n Feature Article

Surgical Indications for Distal Tibial

Epiphyseal Fractures in Children
Haoqi Cai, MD; Zhigang Wang, MD; Haiqing Cai, MD

abstract

The goal of this study was to investigate the treatment methods and surgical indica-
tions of distal tibial epiphyseal fractures in children. Two hundred eighty-six children
with distal tibial epiphyseal fractures were included in the study. Among these pa-
tients, 202 were male and 84 were female. Mean age was 11.7 years. A retrospective
study on the postoperative long-term complications and related risk factors was per-
formed. Treatment methods were determined according to the distance of fracture
displacement. A long-leg cast was applied after closed reduction for patients with
primary fracture displacement less than 2 mm. For cases with more than 2 mm of
fracture displacement, K-wire or screw fixation was performed. For patients with
less than 2 mm of fracture displacement, closed reduction and internal fixation was
performed. Open reduction was performed in patients with more than 2 mm of
fracture displacement, even after closed reduction. Mean follow-up was 6.4 years.
Premature physeal closure occurred in 42 patients, and, among them, varus and val-
gus ankle deformities occurred in 16 patients. Associated fibular fractures and cast
immobilization after closed reduction for Salter-Harris type III and IV fractures were
risk factors for premature physeal closure. It is not effective to determine the surgi-
cal procedure according to the distance of preoperative fracture displacement for
improving the prognosis of distal tibial epiphyseal fractures in children. Conservative
treatment should be performed for patients with Salter-Harris type I and II distal tibial
epiphyseal fractures, and surgery should be performed in patients with Salter-Harris
type III and IV distal tibial epiphyseal fractures to reduce the incidence of premature
physeal closure. [Orthopedics. 2015; 38(3):e189-e195.]

The authors are from the Department of Orthopedic Surgery, Shanghai Children’s Medical Center,
School of Medicine, Shanghai JiaoTong University, Shanghai, China.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Zhigang Wang, MD, Department of Orthopedic Surgery,
Shanghai Children’s Medical Center, School of Medicine, Shanghai JiaoTong University, No. 1678,
Pudong Dongfang Rd, 200127, Shanghai, China (zhigang_wangmd@163.com).
Received: January 14, 2014; Accepted: May 13, 2014.
doi: 10.3928/01477447-20150305-55

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n Feature Article
T
he distal tibial epiphysis is the third
most vulnerable epiphysis,1-4 and
distal tibial epiphyseal injuries ac-
count for 11% of all epiphyseal injuries.5,6
The main complications of distal tibial
epiphyseal injuries include premature
physeal closure and joint deformity. The
incidence of premature physeal closure
after fracture in this site has been reported
to be 17% to 60%.7-9 In addition, distal
tibial epiphyseal fractures are the most
common cause of deformity after fracture
in children.10 The treatment strategy and
surgical indication are still controversial.
The authors performed a retrospec-
tive study on the postoperative long-term
complications and related risk factors for
286 patients with distal tibial epiphyseal
fractures who were treated in the authors’
institution during the past 10 years to in-
vestigate the treatment strategy and surgi-
cal indication for this kind of fracture.
Materials and Methods
Inclusion Criteria
Two hundred eighty-six patients with
distal tibial epiphyseal fractures were in-
cluded in the current study. Patients with
open fractures, patients who were treated
5 days after fracture, and patients with less
than 6 months of follow-up were excluded.
Conservative Treatment
Conservative treatment was de-
termined according to the distance of
Figure 1: Surgical procedures performed based on type of injury sustained.
e190
fracture displacement on preoperative
anteroposterior radiographs or computed
tomography (CT) images. If the distance
was less than 2 mm, a long-leg cast was
applied for 6 weeks after manual reduc-
tion. Anteroposterior radiographs of the
ankle were taken 5, 10, and 15 days after
cast immobilization. If the fracture dis-
placement was more than 2 mm, surgery
was performed.
Surgical Indication
If the preoperative fracture displace-
ment was less than 2 mm, closed reduc-
tion was performed after anesthesia. If
the fracture displacement was more than
2 mm after reduction and the articular
surface was even, then K-wire fixation
or screw fixation was performed. If the
fracture displacement was still more than
2 mm after reduction, open reduction and
internal fixation (ORIF) was performed.
A long-leg, non–weight-bearing cast was
applied for 4 weeks postoperatively and
was changed into a short-leg, weight-
bearing cast for 2 weeks. If the K-wire
was used for internal fixation, it was re-
moved 6 weeks postoperatively. If a screw
was used for fixation, it was removed 2 to
6 months postoperatively.
Long-term Follow-up
Anteroposterior radiographs of the
ankle were taken 5, 10, and 15 days after
fracture. Computed tomography was not
obtained as a routine examination but af-
ter the appearance of premature physeal
closure on radiographs to identify the
range of the bony bridge. Magnetic reso-
nance imaging (MRI) was performed as
needed.
Data Collection
The collected data included sex, age,
age of contralateral physeal closure, injury
mechanism, state of the fibula, distance of
the primary fracture displacement, distance
of the fracture displacement after closed re-
duction, surgical method, long-term com-
plications, and secondary surgery.
Statistical Analysis
The authors analyzed the following
possible risk factors for premature physe-
al closure: age, sex, side of injury, primary
fracture displacement, fracture displace-
ment after closed reduction, associated
distal fibular fractures, and ORIFs. These
analyses were performed using the t test
(for measurement data) and Fisher’s exact
probability test (for numeration data). A
P value less than .05 was considered sta-
tistically significant. SPSS version 16.0
statistical software (SPSS Inc, Chicago,
Illinois) was used for all analyses.
Results
Among 286 patients, 202 were males
and 84 were females. Mean age was 11.7
years. Mean follow-up was 6.4 years.
Copyright © SLACK Incorporated
 n Feature Article

