The Triplane Fracture Four Years of Follow-up of 21 Cases and Review of the Literature

Continuing Education Action

Triplane ankle fractures are distal tibia physeal fractures that occur in children from 10 to 17 years of age. The physis ossifies in a anticipated society, and transitional ankle fractures occur in this period of incomplete physeal closure. Handling depends on the quality of the reduction of the articular surface with patients with nether 2 mm of displacement managed nonoperatively and those with over 2 mm deportation managed with closed versus open reduction and internal fixation. This activity outlines the evaluation and treatment of triplane ankle fractures and reviews the healthcare team'southward role in managing patients with this condition.

Objectives:

  • Describe the etiology of triplane ankle fractures.

  • Review the pathophysiology of triplane ankle fractures.

  • Identify imaging findings associated with triplane ankle fractures.

  • Explain the interprofessional squad'due south importance in diagnosing and managing the triplane ankle fractures and providing the all-time possible care and education of the patient.

Access costless multiple pick questions on this topic.

Introduction

Growth plate or physeal fractures are mutual injuries in skeletally immature children and adolescents. Most fractures in skeletally immature individuals involve the physis equally this cartilaginous growth middle is the weakest part of the bone and, therefore, more susceptible to injury. Triplane talocrural joint fractures are complex traumatic Salter-Harris IV fractures involving the metaphysis, physis, and epiphysis. The term "triplane" refers to the different orientations of the fracture lines in the distal tibia and represents a frequent diagnostic challenge. The epiphysis is fractured in the sagittal plane and is visible on the anteroposterior (AP) radiograph. The posterior attribute of the metaphysis is fractured in the coronal aeroplane and appreciated on the lateral radiograph. The physis becomes separated in the axial airplane. Treatment is closed reduction or surgical fixation depending on the degree of fracture displacement and articular step-off. The prognosis is excellent, given the triplane ankle fracture is identified and appropriately treated.

Etiology

Triplane ankle fractures occur secondary to ankle trauma in an adolescent during a transitional period of partial physeal closure. Like to Tillaux fractures (transitional Salter-Harris Iii ankle fracture), a supination-external rotational forcefulness is often the reported machinery.[1] Lateral-sided triplane injuries are the nearly mutual as the lateral physis is the weakest and the point of insertion of the stout anterior inferior tibiofibular ligament (AITL).[ii] Medial triplane injuries are rare and occur secondary to an adduction force.[three]

Epidemiology

Ankle injuries are mutual in children and rank second only to injuries to the hand and wrist in those anile 10 to 15 years.[4][5][6] Ankle fractures occur twice equally frequently in males and represent 5% of all pediatric fractures and nine% to 18% of all physeal injuries.[3][5][seven][8][9] Triplane fractures specifically account for 5% to xv% of pediatric talocrural joint fractures and occur in adolescents with a mean historic period of 13 years and five months and a range of 10 to 17 years.[10] Tillaux fractures classically occur in older adolescents with more resulting physeal closure.[2]

Pathophysiology

Skeletal growth typically continues until sixteen years in males and 14 years in females.[2][3] Physeal closure is driven by the hormone estrogen, which gets produced at a younger age in females. Physeal closure occurs in a predictable pattern commencement centrally and progresses anteromedially, posteromedially, and finally laterally.[ii] Once closure of the distal tibia physis begins, in that location is an 18 to 20-month transitional period where closure is incomplete.[11] The unfused portions of the physis are at risk for transitional ankle fractures (triplane and Tillaux) during this period of incomplete growth plate closure. Equally the lateral aspect of the physis is the last to close, lateral epiphysis fractures are much more common than medial patterns.[2]

History and Physical

Adolescents typically written report a twisting injury often during a sporting activity with resulting ankle pain and inability to bear weight. The most common injury machinery is supination and external rotation, while the uncommon medial triplane fracture occurs with an adduction force.[1][3] Swelling or ecchymosis are commonly appreciated, but angular deformity can nowadays in severe injuries. Gross instability is rarely appreciated. Patients will be tender to directly palpation of the physis circumferentially. Every bit in all talocrural joint injuries, the clinician should perform and certificate a thorough neurovascular exam.

Evaluation

Triplane ankle fractures are often under-appreciated with obviously radiographs as each view typically only reveals a single fracture line. AP, mortise, and lateral views are essential. The AP view reveals the sagittal fracture line in the epiphysis (Salter-Harris III), and the lateral view demonstrating the coronal fracture line in the posterior metaphysis (Salter-Harris Two). The mortise radiograph is the best style to appreciate articular deportation on obviously films. Computed tomography (CT) is a vital tool for assessing the exact fracture design, caste of displacement, and articular step-off. Jones et al. demonstrated that all surgeons surveyed changed the starting point and trajectory of planned screw fixation after reviewing the CT scan versus relying on plain radiographs in a series of triplane ankle fractures.[12] Of note, the rare medial triplane fracture differs from the lateral injury in that the metaphyseal fracture occurs in the sagittal plane and the epiphysis injury is more than medial and coronally oriented.

