AJR 2004; 183:1489-1495
© American Roentgen Ray Society
Analysis of 51 Tibial Triplane Fractures Using CT with Multiplanar Reconstruction
Stephen D. Brown1,
James R. Kasser2,
David Zurakowski2 and
Diego Jaramillo3
1 Department of Radiology, Children's Hospital, 300 Longwood Ave., Boston, MA
02115.
2 Department of Orthopaedic Surgery, Children's Hospital, Boston, MA
02115.
3 Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
19104.
Received February 17, 2004;
accepted after revision April 28, 2004.
Address correspondence to S. D. Brown
(Stephen.brown{at}tch.harvard.edu).
Abstract
OBJECTIVE. We determined the most common patterns of triplane
fractures and assessed the risk of epiphyseal separation in each pattern.
MATERIALS AND METHODS. Fifty-one children with tibial triplane
fractures underwent CT, and the resultant scans underwent multiplanar
reconstruction. We categorized epiphyseal and physeal involvement, the number
of fragments, the appearance of the Salter-Harris fracture in each plane, and
the degree of separation of the epiphyseal fragments.
RESULTS. The classic two-fragment type of fracture with medial
epiphyseal extension occurred most frequently (33/51). All three-fragment
types (8/51) of fractures resulted in a separate anterolateral fragment.
Extension to the medial malleolus was common (12/51). None of the four
reported fractures types involving anteromedial physeal separation was seen.
Children with epiphyseal separation requiring surgery were older (odds ratio
[OR] = 1.7) and had plafond involvement (OR = 5),
CONCLUSION. CT and multiplanar reconstruction of triplane fractures
improve the understanding of patterns of injury and their relative
prevalence.
Introduction
The triplane fracture involves the closing physis of the distal tibia in
adolescents, with fracture lines occurring in the axial, sagittal, and coronal
planes [1,
2]. This complex injury
accounts for 6–10% of distal tibial epiphyseal fractures in this age
group [3,
4]. Eight triplane fracture
configurations have been described, including variants with two, three, and
four fragments; medial variants with a separation through the anteromedial
physeal undulation, or Kump's bump; lateral variants without separation at
Kump's bump; and variants involving the medial malleolus
[2,
5–10].
In the classic lateral two-fragment fracture
(Fig. 1A), a sagittal break
occurs through the bone of the anterior epiphysis; a coronal break, through
the posterior metaphysis; and an axial break, along the physeal cartilage. A
posterolateral fragment, consisting of the posterolateral epiphysis and
posterior metaphysis, separates from the anteromedial epiphysis, which remains
attached to the tibial shaft
[11,
12]. The classic medial
three-fragment fracture (Fig.
1B) separates the physis at Kump's bump (the site of first closure
of the distal tibial physis), defining the following fragments: a free
anterolateral epiphyseal fragment, a fragment involving the rest of the
epiphysis and the posterior metaphysis, and the main fragment corresponding to
the rest of the tibial metaphysis and shaft
[1,
2,
8,
9]. Other three-fragment
fractures described involve a separate anterolateral epiphyseal fragment
without separation at Kump's bump
[2,
5–10]
(Fig. 1C).
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Fig. 1A. —Illustrations of two- and three-fragment triplane fractures
as classically described in literature. In classic lateral two-fragment
fracture, posterolateral fragment, consisting of posterolateral epiphysis and
posterior metaphysis, separates from anteromedial epiphysis, which remains
attached to tibial shaft.
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Fig. 1B. —Illustrations of two- and three-fragment triplane fractures
as classically described in literature. In classic medial three-fragment
fracture, separation of physis at Kump's bump results in one free
anterolateral epiphyseal fragment, one fragment that involves rest of
epiphysis and posterior metaphysis, and one main fragment corresponding to
remaining tibial metaphysis and shaft.
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Fig. 1C. —Illustrations of two- and three-fragment triplane fractures
as classically described in literature. In three-fragment fracture without
separation at Kump's bump, there is one fragment consisting of posterior
epiphysis, posterior metaphysis, and seperate anterolateral epiphyseal
fragment. Anteromedial epiphysis remains attached to anterior tibial
metaphysis.