Surgical Procedures
Surgery was performed if the preop-
erative fracture displacement was more
than 2 mm. Closed reduction and internal
fixation (CRIF) was performed for 4 pa-
tients with Salter-Harris type I fractures.
Among 191 patients with Salter-Harris
type II fractures, 70 underwent cast im-
mobilization, 73 underwent CRIF, and 48
underwent ORIF. Among 53 patients with
Salter-Harris type III fractures, 9 under-
went cast immobilization, 12 underwent
CRIF, and 32 underwent ORIF. Among 38
patients with Salter-Harris type IV frac-
tures, 8 underwent cast immobilization, 9
underwent CRIF, and 21 underwent ORIF
(Figure 1). Figure 2: The correlation between the incidence of premature physeal closure and the distance of primary
fracture displacement.
Treatment Outcomes and Postoperative
Complications
Premature physeal closure was ob-
Table 1
served in 42 of 286 patients. Varus and
valgus ankle deformities were observed in Characteristics of Study Population (N=286)
16 patients. No Premature Epiphysis Premature Physeal
Variable Closure (n=244) Closure (n=42) P

Further Surgery Age, mean±SD, y 11.7±3.3 11.9±3.7 NS

Bony bridge resection was performed Male, No. 172 30 NS

in 24 of 42 patients with premature physe-
al closure. Supramalleolar osteotomy was
performed in 5 patients, and epiphyseal
arrest was performed in 2 patients.
Statistical Analysis
Two hundred eighty-six patients were
divided into 2 groups based on whether
there was postoperative premature phy-
seal closure. There were no significant
differences between the 2 groups with
respect to sex, injury side, age, distance
of primary fracture displacement, and dis-
tance of fracture displacement after closed
reduction. However, fibular fracture was a
risk factor for premature physeal closure
(Figure 2; Table 1).
A patient with preoperative fracture
displacement less than 2 mm underwent
CRIF; the premature physeal closure was
observed during follow-up (Figure 3). In
other children with preoperative fracture
displacement of more than 2 mm, the pre-
Right-sided injuries, No. 138 26 NS
Primary fracture displace- 7.3±2.3 8.2±3.8 NS
ment, mean±SD, mm
Fracture displacement after 3.1±2.7 3.8±3.6 NS
closed reduction, mean±SD,
mm
Associated distal fibular frac- 56 23 <.01
tures, No.
ORIFs, No. 89 12 NS
Abbreviations: NS, not significant; ORIFs, open reduction and internal fixations.
mature physeal closure occurred despite seal closure, the authors observed signifi-
active open anatomic reduction (Patients cantly different results. There were no sig-
2 and 3; Figures 4-5). nificant differences between the 2 groups
The authors’ data showed that prema- with respect to age, sex, injury side, and
ture physeal closure may be related to the distance of preoperative fracture displace-
Salter-Harris classification. When the cas- ment. However, the incidence of prema-
es were divided into 2 groups according ture physeal closure in the group of Salter-
to the Salter-Harris classification (type I/II Harris type I/II fractures was significantly
fractures vs type III/IV fractures) and the higher than that in the group of Salter-
cases in each group were further divided Harris type III/IV fractures. In addition,
into 2 subgroups based on premature phy- there were no significant differences be-

