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Pediatric Proximal Tibial Physeal Fracture

 

synonyms: Proximal tibial physeal fracture

Pediatric Proximal Tibial Physeal Fracture ICD-9

  • 823.00(upper end, closed), 823.20(upper end open), 823.02(upper end with fibula fx, closed), 823.22(upper end with fibular fx, open), 823.20(shaft closed), 823.22(shaft closed with fibula fx), 823.30(shaft, open)

Pediatric Proximal Tibial Physeal Fracture Etiology / Epidemiology / Natural History

  • Uncommon
  • Boys are 12 to 14 years.
  • Generally occurs from indirect forces such as valgus load to the knee or hyperextension injuries

Pediatric Proximal Tibial Physeal Fracture Anatomy

  • Proximal tibial physis is protected by the ligamentous attachments on the proximal tibia distal to the epiphysis
    and by the proximal tibiofibular joint.
  • The popliteal artery is tethered to the posterior tibial metaphysis by its articular branches and proximal tibial physeal fractures can causes local compression or laceration of the popliteal artery.

Pediatric Proximal Tibial Physeal Fracture Clinical Evaluation

  • Leg pain, inability to bear weight, contusions, deformity.
  • May and skin dimpling anteriorly in hyperextension injuries.
  • Evaluate extent of soft tissues, open fracture injury
  • Document neurovascular exam before and after any treatment
  • Evaluate for Compartment Syndrome.

Pediatric Proximal Tibial Physeal Fracture Xray / Diagnositc Tests

  • A/P and Lateral of tibia, must include ankle and knee
  • CT if intraarticular extention is a concern.

Pediatric Proximal Tibial Physeal Fracture Classification / Treatment

  • Salter-Harris I or II proximal tibial physeal fracture: most common; closed reduction and long-leg casting.  Consider percutaneous metaphyseal pinning if unstable after reduction.  Smooth pins are placed in the metaphyseal fragment parallel to the physis in type II fractures.  Transphyseal pins are required for unstable type I fractures.  Open reduction indicated if closed reduction is unsuccessful (generally caused by periosteal flap interposition).
  • Salter-Harris III or IV proximal tibial physeal fracture: uncommon; generally treated with ORIF with smooth pins parallel to the physis. 

Pediatric Proximal Tibial Physeal Fracture Associated Injuries / Differential Diagnosis

  • Pediatric tibial shaft fracture
  • Pediatric proximal tibial metaphyseal fracture
  • Vascular injury: popliteal artery is tethered by the major branches near the posterior aspect of the proximal tibial epiphysis.

Pediatric Proximal Tibial Physeal Fracture Complications

  • Limb-length inequality-20% (Shelton WR, JBJS 1979;61A:167)
  • Growth arrest
  • Angular deformity
  • Infection (open fractures)

Pediatric Proximal Tibial Physeal Fracture Follow-up Care

  • Followly weekly initially to ensure reduciton is maintained.

Pediatric Proximal Tibial Physeal Fracture Review References

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