Treatment / Direction

The treatment of triplane talocrural joint fractures depends on the amount of fracture fragment displacement and degree of articular step-off visualized on CT. Nondisplaced and minimally displaced (less than two mm) injuries tin can effectively undergo management with long leg cast immobilization.[3] The reduction maneuver for the classic triplane ankle fracture pattern is ankle internal rotation with a post-reduction CT browse used to assess residual displacement and articular step-off. Rapariz et al. reported excellent outcomes in a series of triplane fractures displaced less than 2 mm, while displaced injuries developed chronic pain and talocrural joint degenerative changes.[13]

Surgery is reserved for triplane fractures with over 2 mm of displacement or injuries that lost reduction during attempted nonoperative management. Fixation is typically accomplished with i or ii screws placed parallel to the physis. Screw placement can be in the metaphysis, epiphysis, or both depending on the fracture blueprint. Spiral types utilized for fixation vary widely no evidence suggesting the superiority of cannulated versus non-cannulated or fully threaded versus partially threaded screw fixation in triplane talocrural joint fractures. Congruity of the articular surface must be restored to optimize outcomes.[11] Care is necessary to place screws perpendicularly as possible to fracture lines to maximize compression and maintain reduction. Clinicians and researchers have described both closed reduction and open up reduction techniques with universally proficient outcomes.[fourteen][xv]

Several clinicians' preferred technique includes percutaneous reduction via minor incisions and fixation with one or two non-cannulated partially threaded 3.five mm screws placed parallel to the physis. The epiphyseal fracture is normally amenable to anterolateral to posteromedial placed screws, while the metaphyseal fragment commonly gets captured with direct anterior to posterior based screws. Care is besides necessary to ensure all spiral threads are by the fracture if using partially threaded screws. [Level 5]

Differential Diagnosis

Differential diagnoses of boyish ankle pain include sprain, Tillaux fracture, triplane fracture, syndesmosis injury, talocrural joint dislocation, subtalar dislocation, calcaneal fracture, talus fracture, malignancy, and infection.

Staging

Triplane ankle fractures are classified based on the number of parts every bit well as the pattern.

Classification by Parts

  • 2-office

    • Function 1: anterolateral and posterior epiphysis

    • Role 2: anteromedial epiphysis

  • 3-part

    • Anterolateral epiphysis

    • Posterior epiphysis

    • Anteromedial epiphysis

Nomenclature by Pattern

  • Lateral

    • Most common

    • Epiphyseal fracture: sagittal airplane

    • Physeal fracture: centric plane

    • Metaphyseal fracture: coronal plane

  • Medial

    • Epiphyseal fracture: coronal airplane

    • Physeal fracture: axial aeroplane

    • Metaphyseal fracture: sagittal plane

  • Intramalleolar

    • Type I: intraarticular, involving weight-begetting surface

    • Type II: intraarticular, non involving weight-bearing surface

    • Type III: extraarticular

Prognosis

Accordingly identified and treated triplane ankle fractures have an excellent prognosis. Physeal harm or premature closure occurs in vii% to 21% of cases.[16][17][18][xix] Many have questioned the significance of preserving the physis, given the limited remaining growth potential. The clinician should clinically follow patients with more than two years of expected growth should be followed clinically. Cooperman et al. reported a serial of 14 triplane ankle fractures with 3 growth disturbance complications.[20] All occurred in patients with more than ii years of growth remaining.[20]

Complications

Complications during nonoperative management include loss of reduction requiring operative fixation, nonunion, malunion, and persistent pain. Surgical agin events are rare and include haemorrhage, infection, nonunion, painful hardware, and transient neuropathy.

Deterrence and Patient Pedagogy

A provider should not assume a pediatric talocrural joint injury is merely a ligamentous sprain. The ligamentous stabilizers of the talocrural joint are stronger than the physis making physeal fracture much more mutual. For appropriately aged patients, scrutinize orthogonal radiographic views in patients with apparent distal tibia Salter-Harris Ii or Three fractures to avoid missing a more significant Salter-Harris Four triplane ankle fracture.