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n Feature Article

Figure 5: Three-dimensional computed tomogra-

Figure 3: Anteroposterior (left) and lateral (right)
radiographs of the ankle of a 10-year-old boy with
a Salter-Harris type III fracture and associated
fibular fracture (A). Anteroposterior (left) and lat-
eral (right) radiographs showing K-wire fixation
performed for closed reduction because displace-
ment was less than 2 mm (B). Lateral (left) and
anteroposterior (right) radiographs showing pre-
mature physeal closure at 1 year postoperatively
(C). Computed tomography scan (upper) and mag-
netic resonance image (lower) showing premature
physeal closure of the distal tibia (D). Lateral (left)
and anteroposterior (right) radiographs showing
bony bridge resection (E). Bilateral full-leg stand-
ing radiograph taken 1 year after bony bridge re-
section showing symmetrical legs (F).
tween the 2 subgroups in the Salter-Harris
type I/II group with respect to age, sex,
injury side, and distance of preoperative
fracture displacement, and the surgical
procedure did not significantly affect the
Figure 4: Anteroposterior (left) and lateral (right)
radiographs of the ankle of a 10-year-old boy
with a Salter-Harris type II fracture and associ-
ated fibular fracture (A). Computed tomography
scan showing displacement of more than 2 mm
after reduction (B). Anteroposterior (left) and lat-
eral (right) radiographs after open reduction and
screw fixation (C). Anteroposterior (left) and later-
al (right) radiographs showing premature physeal
closure 1 year postoperatively (D). Computed to-
mography scan (upper) and magnetic resonance
image (lower) showing premature physeal closure
of the distal tibia (E). Bilateral full-leg standing ra-
diograph taken at follow-up showing symmetrical
legs (F).
incidence of premature physeal closure.
There were no significant differences be-
tween the 2 subgroups in the Salter-Harris
type III/IV group with respect to age, sex,
injury side, and distance of preoperative
phy scan of the ankle of a 9-year-old boy with a
Salter-Harris type II fracture and associated fibu-
lar fracture (A). Lateral (left) and anteroposterior
(right) radiographs after open reduction and K-
wire fixation (B). Anteroposterior (left) and lateral
(right) radiographs showing premature physeal
closure 15 months postoperatively (C). Computed
tomography scan (left) and magnetic resonance
image (right) showing premature physeal closure
of the distal tibia (D). Anteroposterior (left) and lat-
eral (right) radiographs 1 year after bony bridge re-
section (E). Anteroposterior (left) and lateral (right)
radiographs at last follow-up (F).
fracture displacement; however, the sur-
gical procedure significantly affected the
incidence of premature physeal closure.
Open reduction significantly reduced the
incidence of premature physeal closure,
whereas cast immobilization after closed
reduction was a risk factor for premature
physeal closure (Tables 2-3; Figure 6).

