PubMed^® Literature Review

Paediatric triplane physeal tibial fractures represent a unique injury pattern that occurs during the transitional phase of skeletal maturation when the distal tibial physis closes asymmetrically [1]. These injuries typically occur between ages 10 to 15 due to an external rotation mechanism on the ankle, leading to fracture lines propagating through three planes: axial, sagittal, and coronal [5, 7, 8].

Recent literature has however challenged traditional teachings regarding these injuries. A study utilizing fracture mapping techniques revealed that regardless of age or sex, triplane ankle fractures consolidate into a characteristic Y-pattern without shifting with physeal closure. This suggests that ligament attachments play a significant role in influencing fracture patterns rather than just physeal closure alone.

Given the complexity of these fractures and their potential to impact long-term growth, accurate classification and appropriate treatment planning are critical. The utilization of computed tomography (CT) has been shown to significantly impact fracture classification, displacement measurement, and treatment planning, suggesting its importance as an adjunctive tool to radiographs [5]. This is supported by evidence demonstrating improved accuracy in diagnosing triplane fractures with CT, especially among more experienced surgeons [6].

Furthermore, a new classification system based on axial CT scans has been proposed, which could optimize screw trajectory during surgical intervention [9]. In the treatment of triplane fractures, both non-operative (closed reduction and casting) and operative (open reduction and internal fixation) strategies have been employed. The decision between these approaches is often determined by the degree of displacement and fracture instability [11, 12, 14].

Studies have shown that non-operative treatment can yield satisfactory outcomes for fractures with minimal displacement [12, 13]. However, for fractures with displacement greater than 2 mm, surgical intervention is typically indicated to minimize the risk of long-term complications, such as degenerative joint disease and growth disturbances [10, 11, 14]. Comparative studies have evaluated different fixation techniques, such as lag screw versus Kirschner wire fixation, with the former showing a lower rate of premature physeal closure [3]. Moreover, case reports and retrospective case series have highlighted the importance of considering atypical triplane fracture patterns and the role of percutaneous screw fixation in achieving anatomic reduction and earlier mobilization [4, 7].

Despite the evidence provided, the literature also reveals the possibility of missed or delayed diagnosis, particularly in the presence of concurrent ipsilateral tibial shaft fractures [2, 11]. This underscores the need for a high index of suspicion and thorough clinical and radiographic assessment to prevent overlooking these significant injuries.

In summary, the current evidence indicates that while non-operative treatment may be adequate for non-displaced or minimally displaced triplane fractures, displaced fractures generally require operative intervention to restore anatomic alignment and prevent growth disturbances and degenerative changes. The application of CT scans has improved the classification and treatment planning for these fractures, thereby influencing outcomes positively.

Author's Resources & References