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Because all triplane fractures involve the epiphysis, physis, and
metaphysis, they are Salter-Harris type IV injuries. However, triplane
fractures appear to conform to different Salter-Harris configurations
depending on the location within the distal tibia and the plane that is being
studied, which makes the evaluation of the anatomy of these complex
multiplanar fractures even more confusing. Radiologic evaluation of triplane
fractures is optimally performed on CT, with its excellent spatial resolution.
Over the past decade, multiplanar reconstruction of CT data has become
routine, greatly enhancing our understanding of this complex injury and
facilitating treatment decisions
[13–15].
To the best of our knowledge, multiplanar CT has not been used systematically
to evaluate triplane fractures. We hypothesize that multiplanar reconstruction
(which depicts physeal separations in the axial plane, something not well done
on radiographs alone or on axial CT images) greatly improves the definition of
triplane fracture patterns. We have analyzed an 8-year experience with
triplane fractures using helical CT and coronal and sagittal reconstructions.
We have categorized the main patterns and the relationship of fracture
patterns to physeal closure.
Materials and Methods
Patients
We searched 900 reports from our radiology database of patients who
underwent CT of the ankle from January 1992 through February 2000 and found 96
patients who had acute ankle fractures. One or both of the authors who are
pediatric radiologists reviewed all 96 CT studies to identify those patients
with triplane fractures. Patients were included in our study if they had a
partially or completely open physis; if the fracture included a break in the
epiphysis, a separation of the physis, and a break in the metaphysis; and if
the fracture lines ran through sagittal, coronal, and axial planes. These
criteria excluded Salter-Harris IV fractures in which the bone is broken in
one plane only. Forty-five patients in whom the fracture was incomplete or for
whom the reconstructions were unavailable or were incomplete were excluded,
yielding a total study population of 51 fractures in 51 children—21 boys
and 30 girls (median age for girls, 12.6 years [age range, from 10 years 6
months to 15 years 4 months] and median age for boys, 14.7 years [age range,
from 12 years 7 months to 16 years 7 months]. All except one of the 51 CT
scans were acquired preoperatively.
CT Technique
The 32 CT examinations performed since 1996 were helical, whereas the 19
examinations performed before that time were axial. All studies were obtained
in the axial plane with 1.0- to 1.5-mm collimation. Other imaging parameters
varied greatly. On average, the technique for acquiring helical images used
120 kVp and 140 mAs, delivering a dose of 3.5 rad to the involved ankle.
Image Analysis
The CT images and multiplanar reformations of each of the 51 fractures were
reviewed retrospectively by one of the pediatric radiologists who was unaware
of the status of the patient. The fractures were evaluated and scored
according to specific imaging findings that were treated as independent
variables. We recorded the number of fragments and the apparent Salter-Harris
configuration in the anterior, posterior, medial, and lateral segments of the
tibia. We tabulated the findings listed in
Table 1. To achieve uniformity,
the radiologists first reviewed 10 studies jointly. Those studies were then
mixed with the remainder of the cases, and all the examinations were reviewed
in a random order, without knowledge of treatment or outcome.
Statistical Analysis
Simple proportions were compared using Fisher's exact test. Univariate and
multivariate logistic regression was performed to identify factors that
differentiated a separation of less than 2 mm from a separation of 2 mm or
greater, which is the criterion usually taken as indicating the need for
surgery. Odds ratios (OR) and 95% confidence intervals (CI) were calculated
for significant predictor variables. Two-tailed values in which p was
less than 0.05 were considered statistically significant. Analysis of the data
was performed using the statistical software package (version 11.5,
Statistical Package for the Social Sciences).
Results
The girls with these fractures were younger than the boys (p <
0.001). The posterior physis was closed completely in 34 (67%) of the 51
patients. Kump's bump was fused in 46 (90%) of the patients. Physeal closure
was observed in 21 (70%) of the 30 girls and 13 (62%) of the 21 boys; this sex
difference in our study was not statistically significant (p = 0.56,
Fisher's exact test).
