In this section
See also: Distal tibia and or fibular physeal fracture
Isolated undisplaced distal fibula physeal - Salter-Harris type I and II
Below-knee cast, non-weight bearing
Fracture clinic within 7-10 days with x-ray
Undisplaced distal tibia physeal
No reduction required. Immobilise in above-knee cast, non-weight bearing
For Salter-Harris type III and IV, discuss with orthopaedic on call service whether CT scan is required to confirm that fracture is truly undisplaced
Fracture clinic within 7 days with x-ray
Displaced distal tibia physeal
Closed reduction with above-knee cast, non-weight bearing.
If reduction not anatomic, discuss with orthopaedic on call service
For Salter-Harris type III and IV, refer to orthopaedic on call service
If treated with closed reduction, fracture clinic within 5 days
If treated operatively, to be arranged by orthopaedic service
Tillaux and triplane fracture <2 mm displacement
No reduction. Above-knee cast, non-weight bearing
Discuss with orthopaedic on call service whether CT scan is required to confirm that fracture is truly undisplaced
Fracture clinic within 7 days
Tillaux and triplane fracture >2 mm displacement
Refer to orthopaedic on call service. Typically requires operative management
To be arranged by orthopaedic service
Distal tibial physeal fractures are classified by the Salter-Harris classification.
They can also be classified by the mechanism or direction of force applied to the injured ankle.
Due to the asymmetrical closure of the distal tibial physis (Figure 1) during early adolescence, transitional fractures can also occur.
Figure 1: Closure of the distal tibial physis begins 1) centrally, followed by 2) medial closure and then 3) lateral closure.
Figure 2: Tillaux fracture.
Figure 3: In a triplane fracture, the fracture line occurs in three planes. 1) Transverse (horizontal) plane - through the growth plate. 2) Coronal plane - through the posterior metaphysis. 3) Sagittal (anteroposterior; AP) plane - within the epiphysis and extending into the joint.
These injuries account for 25% of all physeal injuries. The distal tibia is the third most common physis to be injured.
These injuries commonly occur from a torsional or twisting mechanism about the ankle. The patient will present with a painful, swollen ankle. The foot can be in a deformed position. The patient will not want to weight bear.
Salter-Harris type I distal fibula fractures are the most common ankle fractures. They are often misdiagnosed as an ankle sprain or are missed. Tenderness will be located directly over the lateral malleolus rather than at the lateral ligaments
AP, lateral and mortise views of the ankle should be ordered.
If a tillaux or triplane fracture is suspected, discuss with orthopaedics for need to order a CT scan.
Figure 4: Displaced Salter-Harris type II distal tibia fracture with associated fibula fracture. This was initially managed with closed reduction. Due to poor alignment, a screw was inserted across the fracture site.
Figure 5: Sixteen year old boy with a Salter-Harris type III fracture of the distal tibia. There is also a fracture of the distal shaft of the fibula.
Figure 6: A) X-ray showing tillaux fracture (<2 mm). The fracture was treated non-operatively. B) Axial CT scan of the tillaux fracture, confirming that it is <2 mm displaced.
A B C
Figure 7: Ten year old female with triplane fracture. A) The AP view shows that the fracture is intra-articular. B) The oblique view shows opening of the lateral distal physis. C) The lateral view shows the opening of the physis anteriorly.
All displaced or angulated fractures should have a reduction. Anatomic reduction is preferred. If less than anatomic, discuss with the orthopaedic service.
Indications for prompt consultation include:
Management depends on the location of the fracture, the degree of displacement, and the age of the child.
Type of reduction
Immobilisation method and duration
No reduction required
Above-knee cast, non-weight bearing
Closed reduction. If reduction is not anatomic, discuss with orthopaedic on call service
Above-knee cast, non-weight bearing if managed with closed reduction.
Isolated distal fibula physeal fractures should be followed up in fracture clinic in 7-10 days with repeat x-ray.
For undisplaced distal tibial physeal fractures, follow-up in fracture clinic should occur within 7 days with a repeat x-ray.
For displaced distal tibia physeal fractures managed with closed reduction and immobilisation should be reviewed in fracture clinic within 5 days.
For tillaux and triplane fractures < 2mm displacement, these can be followed up in 7 days.
The child should remain non-weight bearing until instructed by orthopaedics.
There is a risk of compartment syndrome with the cast. Provide parents with "Caring for your child in a leg cast" and warning signs of a tight cast: increased pain despite analgesia, change in toes - colour, perfusion, increased swelling. Any concern should prompt immediate return to ED for evaluation.
The majority of fractures heal well and the outcome is excellent. With any fracture involving the growth plate, there is a risk of growth arrest. With any fracture involving the joint surface, there is a risk of future arthritis in that joint.
See fracture clinics for other potential complications.
Cummings RJ, Shea KG. Distal tibial and fibular fractures. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.967-1016.
Schnetzler KA, Hoernschemeyer D. The pediatric triplane ankle fracture. J Am Acad Orthop Surg 2007; 15(12): 738-47.