Salter-Harris Type III and IV Medial Malleolar Fractures

Abstract

Salter-Harris type III and IV medial malleolar fractures (MacFarland fracture) is a joint fracture of the ankle in children. The fracture line passes through the medial part of the lower epiphyseal disk of the tibia. Prognosis is dominated by later risk of misalignment and osteoarthritis. The aim of this study was to evaluate the functional and radiological outcome of these fractures. We retrospectively analyzed the cases of 48 children with MacFarland fractures (31 boys and 17 girls), mean age at the time of trauma 11 years 6 months (range, 8-15 years). The fractures were classed into two groups according to the Salter and Harris classification for epiphyseal detachment: Salter III (30 cases) and Salter IV (18 cases). Surgical treatment was given in all cases (46 screw fixations, 2 pin fixations). Three outcome categories were used: good (no pain, no stiffness, no limp, no misalignment, no surgical complication, no healing problem), fair (pain and/or stiffness and/or limp and/or healing problem without misalignment, no surgical complication), and poor (misalignment or surgical complication). Mean follow-up was 3 years and 3 months (24-94 months). Twenty-eight children were skeletally mature at the longest follow-up. The three-month postoperative assessment showed 35 patients with good results and 13 children with fair results. Ankle stiffness was noted in 6 cases, ankle pain in 4 cases, wound healing complications in 4 cases, limp in 1 case, and snapping in 1 case. The long-term outcome was considered good for 45 patients, fair for 2 patients (1 wound adherence and 1 hypertrophic scar tissue), and poor for 1 patient (6-degree varus deformity). We did not note leg-length discrepancy or malunion at the longest follow-up. Our results show that growth arrest after MacFarland fracture is no fate. We used surgery more than is generally reported by other teams, opting for surgery as soon as the displacement was >or=1 mm. Surgical treatment was arthrotomy in all cases to achieve anatomical reduction under direct view, followed by osteosynthesis. We believe that it is difficult to evaluate if the reduction is perfect under the control of the intensifier screen alone. Arthrotomy did not lead to ankle stiffness, in any of our patients at longest follow-up.

Displaced juvenile Tillaux fractures

“…The lack of complications after surgery at the longest follow-up suggests that open reduction with internal fixation is a safe procedure for treatment of this type of fracture [21]. …”

“…1983 [24]8–––––––NoCottalorda J. et al. 2008 [21]30ORIF–––––Mean 3 yearsNoKaya A. et al. 2007 [11]10ORIFNot neededYes10° loss of plantar flexion in 2 patients, in 1 patient limitation of recreational activitiesAOFAS mean 99.36 weeksMean 54 monthsYesSchlesinger I. et al.…”

Physeal injuries of the distal tibia: long-term results in 376 patients

“…The consequence is that the larger the fracture gap, the bigger the bone bridge. Therefore, displaced type III and IV Salter-Harris fractures require an early anatomical reduction by closed or open means [16].…”

Foot and ankle fractures during childhood: review of the literature and scientific evidence for appropriate treatment

“…In intra-articular fractures, open reduction is recommended for those with a displacement measuring 2 mm or more 14 ; however, some authors argue that this procedure should be performed in fractures greater than 1 mm 17, 18…”

“…When instability is present, which requires implants to be passed through the growth plates, this should be made with Kirschner wires only temporarily 14, 17, 18…”