Epiphyseal Involvement
The epiphyseal fracture extended medially from its anterior aspect in 33
patients (65%). These 33 cases included all the fractures involving the medial
malleolus. The fracture extended both medially and laterally in 17 cases
(33%). Of the 51 fractures, 23 (45%) involved only the plafond (Fig.
2A,
2B,
2C,
2D) and 12 (24%) involved only
the malleolus (Fig. 3A,
3B,
3C,
3D). Sixteen (31%) involved
both the plafond and the malleolus. Thus, the plafond was involved in 39 (76%)
of the 51 fractures.
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Fig. 2A. —Fracture patterns through epiphysis encountered in triplane
fractures. Axial (A) and 3D reconstructed (B) CT images obtained
in 13-year-old boy show most common epiphyseal fracture
pattern—two-fragment fracture in which fracture first runs
anteroposteriorly and then courses medially around Kump's bump anteriorly.
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Fig. 2B. —Fracture patterns through epiphysis encountered in triplane
fractures. Axial (A) and 3D reconstructed (B) CT images obtained
in 13-year-old boy show most common epiphyseal fracture
pattern—two-fragment fracture in which fracture first runs
anteroposteriorly and then courses medially around Kump's bump anteriorly.
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Fig. 2C. —Fracture patterns through epiphysis encountered in triplane
fractures. Axial CT image obtained in 14-year-old boy shows two-fragment
fracture in which epiphyseal fracture courses laterally without coursing
medially. In axial plane, this type of fracture is indistinguishable from
juvenile Tillaux fracture; it occurred only once in this series.
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Fig. 2D. —Fracture patterns through epiphysis encountered in triplane
fractures. Axial CT image obtained in 12-year-old girl shows common
three-fragment fracture, in which fracture extends medially and laterally.
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Fig. 3A. —Extraarticular–Intramalleolar triplane fracture in
15-year-old boy. Axial (A), sagittal (B), and coronal
reformations (C) and coronal 3D reconstruction (D) show triplane
fracture of right ankle that traverses physis and exits through medial
malleolus, without involving plafond.
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Fig. 3B. —Extraarticular–Intramalleolar triplane fracture in
15-year-old boy. Axial (A), sagittal (B), and coronal
reformations (C) and coronal 3D reconstruction (D) show triplane
fracture of right ankle that traverses physis and exits through medial
malleolus, without involving plafond.
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Fig. 3C. —Extraarticular–Intramalleolar triplane fracture in
15-year-old boy. Axial (A), sagittal (B), and coronal
reformations (C) and coronal 3D reconstruction (D) show triplane
fracture of right ankle that traverses physis and exits through medial
malleolus, without involving plafond.
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Fig. 3D. —Extraarticular–Intramalleolar triplane fracture in
15-year-old boy. Axial (A), sagittal (B), and coronal
reformations (C) and coronal 3D reconstruction (D) show triplane
fracture of right ankle that traverses physis and exits through medial
malleolus, without involving plafond.
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Physeal Involvement
All 51 cases showed separation along the anterolateral physis. Anteromedial
separation of the metaphysis from the physis (i.e., separation at Kump's bump)
leaving a separate anteromedial epiphyseal fragment was found in only two
cases (4%) (Fig. 4). In both
cases, the physis around Kump's bump was already fused.
Number of Fragments
Overall, there were 33 classic two-fragment fractures in which the
epiphyseal break traversed at first anteroposteriorly (through the plafond or
the medial malleolus) and then medially without involving Kump's bump and
without traversing laterally (Figs.
1A,
2A, and
2B). In only one case did the
epiphyseal fracture course laterally without a corresponding medial extension,
resulting in a rare two-fragment variant
(Fig. 2C). In a single case, an
isolated fragment including the anterolateral epiphysis resulted in a
two-fragment fracture, with the posterior and anteromedial epiphysis remaining
intact as one structure and attached to the metaphysis. The coronal fracture
through the distal metaphysis involved only the lateral aspect and did not
extend to the medial edge. A more common two-fragment variant (9/51 patients,
18%) occurred when the epiphyseal fracture coursed medially and laterally but
did not break through the lateral cortex.