Discussion
Table 2
The growth plate of the distal tibia
Characteristics of Salter-Harris Type I/II Subgroup (n=195) consists of the proliferative and hypertro-
phic layers, which are located at the ar-
No Premature
Physeal Premature Physeal ticular surface of the metaphysis (Figure
Variable Closure (n=163) Closure (n=32) P 7A). Premature physeal closure largely
Age, mean±SD, y 11.3±2.3 11.8±1.7 NS occurs due to the infiltration of bone mar-
Male, No. 119 23 NS row cells, osteoblasts, and osteoclasts
Right-sided injuries, No. 88 20 NS
from the epiphysis or metaphysis to the
vertical cavity, which is formed due to
Primary fracture displacement, 7.3±2.3 8.2±3.8 NS
mean±SD, mm the damage in the proliferative layer of
Fracture displacement after closed 3.1±2.7 3.8±3.6 NS the growth plate.11 There are 2 causes of
reduction, mean±SD, mm vertical cavity formation. One cause is
Associated distal fibular fractures, No. 37 15 <.01 the death of proliferating cells caused by
ORIFs, No. 40 8 NS violent forces, including squeezing, tor-
Abbreviations: NS, not significant; ORIFs, open reduction and internal fixations.
sion, and grinding at the time of injury;
this cause cannot be improved, even after

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 n Feature Article

treatment. Aitken10 concluded that the im-

pact on the growth plate at the time of in- Table 3
jury is the main cause of growth disorders
Characteristics of Salter-Harris Type III/IV Subgroup (n=91)
and that any subsequent treatments cannot
No Premature
completely resolve this type of growth Physeal Premature Physeal
disorder. Another cause of vertical cavity Variable Closure (n=81) Closure (n=10) P
formation is displacement of the prolifera- Age, mean±SD, y 12.4±2.1 12.1±3.2 NS
tive layer due to the fracture crossing the Male, No. 53 7 NS
entire growth plate, which directly forms
Right-sided injuries, No. 50 6 NS
a vertical cavity in the fracture gap. At this
Primary fracture displacement,
time, it is important to perform anatomic mean±SD, mm 8.3±2.8 9.7±4.1 NS
reduction of the growth plate, especially Fracture displacement after closed
the proliferative layer, to prevent prema- reduction, mean±SD, mm 3.5±3.7 4.3±5.1 NS
ture physeal closure.12 Associated distal fibular fractures, No. 19 8 <.01
Type I/II fractures are limited in the ORIFs, No. 49 4 <.01
deep hypertrophic layer and metaphysis
Abbreviations: NS, not significant; ORIFs, open reduction and internal fixations.
and do not invade the proliferative layer
(Figure 7B). In 2003, Barmada et al7
reported that the incidence of premature
physeal closure was 36% to 40% in pa-
tients with Salter-Harris type II distal tibial
epiphyseal fractures. In patients with Salt-
er-Harris type II distal tibial epiphyseal
fractures with more than 2 years of growth
potential, surgical ORIF is recommended
if the fracture displacement is more than 3
mm to reduce the incidence of premature
physeal closure.7,9 The goal of surgery is
to remove the periosteum embedded in the
fracture gap to obtain anatomic reduction
and reduce the incidence of premature
physeal closure.7,13 However, Russo et
al14 reported that although open reduction
could remove the periosteum embedded
in the fracture gap and obtain anatomic Figure 6: Different incidence of premature fracture displacement in 4 subgroups classified by Salter-
reduction for displaced Salter-Harris type Harris classification and with/without open reduction.
II distal tibial epiphyseal fractures, open
reduction cannot reduce the incidence of although the proliferative layer is dam- in preventing premature physeal closure.
premature physeal closure. In contrast, the aged at the time of injury. The formation Therefore, it is recommended that surgery
procedure may increase the chance of sec- of the vertical cavity within the prolifera- not be performed based on preoperative
ondary and tertiary surgeries and the in- tive layer of the growth plate is mainly fracture displacement of more than 2 mm.
cidence of surgery-related complications. caused by the death of proliferating cells With the exception of extremely serious
One possible reason why open reduc- caused by violent forces at the moment deformities, conservative treatments, such
tion cannot reduce the incidence of pre- of injury, but not by fracture displace- as closed reduction and cast immobiliza-
mature physeal closure is that the Salter- ment. Therefore, anatomic reduction can- tion, should be used; however, all patients
Harris type II fracture line transversely not avoid formation of the vertical cavity. should be closely followed for at least 12
crosses the hypertrophic layer and extends Moreover, Gruber et al15 confirmed that months. If bony bridges are observed on
to the metaphysis; the proliferative layer bony bridge formation is not affected by radiographs or CT scans, surgery should
is not involved.15 No significant displace- periosteum embedding. Open reduction be performed to maintain normal anatomy
ment of the proliferative layer may exist, has a limited effect on type I/II fractures of the ankle joint.14

