Phil Hyun Chung; Suk Kang; Jong Pil Kim; Young Sung Kim; Jae Woo Cho

doi:10.12671/jkfs.2011.24.1.73

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Original Article
Interposition of Periosteum in Distal Tibial Physeal Fractures of Children: Phil Hyun Chung, M.D., Suk Kang, M.D., Jong Pil Kim, M.D., Young Sung Kim, M.D., Jae Woo Cho, M.D.; Journal of the Korean Fracture Society 2011;24(1):73-78.
DOI: https://doi.org/10.12671/jkfs.2011.24.1.73
Published online: January 21, 2011

Department of Orthopedic Surgery, College of Medicine, Dongguk University, Gyeonju, Korea.

Address reprint requests to: Young Sung Kim, M.D. Department of Orthopedic Surgery, College of Medicine, Dongguk University, 1090-1, Seokjang-dong, Gyeonju 780-350, Korea. Tel: 82-54-770-8222·Fax: 82-54-770-8378, kys7374@freechal.com

• Received: September 30, 2010 • Accepted: October 27, 2010

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Abstract
REFERENCES

Abstract

Purpose
To evaluate the factors influencing periosteal interposition in distal tibial physeal fractures of children.
Materials and Methods
34 cases of distal tibial physeal fractures were analysed. We confirmed the presence of periosteal interposition with MRI in all cases and accessed the relationship between periosteal interposition and gender, age, cause of injury, type of fracture, degree of initial displacement and after closed reduction.
Results
9 (26.5%) of 34 fractures had interposed periosteum. There was no statistically significant correlation between periosteal interposition and gender, age, cause of injury (p>0.05). 5 (83.3%) of 6 pronation-eversion-external rotation type of fractures according to Dias-Tachjian classification had interposed periosteum and that was a statistically significant correlation (p=0.006). As Salter-Harris type was toward to high degree, there were decreasing tendency of periosteal interposition (p=0.026). There was high rate of periosteal interposition in case of displacement more than 2 mm in each initial and after closed reduction (p<0.05).
Conclusion
There was high incidence of periosteal interposition in pronation-eversion-external rotation type with displacement more than 2 mm in distal tibial physeal fractures of children. But, periosteal interposition could occur in fractures with mild displacement less than 2 mm, if initial fracture displacement was more than 2 mm, the methods of treatment should be decided after confirm the presence of periosteal interposition with MRI after closed reduction.
Key words: Child, Distal tibia, Physeal fracture, Periosteal interposition

REFERENCES

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3. Dias LS, Tachdjian MO. Physeal injuries of the ankle in children: classification. Clin Orthop Relat Res, 1978;136:230-233.
4. Gruber HE, Phieffer LS, Wattenbarger JM. Physeal fractures, part II: fate of interposed periosteum in a physeal fracture. J Pediatr Orthop, 2002;22:710-716.
5. Hahn SH, Yang BK, Yi SR, Yoo SH. Treatment of distal tibial epiphyseal fracture salter-harris type I & II. J Korean Soc Fract, 1999;12:1065-1070.
6. Kim JR, Pyo SH, Hwang BY. Results of treatment for epiphyseal injuries of the ankle in children. J Korean Soc Fract, 2000;13:680-685.
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9. Kling TF Jr, Bright RW, Hensinger RN. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am, 1984;66:647-657.
10. Leary JT, Handling M, Talerico M, Yong L, Bowe JA. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop, 2009;29:356-361.
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Fig. 1

A 7 year-old boy sustained physeal injury of the ankle.

(A) According to the Dias-Dachjian classification, initial radiographs show pronation-eversion-external rotation type of distal tibial physeal fracture.

(B) Post-reduction radiographs demonstrate satisfactory closed reduction. Distal tibia fracture has Thurston-Holland fragment (arrow), it representing Salter-Harris type II injury.

Fig. 2

Coronal and sagittal T2W MRI show the interposed periosteum in antero-medial aspect of distal tibial physeal fracture (arrow).

Fig. 3

(A) Intraoperative finding gross photography shows the interposed periosteun.

(B) The probe is inserted into fractured physeal space.

(C) The interposed periosteum was extracted.

(D) The extracted periosteum was repaired with absorbable suture.

Fig. 4

(A) The distal tibial physeal fracture was fixed with 2 smooth pins.

(B) At postoperative 4 years, the radiographs show no deformity or premature physeal closure.

Table 1

Periosteal interposition in Dias-Tachjian classification (p=0.006)

^*PEER: Pronation-Eversion-External Rotation, ^†SI: Supination-Inversion, ^‡SER: Supination-External Rotation, ^§SP: Supination-Plantar Flexion.

Table 2

Periosteal interposition in Salter-Harris classification (p=0.026)

Table 3

Relationship between initial displacement and periosteal interposition (p=0.000)

Table 4

Relationship between displacement after closed reduction and periosteal interposition (p=0.007)

Figure & Data

REFERENCES

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Interposition of Periosteum in Distal Tibial Physeal Fractures of Children

J Korean Fract Soc. 2011;24(1):73-78. Published online January 31, 2011

DOI: https://doi.org/10.12671/jkfs.2011.24.1.73

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Interposition of Periosteum in Distal Tibial Physeal Fractures of Children

Fig. 1 A 7 year-old boy sustained physeal injury of the ankle. (A) According to the Dias-Dachjian classification, initial radiographs show pronation-eversion-external rotation type of distal tibial physeal fracture. (B) Post-reduction radiographs demonstrate satisfactory closed reduction. Distal tibia fracture has Thurston-Holland fragment (arrow), it representing Salter-Harris type II injury.

Fig. 2 Coronal and sagittal T2W MRI show the interposed periosteum in antero-medial aspect of distal tibial physeal fracture (arrow).

Fig. 3 (A) Intraoperative finding gross photography shows the interposed periosteun. (B) The probe is inserted into fractured physeal space. (C) The interposed periosteum was extracted. (D) The extracted periosteum was repaired with absorbable suture.

Fig. 4 (A) The distal tibial physeal fracture was fixed with 2 smooth pins. (B) At postoperative 4 years, the radiographs show no deformity or premature physeal closure.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Interposition of Periosteum in Distal Tibial Physeal Fractures of Children

Table 1

Periosteal interposition in Dias-Tachjian classification (p=0.006)

^*PEER: Pronation-Eversion-External Rotation, ^†SI: Supination-Inversion, ^‡SER: Supination-External Rotation, ^§SP: Supination-Plantar Flexion.

Table 2

Periosteal interposition in Salter-Harris classification (p=0.026)

Table 3

Relationship between initial displacement and periosteal interposition (p=0.000)

Table 4

Relationship between displacement after closed reduction and periosteal interposition (p=0.007)

Table 1 Periosteal interposition in Dias-Tachjian classification (p=0.006)

^*PEER: Pronation-Eversion-External Rotation, ^†SI: Supination-Inversion, ^‡SER: Supination-External Rotation, ^§SP: Supination-Plantar Flexion.

Table 2 Periosteal interposition in Salter-Harris classification (p=0.026)

Table 3 Relationship between initial displacement and periosteal interposition (p=0.000)

Table 4 Relationship between displacement after closed reduction and periosteal interposition (p=0.007)