The most common three-fragment fracture (8/51 patients, 16%) involved
extension of the epiphyseal fracture through the cortex medially and
laterally, resulting in a separate anterolateral fragment, but leaving the
anteromedial epiphyseal fragment attached to the anterior tibial metaphysis,
and the posterior epiphyseal fragment attached to the posterior metaphysis
(Figs. 1C and
2D). This fracture is distinct
from what has been described as the classic three-fragment fracture
(Fig. 1B), which involves a
separation at Kump's bump and which we did not encounter in this series. None
of the four triplane fracture types that include a separation of the
anteromedial physis occurred in this population. Fibular fractures occurred in
18 (35%) of the 51 patients.
Salter-Harris Configuration of Longitudinal Reconstructions
The sagittal and coronal reconstructions were reviewed to analyze the
conformity of the fractures to the appearance of Salter-Harris fracture types
(Fig. 5A,
5B,
5C,
5D). In the lateral sagittal
reconstructions, the fractures had the appearance of a Salter-Harris type II
fracture (Fig. 5A) in 33
patients (65%); this type of fracture was significantly more common than the
next most frequent fracture appearance, which was that of a type IV. In the
medial sagittal reconstructions, the appearance of a Salter-Harris type IV
fracture (Fig. 5B) was
exhibited in 40 patients (78%), which was significantly more common than any
other fracture type (p < 0.001). The next most common medial
fractures conformed to type III, which was seen in five patients (10%), and
type II, which was seen in four patients (8%).
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Fig. 5A. —Reformatted CT images in 14-year-old girl can show appearance
of characteristic Salter-Harris fracture patterns emulated in triplane
fractures. Sagittal reformation of lateral aspect of ankle shows coronal-plane
fracture though posterior tibial metaphysis that appears to have configuration
of Salter-Harris type II fracture.
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Fig. 5B. —Reformatted CT images in 14-year-old girl can show appearance
of characteristic Salter-Harris fracture patterns emulated in triplane
fractures. Sagittal reformation through medial aspect of ankle appears to
conform to Salter-Harris type IV fracture, with coronal-plane fracture
extending though growth plate and into plafond.
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Fig. 5C. —Reformatted CT images in 14-year-old girl can show appearance
of characteristic Salter-Harris fracture patterns emulated in triplane
fractures. Coronal reformatted image shows sagittal-plane intraarticular
fracture of ankle though epiphysis that has appearance of Salter-Harris type
III fracture.
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Fig. 5D. —Reformatted CT images in 14-year-old girl can show appearance
of characteristic Salter-Harris fracture patterns emulated in triplane
fractures. Three-dimensional reconstruction shows sagittal-plane fracture of
ankle through anterior aspect of epiphysis as well as edge of posterior tibial
metaphyseal fracture that is attached to anterolateral epiphysis. This is most
common triplane fracture pattern.
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In the coronal plane, the fractures conformed to the appearance of a
Salter-Harris type III pattern anteriorly in 46 patients (90%)
(Fig. 5C). Posteriorly,
patterns were random, assuming the appearance of a type-II configuration in 15
patients (29%) and a type-IV configuration in 11 patients (22%). In another 16
patients (31%), no fracture was present posteriorly. More than half of the
fractures (27/51, 53%) conformed to a single combined configuration consisting
of a Salter-Harris type-IV fracture appearance medially, type-II appearance
laterally, and type-III appearance anteriorly (Fig.
5A,
5B,
5C,
5D). This configuration was
more common than the next most frequent configuration, which appeared as a
Salter-Harris type-IV configuration laterally (p < 0.001)
(Table 2).
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TABLE 2 Frequency of Triplane Fracture Configurations According to Conformity of
Appearance with Salter-Harris Fracture Type
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Risk Factors for Epiphyseal Separation of 2 mm or Greater
An anterior epiphyseal separation of 2 mm or greater was seen in 31 (61%)
of the 51 fractures. Results of the univariate analysis indicated that plafond
involvement (p = 0.02) and older age (p = 0.03) were each
associated with a separation of 2 mm or greater. Specifically, children with
plafond injuries were estimated to be five times more likely to have a
separation of 2 mm or more than those with only malleolar injuries (OR = 5.0;
95% CI, 2.0–15.0; p = 0.01), and older children were also more
likely to have greater separation (OR = 1.7; 95% CI, 1.2–2.5; p
= 0.03). Stepwise multiple logistic regression confirmed that these two
variables were independently predictive of a separation of 2 mm or greater.
