Concomitant Tibia Shaft and Distal Triplane Fractures

N. K. Sferopoulos

N. K. Sferopoulos, Department of Pediatric Orthopaedics, "G. Gennimatas" Hospital, Thessaloniki, Greece

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: N. Sferopoulos, P. Papageorgiou 3, 546 35, Thessaloniki, Greece.
Email: sferopoulos@in.gr, sferopoulos@yahoo.com
Telephone: +00302310963270
Fax: + 00302310968265

Received: November 22, 2018
Revised: December 1, 2018
Accepted: December 3, 2018
Published online: December 25, 2018


Concomitant tibia shaft fracture and triplane fracture of the distal tibia are very rare in the pediatric orthopaedic traumatology. The very limited number of cases in the world literature has all been documented in older children or adolescent patients. Appropriate diagnostic evaluation and treatment is required to minimize the incidence of delayed or missed diagnosis of the ankle injury, prevent complications and optimize outcomes of both fractures. A new case as well as an extensive review of the literature is presented in this editorial.

Key words: Concomitant; Ipsilateral; Tibia shaft; Triplane; Fracture

© 2018 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Sferopoulos NK. Concomitant Tibia Shaft and Distal Triplane Fractures. International Journal of Radiology 2018; 5(1): 197-201 Available from: URL: http://www.ghrnet.org/index.php/ijr/article/view/2469


Pediatric tibia shaft fracture is the third most common diaphyseal long bone fracture, next to the clavicle and forearm bones. It is also the third most common diaphyseal fracture after the femur and humerus in polytrauma pediatric patients[1-7].

Physeal injuries have been reported to occur in approximately 15-30% of children's long bone fractures. Injuries to the physis of the distal tibia are the second most common growth plate injuries (17.8%) following those of the distal radius (29.6%), if physeal fractures involving the phalanges are excluded. Randsborg et al. have found that fracture rates differ between various physical activities. They reported that the distal part of the radius was the commonest fracture site (31.1%) for the most common childhood sport and recreational activities, while tibial shaft (4.8%) and ankle (3.6%) fracture rates accounted less than distal radius, hand, foot, distal humerus, clavicle and forearm fractures[8-13].

Pediatric ankle physeal fractures are most commonly described by the Salter-Harris classification types. Classification schemes for adult ankle fractures, such as the anatomically-based Weber system and the mechanism-based Lauge-Hansen system, are not particularly useful in children. The Dias-Tachdjian classification is a mechanism-based pediatric ankle fracture classification system that is a synthesis of the Salter-Harris and Lauge-Hansen classifications[14-16]. The correlation of the frequency of distal tibial physeal fractures with the Salter-Harris classification in the world literature confirms that the most common radiographic injury patterns are type II injuries[17-20]. The results of two studies are presented. In the former, 376 children and adolescents were included. A group of 181 patients with a clinically diagnosed epiphyseal separation, having a negative x-ray (Salter-Harries type I), was excluded from the results and analysis. Subsequently, without respect to type I injuries, 113 (58%) with type II, 66 (33.8%) with type III and 16 patients (8.2%) with type IV fractures were diagnosed[21]. In the latter, 96 distal tibia physeal fractures were included. The average age was 12 years and 8 months (range 2-17 years), but 71 were 11-14 years old. Using the Salter-Harris classification 12 type I, 42 type II, 30 type III and 12 type IV fractures were diagnosed. There were also 4 triplane fractures and 7 Tillaux fractures[22].

The pediatric triplane ankle fracture represents a unique spectrum of injury that does not fit neatly into the Salter-Harris classification of physeal injuries. This fracture is particular to the pediatric population and it is often termed a transitional injury. Transitional period refers to the time of epiphysiodesis from adolescent to skeletally mature bone. It is the result of the characteristic asymmetric closure of the distal physeal plate of the tibia, over a period of approximately 18 months, in children aged 12 to 15 years. Classically, this fracture appears as a Salter-Harris type III injury in the anteroposterior x-ray and as a type II injury on the lateral view. The triplane ankle fracture is a multiplanar injury, since it may incorporate fracture lines in the sagittal, coronal, and axial anatomical planes (corresponding to Salter-Harris fracture types II, III, and IV, respectively). The incidence, classification, treatment and outcome of triplane fractures have been extensively studied in the English literature[23-31].

The application of external rotation and plantar flexion force on the foot in relation to the leg in adolescents forces the talus against the fibula and places the anterior inferior tibiofibular ligament under tension resulting in an avulsion fracture of the anterolateral epiphysis. This isolated Salter-Harris type III injury is referred as the biplane fracture of Tillaux. Further forcing of the foot may result in a triplane fracture of the distal tibia. Subsequently, the juvenile Tillaux and the triplane fracrures were both included in the classification scheme developed by Diaz-Giegerich, which was based on created increasing forces, as stage I and stage II injuries, respectively. Stage III injuries were due to the transmission of still further external rotation forces and included a stage II injury associated with an ipsilateral spiral or oblique fracture of the fibula. Morgan and Jimenez considered that continued external rotation transmitted through the tibia may finally result in a stage II injury associated with an oblique fracture of the tibia shaft. They classified it as a new stage injury[32-35].

