proximal subluxation and popliteal artery thrombosis

“…Ligamentous injuries around the knees and traction injuries to the peroneal nerves are also found in these patients. 7 Guled et al could salvage the limb, but foot drop persisted as in our case. 9 Finally, extended follow-up may be required as PI can cause limb length discrepancy or angular deformities in 25% of cases, necessitating a follow-up to skeletal maturity.…”

“…CT angiography is the best modality of investigation to detect any vascular damage though an ultrasonographic colour Doppler can be helpful. Ligamentous injuries around the knees and traction injuries to the peroneal nerves are also found in these patients 7. Guled et al could salvage the limb, but foot drop persisted as in our case 9.…”

“…Yadav et al described a case of proximal tibial PI where the vascularity returned after closed reduction and pinning. 7 Clement and Goswami described a case of proximal tibial type II PI, where they had a vascular compromise due to compartment syndrome and required four-compartment fasciotomies in addition to reduction and pinning. 8 Guled et al reported a case of proximal tibial and fibular PI causing vascular injury, compartment syndrome and associated peroneal nerve injury.…”

“…The vascular insufficiency could arise due to either direct pressure on the vessel due to displaced fracture fragment, tight compartment (compartment syndrome), an associated arterial injury or a developing thrombosis. Yadav et al described a case of proximal tibial PI where the vascularity returned after closed reduction and pinning 7. Clement and Goswami described a case of proximal tibial type II PI, where they had a vascular compromise due to compartment syndrome and required four-compartment fasciotomies in addition to reduction and pinning 8.…”