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n Feature Article
Figure 7: The growth plate of the distal tibia consists of the proliferative layer and the hypertrophic layer,
located from the articular surface to the metaphysis (A). In type I/II fractures, the fracture is limited to
the deep hypertrophic layer and metaphysis and does not invade the proliferative layer (B). In type III/IV
fractures, the fracture line passes through the proliferative layer and there is displacement in this layer,
which directly forms the vertical cavity (C).
In type III/IV fractures, the fracture
line crosses the proliferative layer and
there is displacement of the proliferative
layer, which directly forms the vertical
cavity (Figure 7C). For type III/IV frac-
tures, anatomic reduction should be per-
formed. Reduction of the proliferative
layer is important for preventing prema-
ture physeal closure in patients with type
III/IV fractures. If surgery is performed
only in patients with preoperative fracture
displacement more than 2 mm, the prog-
nosis may be poor because 2 mm of thick-
ness exceeds the thickness of the growth
plate. Displacement in the proliferative
layer of more than 1 mm is sufficient
for vertical cavity formation. Therefore,
surgery should be performed on patients
with type III/IV fractures. Seel et al16 per-
formed anatomic ORIF for patients with
primary displacement of more than 2 mm
or even less than 1 mm. The incidences
of premature physeal closure were 7.4%
and 8.7% in patients with type III and IV
fractures, respectively, which is signifi-
cantly less than in other reports (38%7 and
50%17).
Based on the better results of Seel et
al16 and the theory of anatomical reduc-
tion with displacement less than 2 mm
decreasing the risk of epiphysiodesis and
preventing degenerative joint disease,18
the current authors took displacement of
2 mm as the cutoff. In addition, if a stable
internal fixation is not performed after re-
duction, fracture displacement may occur
due to the subsidence of swelling, poor
e194
patient compliance, and occasional weight
bearing. Although the current authors
conducted radiographic examinations 5,
10, and 15 days after cast immobilization,
a simple radiographic examination could
not show minimal displacements, and the
timing of treatment might be delayed.
Kling et al12 also demonstrated that closed
reduction and cast immobilization is a risk
factor for growth disorders following type
III/IV fractures.
In a study by De Sanctis et al,18 72 pa-
tients with distal tibial epiphyseal fractures
underwent conservative treatment (n=64)
or surgical treatment (n=8). Sixty (83%)
of 72 patients had good results. Good re-
sults were achieved in 8 of 11 (73%) type
III fractures, 7 of 10 (70%) type IV frac-
tures, 7 of 7 (100%) type I fractures, and
38 of 39 (97%) type II fractures. Another
study of 59 patients included 4 with type I
fractures, 22 with type II fractures, 29 with
type III fractures, and 4 with type IV frac-
tures.19 All 4 (100%) patients with type
I fractures underwent closed reduction.
Of the 22 patients with type II fractures,
4 (18%) underwent ORIF and 18 (82%)
underwent closed reduction. Twenty-two
(76%) of the 29 patients with type III fac-
tures underwent ORIF. One (25%) of the 4
patients with type IV fractures underwent
closed reduction. Mean American Ortho-
paedic Foot and Ankle Society score was
86.6 (range, 65-100) at last follow-up. In
the current study, 195 patients had type I/
II fractures and 91 patients had type III/
IV fractures. Open reduction and internal
fixation was performed in 101 patients, in-
cluding 48 with type I/II fractures and 53
with type III/IV fractures.
The current authors suggest that sur-
gery be performed on patients with Salter-
Harris type III/IV distal tibial epiphyseal
fractures to obtain anatomic reduction;
specifically, alignment of the prolifera-
tive layer should be restored, and stable
internal fixation should be applied subse-
quently.
Conclusion
If the surgical indication is based on
the distance of the preoperative fracture
displacement, the prognosis of the distal
tibial epiphyseal fracture cannot improve
significantly. Conservative treatment
should be used for cases with Salter-
Harris type I/II distal tibial epiphyseal
fractures, and patients should be followed
closely. Surgeries such as bony bridge
resection, osteotomy, and epiphyseal ar-
rest should be performed in patients with
bony bridge or ankle deformities. Surgi-
cal treatment should be used for patients
with Salter-Harris type III/IV distal tibial
epiphyseal fractures to obtain anatomic
reduction and rigid internal fixation and
further reduce the incidence of premature
physeal closure.
References
1. Mann DC, Rajmaira S. Distribution of phy-
seal and nonphyseal fractures in 2650 long-
bone fractures in children aged 0-16 years. J
Pediatr Orthop. 1990; 10:713-716.
2. Mizuta T, Benson WM, Foster BK, Mor-
ris LL. Statistical analysis of the incidence
of physeal injuries. J Pediatr Orthop. 1987;
7:518-523.
3. Peterson CA, Peterson HA. Analysis of the
incidence of injuries to the epiphyseal growth
plate. J Trauma. 1972; 12:275-281.
4. Peterson HA. Epiphyseal Growth Plate Frac-
tures. New York, NY: Springer; 2007.
5. O WH, Craig C, Banks HH. Epiphyseal in-
juries. Pediatr Clin North Am. 1974; 21:407-
422.
6. Tachdjian MO. Paediatric Orthopaedics.
Philadelphia, PA: Saunders; 2010.
7. Barmada A, Gaynor T, Mubarak SJ. Prema-
ture physeal closure following distal tibia
Copyright © SLACK Incorporated

