![]() Ideally, if an important swelling is present, a splint can be applied and then switched to a cast few days later after swelling resolution. The immobilization of choice is a non-weight bearing long leg cast that will be converted after 3 weeks to a short leg cast to prevent knee stiffness. Moreover, any fracture is prone to secondary displacement with conservative treatment after the subsidence of the edema and the disuse muscle atrophy, which will loosen the cast.Īs mentioned above, the majority of distal tibial metaphyseal fractures in children are treated by closed methods when possible. Second, because of the concomitant fibular fracture, the splint-like effect that is usually provided by the fibula to stabilise the tibial fracture is lost. Thus, the pull exerted by the anterior cortex with the absence of resistance by the posterior periosteum will augment the risk of displacement., especially with foot dorsiflexion. First, in similar fractures with recurvatum, the posterior periosteum is lacerated while the anterior periosteum is intact. This fracture type is considered an unstable fracture, and its secondary displacement is predicted for many reasons. No osseous lesions were detected in the joints cranially or caudally to the fracture.įigure 6: fifteen months after surgery radiographs showing total and anatomical healing. There was also a concomitant fibular fracture (Figure 1). There was a limited recurvatum of 5 degrees with no varus/valgus deformity comparing to the other limb. No accompanying lesions were found.ĪP and lateral radiographs revealed a fracture of the distal tibial metaphysis with no significant displacement neither in the frontal nor in the sagittal plane. The patient was unable to bear weight on the affected limb. During examination, the pain was located in the supramalleolar region and an important swelling was noted. Īn 11-years-old boy, with no medical history, and a BMI of 26.2 kg/m 2, presented to the emergency department of our institution with severe pain in his left ankle following trauma. Plating, elastic stable intramedullary nailing (ESIN), divergent intramedullary nailing (DIN), percutaneous pinning, external fixation and intrafocal pinning, all are debatable choices for surgery and each procedure has its own pros and cons. Therefore, there isn't a "gold standard" surgical technique, and thus, the choice remains controversial. The poor soft tissue coverage, the poor blood supply, and the distality of the fracture, arise a challenge in discerning what type of surgical intervention should be carried out. Indications for surgical treatment were defined as a recurvatum or a procurvatum of more than 10 degrees, a valgus or a varus of more than 5 degrees, or a misalignment of more than 40%. However, when conservative methods don't offer the optimal reduction and stability, surgical intervention is required to restore the length of the bone and correct its rotational angulation and alignment. When the displacement is acceptable, nonoperative treatment by closed reduction and a long leg cast for 6 to 8 weeks is the treatment of choice. A fibular fracture, present or absent, will not affect the final outcome no matter what type of care is provided. An intact fibula will lessen the severity of tibial displacement. Concomitant fibula fracture is a common finding and the pattern of its displacement mirrors the tibial one mentioned before. Due to the thickness of the periosteum, a similar lesion would displace the distal fragment generally in a recurvatum and valgus angulation nevertheless, a deformity by procurvatum and varus can occur. The majority of these fractures are greenstick injuries with a broken cortex posteriorly and a crushed cortex anteriorly. However, distal metaphyseal or supramalleolar fractures are not very common with an approximate incidence of 0.4%. Tibia fractures are frequent during childhood, ranked as the third most common fractures in children, with an incidence of 15%. To best of our knowledge, no cases of intrafocal pinning for DTMF in children were described in literature before. We compare afterwards our procedure to the other interventions in terms of advantages, disadvantages and final outcome. We describe in this article the pathophysiology of this type of fractures as well as the technique applied. This a case of a traumatic progressively displaced DTMF despite cast immobilization in an 11-years-old child, who was treated in our institute by intrafocal pinning and followed for 15 months. However, the choice of the surgical procedure if indicated, remains controversial, and many options of osteosynthesis are still considered. Distal tibial metaphyseal fractures (DTMF) are rare fractures among children, and are usually treated by closed methods for 6 to 8 weeks with reported satisfactory outcomes.
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