That is, children with triplane fractures through the plafond and those who
are older are at significantly higher risk of greater separation (
2 mm)
regardless of physeal closure, fibular fracture, epiphyseal course, or sex.
These other variables were not predictive of separation (p > 0.20
in each case), and no other significant associations were found among any of
these fracture characteristics.
Discussion
Our study shows that multiplanar reconstruction greatly facilitates an
assessment of the patterns of physeal separation and an understanding of the
patterns of fracture extension. The prevalence of different fracture types
found with this technique differs greatly from what has been reported
previously. The classic two-fragment fracture
(Fig. 1A) is the most common.
All three-fragment fractures had a separate anterolateral epiphyseal fragment,
but the medial epiphysis remained attached to the tibial metaphysis
(Fig. 1C). The classic
three-fragment fracture (Fig.
1B), considered common in prior radiographic series, was not
seen.
To the best of our knowledge, this study of 51 patients with triplane
fractures represents the largest published series of these fractures to date
and is the first one in which all fractures were imaged and analyzed with
coronal and sagittal CT reformations. The number of CT evaluations described
in previous studies has been limited
[11,
15–17].
Furthermore, most studies were published before the development of modern
techniques such as helical CT or MDCT that use much finer collimation,
allowing greater resolution and smoother reformations. Triplane fracture
classifications in the literature lack clarity and consistency because they
are based on either the number of fragments or the course of the epiphyseal
fracture. Contradictions regarding the terminology of triplane fractures
reflect the confusion about the configuration of the fracture planes through
the growth plate and epiphysis
[1,
2]. The terminology is quite
confusing because the fracture line that produces the common
"lateral" fracture actually traverses the epiphysis medially.
There is also confusion regarding the "medial" triplane
fractures, in which there is an anteromedial epiphyseal fragment that has
separated from the metaphysis and that may be separate from or remain attached
to the remaining portion of the epiphysis. This injury has been emphasized in
several articles as well as in textbooks, but in others, it has been described
as extremely rare or has been discarded as nonexistent
[1,
2,
6,
7,
15–17].
Only two of our 55 patients presented with a separation of the anteromedial
epiphysis from the anteromedial metaphysis, and in both patients, normal
physeal fusion was nearly complete. In one of these children, there was
shearing off of only the most anterior aspect of the medial epiphysis of the
fused physis at Kump's bump (Fig.
4). The second separation was more dramatic but was associated
with a fracture through the medial malleolus as well as the plafond. Thus,
nearly half of the triplane fracture types described in the literature,
particularly those in which there is separation of the medial epiphysis from
the distal tibial metaphysis, never occurred in our series
[1,
2,
5,
7].
The propensity of triplane fractures to extend laterally along the physis
is believed to result from the normal sequence of physeal closure at the
distal tibia. Distal tibial physeal fusion begins at a central tibial bump
(Kump's bump) that overlies the medial edge of the talar hump
[15,
18]. The anterolateral physis
is the last portion of the growth plate to close and is therefore the most
predisposed to separation from the metaphysis. We believe that the analysis of
the fractures in three planes allowed us to classify the images more
accurately. Specifically, coronal and sagittal reconstructions showed the
pattern of physeal separation to better advantage, making it clear that the
prevalence of fractures that separate Kump's bump is exceedingly low. We found
the most common configuration to be the classic lateral triplane fracture in
which the anteromedial aspect of the epiphysis is attached to the anterior
metaphyseal fragment (Fig. 1A).
The anterolateral epiphyseal fragment is either associated with the posterior
metaphysis (two-fragment) or isolated from the posterior epiphysis that
remains attached to the posterior metaphysis (three-fragment,
Fig. 1C). The classic
two-fragment configuration was far more common than the three-part fracture, a
finding corroborated by others
[2,
7].
The medial malleolar variety of triplane fracture (Fig.
3A,
3B,
3C,
3D), previously considered
rare, was very common. In one fourth of the patients in our cohort, fractures
involved the medial malleolus but spared the plafond (Fig.