physeal fractures: a new radiographic predic-
tor. J Pediatr Orthop. 2003; 23:733-739.
8. Nenopoulos SP, Papavasiliou VA, Papavasi-
liou AV. Outcome of physeal and epiphy-
seal injuries of the distal tibia with intra-
articular involvement. J Pediatr Orthop.
2005; 25:518-522.
9. Rohmiller MT, Gaynor TP, Pawelek J,
Mubarak SJ. Salter-Harris I and II fractures
of the distal tibia: does mechanism of injury
relate to premature physeal closure? J Pediatr
Orthop. 2006; 26:322-328.
10. Aitken AP. Fractures of the epiphyses. Clin
Orthop Relat Res. 1965; 41:19-23.
11. Wattenbarger JM, Gruber HE, Phieffer LS.
Physeal fractures: Part I. Histologic features
of bone, cartilage, and bar formation in a
MARCH 2015 | Volume 38 • Number 3
small animal model. J Pediatr Orthop. 2002;
22:703-709.
12. Kling TF Jr, Bright RW, Hensinger RN. Dis-
tal tibial physeal fractures in children that
may require open reduction. J Bone Joint
Surg Am. 1984; 66:647-657.
13. Phieffer LS, Meyer RA, Gruber HE. Effect of
interposed periosteum in an animal physeal
fracture model. Clin Orthop Relat Res. 2000;
376:15-25.
14. Russo F, Moor MA, Mubarak SJ, Pennock
AT. Salter-Harris II fractures of the distal
tibia: does surgical management reduce the
risk of premature physeal closure? J Pediatr
Orthop. 2013; 33:524-529.
15. Gruber HE, Phieffer LS, Wattenbarger JM.
Physeal fractures: Part II. Fate of interposed
n Feature Article
periosteum in a physeal fracture. J Pediatr
Orthop. 2002; 22:710-716.
16. Seel EH, Noble S, Clarke NM, Uglow MG.
Outcome of distal tibial physeal injuries. J
Pediatr Orthop B. 2011; 20(4):242-248.
17. Lalonde K, Letts M. Traumatic growth arrest
of the distal tibia: a clinical and radiographic
review. Can J Surg. 2005; 48:143-147.
18. De Sanctis N, Della Corte S, Pempinello C.
Distal tibial and fibular epiphyseal fractures
in children: prognostic criteria and long-term
results in 158 patients. J Pediatr Orthop B.
2000; 9(1):40-44.
19. Taskıran MC, Turgut A, Kalenderer O, Agus
H. Clinical and radiological results in distal
tibial physeal injuries. Ulus Travma Acil Cer-
rahi Derg. 2012; 18(6):495-500.
e195