In adults, distal tibia fractures associated with ipsilateral tibia shaft fractures, specifically distal one-third spiral type, are more prevalent than previously reported. The recognition of a distal one-third spiral pattern tibia shaft fracture had 88.6% sensitivity and 63.9% specificity for the presence of an ankle injury. The recognition of the associated ankle injury has been considered sufficiently important for proper preoperative planning and appropriate postoperative physical therapy. Recently, there has been increasing recognition and interest in the association of tibia shaft fractures and ipsilateral ankle injuries, although clinical studies have not sufficiently examined the clinical significance of this entity in adults[36,37].

Unlike adults, the lesion is less reported in children and adolescents. Rapariz et al. found that 48% of triplane fractures were associated with a fractured fibula and 8.5% were associated with an ipsilateral tibia shaft fracture. Healy et al. reported a triplane fracture associated with a proximal fibula fracture and syndesmotic injury (Maisonneuve equivalent). Failure to detect this injury may lead to chronic instability[38-41]. Recently a limited number of new cases suffering from ipsilateral tibia shaft and distal triplane fracture have been presented. They were all recorded in adolescents[42-47].

We were also able to identify, from the hospital database, a single case with this rare concomitant injury. The patient was a 13-year-old boy that was referred for a left tibia fracture associated with an ankle fracture. The left leg twisting injury had occurred after stepping into a hole while running. No open lesions were noted. Neurovascular assessment revealed no abnormal findings. Plain radiographs showed an oblique fracture of the tibia shaft associated with an ipsilateral undisplaced Tillaux fragment and a posterior malleolar shear fragment with an intact fibula (Figure 1A). The leg was immobilized in a long leg cast. A computed tomography (CT) scan was performed the next day. Both 2D-CT (Figure 1B) and 3D-CT (Figure 1C) scans were used in the imaging of the tibial and ankle fractures. There was no evidence of displacement bigger than 2 mm between the ankle fragments. The patient was then taken to theater and an above knee compression cast, with the tibia in valgus, was placed. The reduction of both the tibial and the triplane fracture was considered satisfactory. The patient was discharged on the seventh day post-injury after a satisfactory radiographic examination. He was then followed on an outpatient basis. Radiographs following a 2, 3 and 4 week-period post-injury showed satisfactory reduction of the tibial and ankle fractures. The plaster was removed 7 weeks post-injury, new radiographs were taken, and a below knee splint was applied for a further 2-week period. Radiographs at 3 months showed complete union of the fractured tibia. The triplane fracture was also well united with no disruption of the plafond of the tibia (Figure 1D).

Figure 1 A 13-year-old boy injured his leg and ankle after a fall. The initial anteroposterior and lateral radiographs of the leg and ankle indicated an oblique tibia shaft fracture and a distal tibia triplane fracture (A). A CT scan, in a two-dimensional (2D) form, showed 3-4 millimeters of shortening and a minimal recurvatum deformity of the tibia fracture as well as an undisplaced triplane ankle fracture (B). The three-dimensional (3D) CT reformation form provided better perception of the pattern of the fracture lines (C). Radiographs recorded uneventful healing of the tibia and ankle fractures, following conservative treatment, 3 months post-injury (D).

The term complex triplane fracture has also been used to describe the ipsilateral triplane and diaphyseal shaft fracture in adolescents[42]. This nomenclature is accurate, since it may be used to describe multiple fractures at several levels in a single bone. However, it may also be used to describe either an open/compound triplane fracture or a triplane fracture associated with comminution, cartilage injury, dislocation and bone lose. Therefore, the term concomitant or ipsilateral distal triplane and tibia shaft fracture was preferred in this report.

A high index of suspicion is required for diagnosis. Pediatric orthopaedic surgeons should be aware that tibia shaft fractures, especially oblique or spiral-type fractures, may occasionally be associated with ankle injuries, such as triplane fractures. Minimum appropriate imaging for tibia fractures should always include ankle radiographs. Computed tomography may be required to reveal the full extent of the ankle injury and the degree of displacement. Various reports have showed that CT has a definite impact on the triplane fracture classification, displacement measurement, and treatment planning. The primary goal in treatment is reduction of the joint surface. Growth disturbance is not a common issue, since the fracture occurs just prior to the closure of the physis. Closed reduction is successful if there is no more than 2 millimeters of displacement. Positive results following closed reduction of displaced triplane fractures with internal rotation and casting have been reported throughout the literature. Displaced transitional fractures with a fracture gap of more than 2 millimeters in the weight-bearing portion of the epiphysis require closed or open reduction[39,48-52].

The ipsilateral presence of an oblique tibia shaft fracture may complicate the attempts at closed reduction of distal tibia triplane fractures in children and adolescents. Moreover, tibia shaft fractures with an intact fibula show a higher rate of delayed, non- and mal-union, in varus, than those with an associated fibular fracture[53-57]. We usually offer patients with isolated fractures of the tibia a chance at closed treatment provided that there will be a careful radiographic follow-up of the patient, especially after a 2-4 week-period. During this period, displacement of the tibia fracture in the plaster is most likely due to the decreased swelling of the leg. In such cases a new compression cast with the conventional 3-point molding or cast wedging in valgus may be required.

The concomitant tibia shaft and distal triplane fracture in our patient occurred with an intact fibula. Morgan and Himenez[35] suggested the inclusion of the triplane ankle fracture associated with tibia fracture in the classification scheme suggested by Dias-Tachdjian[16] and modified by Dias-Giegerich[32] as a new last stage injury. However, it may be prudent to consider fractures of the fibula or tibia associated with a concomitant either Tillaux[58-60] or triplane ankle fracture in adolescents as a subtype of the same last stage injury, which previously included only an ipsilateral distal tibia triplane and a fibula fracture.


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