3A,
3B,
3C,
3D). Some authors have stated
that these extraarticular malleolar fractures have a better prognosis
[10]. The presence of a
malleolar fracture was not related to the degree of closure of the growth
plate. Previously, fractures involving the medial malleolus have been found to
be uncommon [10,
19,
20]. Our study suggests
strongly that the incidence of extraarticular intramalleolar triplane
fractures is significantly higher than has been previously reported.
Given the difficulty discussed earlier in describing the fractures
according to the terminology, we propose that a tibial triplane fracture be
described according to the Salter-Harris appearance of the fracture on each of
the four sides of the tibia. The Salter-Harris classification specifically
addresses physeal injuries and is not directly applicable to triplane
fractures. Nonetheless, it has proven to be useful in describing these
injuries [10,
13,
21]. It has been observed
previously that triplane fractures assume the appearance of various
combinations of Salter-Harris fracture patterns, but the application of this
classification has been limited by lack of detailed delineation of the
fracture lines [6,
7], which we accomplished in
our series using the multiplanar reconstructions. Thus, in the sagittal
projection, fractures that assumed Salter-Harris type II configurations
predominated laterally (Fig.
5A), and the type IV configuration predominated medially
(Fig. 5B), corresponding to
the finding on the axial images that the fractures through the epiphysis
coursed medially much more frequently than laterally. The fracture traveling
sagittally through the epiphysis always extended from the anterior aspect of
the growth plate but relatively infrequently extended completely posteriorly.
Instead, it veered laterally or medially, resulting in the predominant
appearance of type III fractures anteriorly in the coronal plane
(Fig. 5C) but type II
fractures posteriorly.
The presence of coincident fibular fractures has been quite variable in
published series. In some series, fibular fractures have been rare or absent
[3,
22]; in others, their
prevalence has been as high as 24–35%
[5,
7,
10]. All but one of these
studies was published before 1989, and the use of CT was limited in all of
them. Our series found fibular fractures in 18 (37.5%) of 51 patients. The use
of modern CT technique may enhance the ability to detect fibular fractures as
well. Fibular fractures are believed to result from more severe rotational
forces and may indicate a lower likelihood for successful closed reduction
[10].
This was a retrospective study, and the treatment of patients varied
according to the clinical judgment of the orthopedic surgeons. Therefore, it
was not possible for us to establish a correlation between the CT appearance
of a fracture and the ultimate outcome. For this reason, we used the
epiphyseal separation of greater than 2 mm as a surrogate for outcome because
patients with these fractures are believed to have worse prognosis and usually
require surgery [7,
10,
12,
20,
21,
23]. We did not evaluate the
role of 3D reconstructions because the original data sets for many of the
patients were not available. However, as the figures illustrate, routine 3D
reconstructions are likely to facilitate the understanding of these injuries.
The median age of the girls with triplane fractures in our study was 2 years
younger than that of the boys. This probably reflects the fact that physeal
closure occurs earlier in girls than in boys. The actual percentage of closed
physes was similar in girls and boys. Triplane fractures, therefore, occur
during physeal closure in both sexes; however, they present earlier in girls
because girls mature before boys.
In conclusion, we believe that our study of 51 patients with triplane
fractures is the largest series to date and the only one in which the CT scans
of every patient were processed as multiplanar reformations. The classic
two-fragment fracture, which has been described as a lateral fracture by some
authors, was the most common configuration encountered. However, the classic
three-fragment fracture never occurred in this series. In fact, of the eight
configurations described in the literature, the four that involve separation
at Kump's bump never occurred, a finding that can be explained by the dynamics
of physeal closure. The only two fractures in which there was a separation
close to Kump's bump were highly atypical injuries that did not conform to any
prior descriptions. Plafond injuries were, as expected, more common than
malleolar injuries, but fractures involving the medial malleolus were more
common than has been previously recognized, probably because of our use of CT.
Fibular fractures were also more common than previously noted. Predictors of a
clinically significant anterior epiphyseal separation were the involvement of
the plafond and occurrence in older children. Finally, although the
Salter-Harris classification cannot be directly applied to triplane fractures,
CT clearly shows that different Salter-Harris fracture configurations are
characteristic of the anterior, posterior, lateral, and medial aspects of the
fractures and can be used to effectively describe them.
