Elsevier

Injury

Volume 46, Issue 11, November 2015, Pages 2177-2180
Injury

The role of CT in diagnosis and treatment of distal tibial fractures with intra-articular involvement in children

https://doi.org/10.1016/j.injury.2015.07.017Get rights and content

Abstract

Aim

Distal tibial fractures with intra-articular involvement during childhood are injuries with potentially severe complications if not treated promptly. Daily clinical practice indicates that sole use of plain radiographs may lead to misdiagnosis and subsequent erroneous selection of suitable treatment. The role of computed tomography (CT) in the classification and treatment decision of these injuries is unclear. This study aims to determine whether CT evaluation is required in the management of these fractures.

Patients and methods

We assessed 64 distal tibial fractures with intra-articular involvement on two separate occasions in a blinded study, in order to classify the fracture and decide the appropriate treatment approach. In the first part of the study, plain radiographs were evaluated in order to diagnose the type of the fracture and select the appropriate treatment. In the second part, CT scans were performed in the same patients in order to re-evaluate diagnosis and treatment. The study included fractures prior to physeal closure (Salter–Harris III and IV fractures, n = 32) as well as transitional fractures (J. Tillaux and triplane fractures, n = 32).

Results

According to plain radiographs, 31 patients were diagnosed with SH III fracture, 8 with SH IV, 9 with J. Tillaux and 16 with triplane fracture. Surgical treatment was decided in 18 patients and non-surgical in 46. After CT scan evaluation, 20 patients were diagnosed with SH III, 12 with SH IV, 9 with J. Tillaux, and 23 with triplane fracture. In this occasion the number of patients referred for surgical treatment raised to 42 leaving only 22 patients to be treated conservatively.

Conclusions

Computed tomography lead to changes in fracture classification and treatment decision. Treatment decision changed for 24 patients after CT evaluation. Treatment decision in patients with SH III and IV did not change significantly opposed to patients with transitional fractures, where CT scan had major impact on treatment decision. Despite the irradiation of immature skeleton and higher cost containment, this study indicates that patients with transitional distal tibial fractures as well as patients with displaced SH III and IV fractures must undergo CT examination in order to make accurate diagnosis and select the appropriate treatment.

Introduction

Distal tibial physeal fractures are the second most common growth plate injuries in children and adolescents [1]. The Salter and Harris (SH) classification is the standard classification method used worldwide [2].

Intra-articular fractures of the distal tibia involve SH type III and IV fractures as well as transitional fractures. These fractures (triplane and juvenile Tillaux fractures) are only seen in adolescents in a period of approximately 18 months when the physis closes in an asymmetric pattern [3], [4].

Inappropriate treatment and inaccuracy on reduction of distal tibial fractures with intra-articular involvement could lead to major complications such as joint incongruity and deformities due to partial premature closure of the physis and post-traumatic arthritis [3], [5], [6]. Every fracture with more than 2 mm intra-articular displacement requires anatomic reduction either by closed or open methods [3], [5].

Anteroposterior and lateral X-rays of the injured ankle can provide sufficient information to diagnose and plan treatment of the fracture [3]. Computed tomography has been proved useful in accurate evaluation of intra-articular fractures [7], [8], [9], [10], [11]. Admittedly, irradiation of patients and cost containment are inhibitory factors towards subjecting every patient with intra-articular distal tibial fracture to a computed tomography (CT)-scan.

A number of studies have previously investigated and proved the necessity and reliability of CT in distal tibial physeal injuries [12], [13], [14], [15]. However, none of the existing studies focused in fractures with intra-articular involvement.

The purpose of this study is to identify the role of CT in diagnosis and selection of appropriate treatment in distal tibial fractures with intra-articular involvement in children and adolescents as well as to propose a diagnostic algorithm for the management of these fractures.

Section snippets

Patients and methods

The medical record from every patient with distal tibia fracture with intra-articular involvement was retrospectively investigated. Patients treated from our observer and patients that did not undergo CT scan were excluded from our study. Sixty-four children and adolescents with intra-articular distal tibial fracture treated in our department between 1993 and 2013 were included in our study. Thirty-six were boys and 28 girls with mean age 11, 8y (5–15y). Routine anteroposterior and lateral

Statistical methods

Statistical analysis was performed with SPSS (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). In order to statistical prove if CT scan is changing the method of treatment of these fractures the McNemar test for paired samples was used [16]. The McNemar test is used to determine if there are differences on a dichotomous dependent variable between two related groups. Significance level was defined at 0.05.

Results

In the first part of this study, the anteroposterior and lateral X-ray of every patient were evaluated. Thirty-one fractures were classified as SH III injury (48.4%), 8 as SH IV (12.5%), 9 as juvenile Tillaux (14.1%), and 16 as triplane fractures (25%). After taking into consideration the CT scans the classification changed to 20 SH type III fractures (31.3), 12 SH IV (18.7%), 9 juvenile Tillaux (14.1%), and 23 triplane fractures (35.9%) (Table 1). The number of SH IV and triplane fractures

Discussion

In this study, diagnosis and treatment decision in children with distal tibial fractures and intra-articular involvement, showed significant diversity after adding computed tomography as a routine diagnostic method. Subsequently CT assisted also in pre-operative planning of fractures originally referred for surgical treatment using only X-ray evaluation.

Cutler et al. [15] studied 62 distal tibial physeal fractures, and reported significant differences between plain radiographs and CT scans in

Conclusions

Despite the higher dose of radiation in patients with immature skeleton as well as the higher cost containment, findings from our study support that the use of CT gives indisputable benefits in understanding the pattern and apply proper treatment of distal tibial fractures with intra-articular involvement in children. This study also suggests that every patient with transitional fracture as well as patients with SH type III and IV fractures that displacement of articular surface or difficulty

Conflicts of interest

The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

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