The Pediatric Triplane Ankle Fracture

1. The Pediatric Triplane Ankle Fracture Mitchell Goldflies, M.D.

2. Overview • Introduction • History • Pathophysiology • Diagnosis • Treatment • Closed • Open • Discussion

3. Pediatric Triplane Ankle Fracture • Complex fracture • Difficult to define according to Salter-Harris classification

4. Pediatric Triplane Ankle Fracture con’t • Meets three-plane criterion • Represents 5 – 10% of pediatric intra-articular ankle injuries • Presents in children age 12 to 15 years of age • Higher incidence among boys • Treatment: • Nondisplaced triplane/extra-articular injuries: • Immobilization in long leg cast • Displaced: • Open reduction and internal fixation

5. History • Lynn • 1972 • Termed injury pattern distal tibial epiphyseal • Produced by combination of mechanisms and characteristic asymmetric pattern of closure

6. History con’t • Marmor • Three fragments requiring cortical screw fixation found

7. Pathophysiology • Susceptible during transitioning skeletal maturity: • Girls:12 to 14 years of age • Boys:13 to 15 years of age • Not younger then age 10 or older than 16.7 years

8. Pathophysiologycon’t • Sustain injury during athletic activity or consequence of fall • Increased incidence among skateboarding, roller skating, inline skating, ice skating, and snowboarding

9. Pathophysiology con’t • Three fracture fragments: • Fracture fragments mimic the juvenile Tillaux fracture • posterior and medial fragments with a metaphyseal spike, and the tibial metaphysis • Fibular fracture in approximately 50% of triplane ankle fractures

10. Pathophysiology con’t • Two fracture fragments: • Lateral: • coronal fragment posterolateral • Medial: • coronal fragment posteromedial • intra- and extra-articular intramalleolar variants have been described

11. Pathophysiology con’t • Quadruple fracture fragments: • External rotation and vertical compression proposed as mechanism for injury

12. Diagnosis • Radiographs • Do not consistently demonstrate the number of fracture fragments • Anterposterior radiographs: • triplane fracture has appearance of Salter-Harris type III • Lateral radiographs: • triplane fracture has appearance of Salter-Harris type II

13. Diagnosis con’t • CT Scans • Used to: • identify configuration of the facture • aid in evaluating residual displacement, • aid in preoperative planning • Three-point star configuration noted

14. Diagnosiscon’t • MRI • Used for: • complex fractures • fractures of uncertain classification based on radiographs

15. Diagnosis con’t • Brown et al study • 51 children aged 10 to 17 years • Most frequent: two-fragment pattern with medial epiphyseal extension (33/51 children) • Three-fragment patterns seen • Extension to medial malleolus evident (12 children)

16. Treatment • Selection based on: • Fracture is nondisplaced or displaced • Magnitude of displacement • Intra- versus extra-articular nature of injury • Fractures with >2mm intra-articular step-off require reduction (closed or open)

17. Treatment – Closed • Nondisplaced triplane and extra-articular fractures (<2mm displacement): • Managed with long leg cast • Closed reduction performed under general anesthesia with axial traction on the ankle and internal rotation of the foot • Reduce fibular fracture first • Medial fractures: • external rotation foot position • Lateral fractures: • internal rotation foot position

18. Treatment – Closed con’t • Nondisplaced triplane and extra-articular fractures (>2 mm displacement): • Requires open or closed reduction • Nondisplaced triplane and extra-articular fractures (>3 mm displacement): • Closed reduction not successful • Extra-articular variants • Nonsurgical management

19. Treatment - Open • ORIF • Anterolateral approach – lateral fractures • Anteromedial approach – medial fractures • Surgical indications: • Fracture displacement >3 mm • Failure to achieve adequate reduction (>2 mm intra-articular step off)

20. Treatment – Open con’t • Arthroscopic reduction and internal fixation of two-part triplane fractures • Advantages: • surgical trauma reduced • clearer identification of fracture fragment orientation • allows for direct visualization of joint congruity and accurate reduction

21. Treatment – Open con’t

22. Discussion • Distal tibial physis • 50% of tibial growth • 4 to 6 mm of longitudinal growth per year • Surgical treatment as measure to prevent residual articular incongruity and long-term degeneration • Most patients return to preinjury activity levels

23. Conclusion • Unique fracture configuration • Not consistent with Salter-Harris classification • Results from asymmetric closures of distal tibial physis and combination of mechanisms • Proper diagnosis and treatment requires: • Evaluation/awareness of associated injury • Understanding of fracture patterns possible • Radiographs and CT necessary to evaluation conduct preoperative planning • Rational treatment approach • Optimal treatment: • Reduction to within 2mm of anatomic

24. Questions?

25. Resources • Journal of the AAOS. Vol. 15. No. 12. pp. 738 – 745.