Enhancing Healthcare Team Outcomes

Treatment strategies of triplane ankle fractures depend on the residual deportation following reduction. Mail-reduction CT scans should be obtained to appraise the quality of reduction and articular step-off. Ertl et al. demonstrated that in a series of 23 triplane ankle fractures managed nonoperatively at a unmarried institution, remainder articular displacement of more than 2 mm results in poor outcomes if managed nonoperatively.[xix]

Triplanar ankle fractures crave an interprofessional team approach. The main care practitioner should immediately enlist an orthopedist for evaluation and eventual treatment. Following any procedure or with non-operative management, an orthopedic specialty-trained nurse is invaluable. They can help during surgery, provide post-surgical care, and help with conservative, not-operative management, monitor progress, and coordinate with concrete therapy when necessary, serving as a coordination point between the treating clinician and other providers. This type of interprofessional collaboration will outcome in meliorate outcomes and improved patient intendance. [Level 5]

Review Questions

Ankle fracture

Figure

Ankle fracture. Prototype courtesy S Bhimji MD

Ankle Fracture Weber C Ankle fracture with dislocation

Figure

Ankle Fracture Weber C Ankle fracture with dislocation. Contributed by Marker A. Dreyer, DPM, FACFAS

References

1.

Feldman DS, Otsuka NY, Hedden DM. Actress-articular triplane fracture of the distal tibial epiphysis. J Pediatr Orthop. 1995 Jul-Aug;15(4):479-81. [PubMed: 7560039]

2.

Kay RM, Matthys GA. Pediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):268-78. [PubMed: 11476537]

3.

Wuerz Thursday, Gurd DP. Pediatric physeal ankle fracture. J Am Acad Orthop Surg. 2013 Apr;21(4):234-44. [PubMed: 23545729]

iv.

King J, Diefendorf D, Apthorp J, Negrete VF, Carlson Thou. Analysis of 429 fractures in 189 battered children. J Pediatr Orthop. 1988 Sep-Oct;8(5):585-9. [PubMed: 3170740]

v.

Peterson HA, Madhok R, Benson JT, Ilstrup DM, Melton LJ. Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979-1988. J Pediatr Orthop. 1994 Jul-Aug;xiv(iv):423-30. [PubMed: 8077422]

vi.

Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop. 1990 Nov-Dec;ten(half dozen):713-6. [PubMed: 2250054]

seven.

Mizuta T, Benson WM, Foster BK, Paterson DC, Morris LL. Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop. 1987 Sep-Oct;seven(5):518-23. [PubMed: 3497947]

8.

Peterson CA, Peterson HA. Assay of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972 Apr;12(4):275-81. [PubMed: 5018408]

9.

Worlock P, Stower M. Fracture patterns in Nottingham children. J Pediatr Orthop. 1986 Nov-Dec;6(6):656-60. [PubMed: 3793885]

10.

Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of two hundred and thirty-seven cases in children. J Os Articulation Surg Am. 1978 Dec;60(8):1046-fifty. [PubMed: 721852]

xi.

Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Articulation Surg Am. 2012 Jul 03;94(thirteen):1234-44. [PubMed: 22760393]

12.

Jones S, Phillips North, Ali F, Fernandes JA, Flowers MJ, Smith TW. Triplane fractures of the distal tibia requiring open reduction and internal fixation. Pre-operative planning using computed tomography. Injury. 2003 May;34(four):293-8. [PubMed: 12667783]

13.

Rapariz JM, Ocete G, González-Herranz P, López-Mondejar JA, Domenech J, Burgos J, Amaya S. Distal tibial triplane fractures: long-term follow-upward. J Pediatr Orthop. 1996 Jan-Feb;xvi(1):113-8. [PubMed: 8747367]

14.

Lintecum Due north, Blasier RD. Directly reduction with indirect fixation of distal tibial physeal fractures: a written report of a technique. J Pediatr Orthop. 1996 Jan-Feb;16(ane):107-12. [PubMed: 8747366]

15.

Castellani C, Riedl G, Eberl R, Grechenig S, Weinberg AM. Transitional fractures of the distal tibia: a minimal access approach for osteosynthesis. J Trauma. 2009 Dec;67(6):1371-5. [PubMed: 20009690]

16.

Kärrholm J. The triplane fracture: iv years of follow-upwardly of 21 cases and review of the literature. J Pediatr Orthop B. 1997 April;6(ii):91-102. [PubMed: 9165437]

17.

Kling TF, Bright RW, Hensinger RN. Distal tibial physeal fractures in children that may require open reduction. J Os Joint Surg Am. 1984 Jun;66(5):647-57. [PubMed: 6725313]

eighteen.

El-Karef E, Sadek Hullo, Nairn DS, Aldam CH, Allen PW. Triplane fracture of the distal tibia. Injury. 2000 Nov;31(9):729-36. [PubMed: 11084162]

19.

Ertl JP, Barrack RL, Alexander AH, VanBuecken K. Triplane fracture of the distal tibial epiphysis. Long-term follow-upward. J Bone Articulation Surg Am. 1988 Aug;70(7):967-76. [PubMed: 3403587]

xx.

Cooperman DR, Spiegel PG, Laros GS. Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture. J Bone Articulation Surg Am. 1978 Dec;60(viii):1040-6. [PubMed: 102648]

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Source: https://www.ncbi.nlm.nih.gov/books/NBK547737/

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