References
- Ogden J. Distal epiphyseal and physeal
injuries. New York, NY: Springer-Verlag,2000
- Rogers L. The ankle. Philadelphia, PA:
Churchill Livingstone, 2002
- 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 Bone Joint Surg Am1978; 60:1046
–1050[Free Full Text]
- Mac Nealy GA, Rogers LF, Hernandez R, Poznanski AK. Injuries of the
distal tibial epiphysis: systematic radiographic evaluation.
AJR 1982;138:683
–689[Abstract/Free Full Text]
- van Laarhoven CJ, Severijnen RS, van der Werken C. Triplane
fractures of the distal tibia. J Foot Ankle Surg1995; 34:556
–559, discussion 594–595[Medline]
- Cone RO, Nguyen V, Flournoy JG, Guerra J Jr. Triplane fracture of
the distal tibial epiphysis: radiographic and CT studies.
Radiology1984; 153:763
–767[Abstract/Free Full Text]
- Karrholm J. The triplane fracture: four years of follow-up of 21
cases and review of the literature. J Pediatr Orthop B1997; 6:91
–102[Medline]
- Marmor L. An unusual fracture of the tibial epiphysis.
Clin Orthop1970; 73:132
–135[Medline]
- Lynn MD. The triplane distal tibial epiphyseal fracture.
Clin Orthop1972; 86:187
–190[Medline]
- El-Karef E, Sadek HI, Nairn DS, Aldam CH, Allen PW. Triplane
fracture of the distal tibia. Injury2000; 31:729
–736[Medline]
- Cooperman DR, Spiegel PG, Laros GS. Tibial fractures involving the
ankle in children. The socalled triplane epiphyseal fracture. J
Bone Joint Surg Am 1978;60:1040
–1046[Abstract/Free Full Text]
- Dailiana ZH, Malizos KN, Zacharis K, Mavrodontidis AN, Shiamishis
GA, Soucacos PN. Distal tibial epiphyseal fractures in adolescents.
Am J Orthop 1999;28
: 309–312[Medline]
- Jones S, Phillips N, 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;34:293
–298[Medline]
- Butt WP. Triplane fractures of the distal tibia.
Orthopedics2001; 24:106[Medline]
- Feldman F, Singson RD, Rosenberg ZS, Berdon WE, Amodio J, Abramson
SJ. Distal tibial triplane fractures: diagnosis with CT.
Radiology1987; 164:429
–435[Abstract/Free Full Text]
- Denton JR, Fischer SJ. The medial triplane fracture: report of an
unusual injury. J Trauma1981; 21:991
–995[Medline]
- Seitz WH Jr, LaPorte J. Medial triplane fracture delineated by
computerized axial tomography. J Pediatr Orthop1988; 8:65
–66[Medline]
- Kump WL. Vertical fractures of the distal tibial epiphysis.
Am J Roentgenol Radium Ther Nucl Med1966; 97:676
–681[Medline]
- Shin AY, Moran ME, Wenger DR. Intramalleolar triplane fractures of
the distal tibial epiphysis. J Pediatr Orthop1997; 17:352
–355[Medline]
- Ertl JP, Barrack RL, Alexander AH, VanBuecken K. Triplane fracture
of the distal tibial epiphysis: long-term follow-up. J Bone Joint
Surg Am 1988;70:967
–976[Abstract/Free Full Text]
- Rifkin GB, Lomasney LM, Demos TC, Tonino P. Radiologic case study:
triplane fracture of the distal tibia. Orthopedics2000; 23: 667,
750–752[Medline]
- von Laer L. Classification, diagnosis, and treatment of
transitional fractures of the distal part of the tibia. J Bone
Joint Surg Am 1985;67:687
–698[Abstract/Free Full Text]
- Rapariz JM, Ocete G, Gonzalez-Herranz P, et al. Distal tibial
triplane fractures: long-term followup. J Pediatr
Orthop 1996;16:113
–118[Medline]
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Abstract
Introduction
