Fractures of the proximal tibia

Proximal Epiphyseal plate

Rare injury, has a higher rate of associated injuries (open fractures, compartment syndrome, and neurovascular injuries) than distal femur fractures due to the higher energy required to produce these fractures.

A particularly dangerous injury is the hyperextension fracture through the proximal tibial growth plate. This is analogous to an adult knee dislocation with the same high risk of neurovascular injury.

Classification

Salter Harris
Displacement - Hyperextension, Varus, Flexion

Treatment

Undisplaced fractures -

Above knee cast, knee flexed 30 degs, check xray 1 week, keep for 6-8 weeks

Displaced fracture:

Most can be treated with reduction and above knee cast.

If unstable post reduction consider smooth K wires inserted from distal to proximal avoiding joint capsule.

Articular injuries require anatomical reduction

Hyperextension injury - BEWARE neurovascular injury, Reduce under GA

Flexing the hip and knee to 45 degrees while applying longitudinal traction.
Hold calf, stabilize distal tibia and pull proximal Tibial metaphysis forward
Above knee cast knee flexed 60 Degs (close attention to circulation, avoid pressure on posterior proxima Tibia
Check x ray next day and 1 week
Extend knee slightly to 30 degs of flexion at 3 to 4 weeks, keep cast 6-8 weeks +- cricket pad splint for few weeks.

Abduction/ Valgus displacement

Aspirate effusion, test MCL
Reduce with longitudinal traction (disimpact growth plate) and gentle varus moulding
Above knee cast 15-20 degress knee flexion
Cast for 6-8 weeks +- cricket pad splint for few weeks

Flexion injury

Reduce with longitudinal traction in extension
Above knee cast in extension 4 to 6 weeks

Complications

Growth disturbance can occur after any physeal injury, the Salter Harris classification is not very useful in predicting growth disturbance after seperation of the proximal tibial epiphysis. Angular deformity (28%) Limb length discrepancy (19%)
BEWARE vascular injury in hyperextension injuries (7%)
Other - anterior compartment syndrome, peroneal nerve palsy, and ligamentous and meniscal injuries.

References

JBJS A, Vol 76 December , 1994.1870-1880; Current Concepts Review. Fractures about the Knee in Children Beaty, James H.; Kumar, Anant.

JBJS- A 84:2288-2300 (2002) The Operative Management of Pediatric Fractures of the Lower Extremity; John M. Flynn, David Skaggs, Paul D. Sponseller, Theodore J. Ganley, Robert M. Kay and K. Kellie Leitch

Curr Opin Orthop, Volume 10(1).February 1999.34-43; Pediatric fractures about the knee; Shaw, Brian A.