The Journal of Bone and Joint Surgery, Vol 65, Issue 8 1059-1070, Copyright © 1983 by Journal of Bone and Joint Surgery, Inc
Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus
JR Cass and HA Peterson
Salter-Harris Type-IV fractures of the epiphysis extend through the
articular cartilage, epiphysis, physis, and metaphysis and have a high rate
of complications secondary to premature partial closure of the physis. In
this study we attempted to determine which Type-IV fractures of the distal
end of the tibia result in premature partial closure, how the various
treatment modalities affect the risk of premature physeal closure, and how
the complication itself might be best managed. Thirty-two Type-IV fractures
of the distal end of the tibia were seen at the Mayo Clinic during a
five-year period. Eighteen injuries involved the medial malleolus, thirteen
were so-called triplane fractures, and one was a fracture of the lateral
part of the plafond. In the eighteen ankles with a fracture that involved
the medial malleolus, extension of the fracture into the metaphysis could
often be appreciated only on oblique roentgenograms. The patients' ages at
the time of fracture ranged from one year and one month to fifteen years
and six months old. In nine of the eighteen tibiae with a fracture of the
medial malleolus premature partial closure of the distal physis developed,
resulting in angular deformity or limb-length discrepancy sufficient to
require operative treatment (epiphyseodesis, corrective osteotomy, or
excision of a physeal bar). A physeal bar was best detected by tomograms
made in two planes and by scanograms. Bar formation may be treated by
excision of the bar, arrest of the whole physis, osteotomy, or combinations
of these procedures. Of the thirteen patients with a triplane fracture and
the one with a Type-IV fracture of the lateral part of the plafond, all
fourteen were near maturity at the time of injury, and no growth-arrest
problems developed.
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