Sat., 10/6/12 Pediatric Fractures, PAPER #113, 3:52 pm OTA-2012
Salter-Harris II Fractures of the Distal Tibia: Does Surgical Management Reduce the Risk of Premature Physeal Closure?
Franco Russo; Molly A. Moor, MPH; Scott J. Mubarak, MD; Andrew T. Pennock, MD;
Rady Children’s Hospital, San Diego, California, USA
Background/Purpose: Premature physeal closure (PPC) is a common complication resulting from the management of a displaced Salter-Harris II (SH II) fracture of the distal tibia. The purpose of this study was to evaluate our institution’s treatment approach to assess PPC and complication rates of fractures treated both surgically and nonsurgically.
Methods: We performed a retrospective review of all patients presenting with a displaced SH II fracture between 2004 and 2010. Initial treatment was closed reduction in the emergency department. Further treatment and subsequent categorization was based on amount of residual displacement. Patients with <2 mm of postreduction displacement were treated with a non–weight-bearing long-leg cast (LLC). Patients with residual displacement between 2 and 4 mm were treated with one of two approaches based on surgeon preference: (1) LLC or (2) open reduction and internal fixation (ORIF) with removal of any interposed tissue. Patients with >4 mm of residual displacement were treated with ORIF. Follow-up radiographs were performed for a minimum of 6 months. If there was clinical concern about PPC, CT imaging was performed to assess for a bony bar.
Results: In total, 96 patients with a mean age of 12.6 years at presentation were included in the study. Among the 14 patients with <2 mm of postreduction displacement, 29% had a PPC and 7% had to undergo a subsequent procedure. Of the 33 patients with 2 to 4 mm of displacement treated with a LLC, 33% had a PPC and 15% underwent a subsequent procedure. Of the 11 patients with 2 to 4 mm of displacement treated with ORIF, 46% had a PPC and 18% had a second procedure. Finally, 38 patients with >4 mm of displacement treated with ORIF had a PPC rate of 55% and 23% had a subsequent procedure. No statistically significant differences in PPC (P = 0.19) or subsequent surgeries (P = 0.57) were observed between groups. Among those with 2 to 4 mm of postreduction displacement, patient age (P = 0.36), gender (P = 0.39), mechanism of injury (P = 0.13), time to fracture management (P = 0.51), amount of initial displacement (P = 0.34), number of reduction attempts (P = 0.43), and operative treatment (P = 0.47) did not significantly influence PPC.
Conclusion: Patients with displaced SH II distal tibia fractures pose a challenging problem for the treating physician with a high rate of PPC (42.7% overall). While surgical fixation with anatomic reduction and removal of interposed tissue may be necessary to improve joint alignment, it does not reduce the incidence of PPC and may increase the need for subsequent surgeries. We recommend closed treatment of SH II fractures unless surgery is necessary to improve joint alignment.
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