Date: Mon, 30 Aug 2004 01:37:54 -0700

Subject: Proximal Tibial fracture

Dear all,

A colleague has brought these Xrays for advice.

A young girl sustained this injury.

My questions are:

1) What is it? A tibial metaphyseal injury, or a Tibial Tubercle injury?
2) Any classification system for these? (Whatever these are)
3) Recommended treatment?
4) Pitfalls and problems.

I tried to look for them in Rockwood and Green, but without any luck. Perhaps somebody on the list will enlighten me.

Meantime, patient is undergoing a MUA

Dr. M. Amin Chinoy FRCS.

Reply at: Orthopaedic Trauma Association forum

Date: Sun, 29 Aug 2004 19:22:13 -0700

From: John Ruth

I have not seen this injury before. I would say it is a metaphyseal injury. How old is the patient? I cannot tell if she is skeletally mature or not. I would recommend at the very least a reduction to improve the alignment on the lateral. If the swelling is not too great and the neurovascular exam is normal then simply casting in extension may be all that is necessary. If reduction is not stable and proximal tibial epiphysis is open and patient still growing then smooth crossed pins and a long leg cast would be my recommendation. Certainly an ORIF with a plate is possible but seems like overkill and I doubt that she will get stiff in a cast.

Date: Mon, 30 Aug 2004 09:43:39 +0600

From: Alexander Chelnokov

Hello Muhammad,

What is it? A tibial metaphyseal injury, or a Tibial Tubercle injury?

A strange pattern. Looks like metaphyseal, involving growth zone of the tuberositas tibiae.

Any classification system for these? (Whatever these are)

No idea.

Recommended treatment?

Ilizarov or hybrid frame would be suitable.

Pitfalls and problems.

Looks like one needs some extra efforts/measures to prevent residual antecurvation.

Best regards,

Alexander N. Chelnokov
Ural Scientific Research Institute of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

Date: Mon, 30 Aug 2004 01:05 AM

From: Bill Burman

It looks similar to a Salter-Harris II proximal tibial fracture posted 2/04 by Charles Blitzer.
Of concern would be a missed popliteal artery/trifurcation injury.
Bill Burman, MD
HWB Foundation

Date: Mon, 30 Aug 2004 15:56:08 -0700

From: Muhammad Amin Chinoy

14 year old, was pushed from behind on stairs I also couldnt make out whether the epiphysis was open or not A MUA was done yesterday and i am told is satisfactory; will try and post the xrays


Muhammad Amin Chinoy FRCS

Date: Mon, 30 Aug 2004 15:57:44 -0700

From: Charles Mehlman

Dr Chinoy:

(1) rather unusual fracture pattern

(2) I would be suspicious of a small nonossifying fibroma acting as a stress riser (posteriorly perhaps?)

(3) In a technical sense this fracture represents a Salter-Harris II injury to the proximal tibia - with the world's biggest Thurstan-Holland fragment (nearly the entire metaphyseal portion)

(4) My first-line treatment would be reduction and casting near full extension - if I was unhappy with reduction I would have reasonably low threshold for crossed K-wire fixation

(5) Beware post-traumatic tibia valga in these proximal tibial fractures (Cozen effect - Lewis Cozen Surg Gyn Obstet 1953) and also tibial tubercle growth arrest with genu recurvatum deformity.

(6) Please share x-rays that show how it was eventually treated

Charles Mehlman, DO, MPH
Cincinnati Children's Hospital
Cincinnati, Ohio (USA)

Date: Mon, 30 Aug 2004 08:53:14 -0400

From: James Carr

It looks like a proximal tibia metaphyseal fx that extends into a partly open tubercle physis. Her major physis of the proximal tibia appears closed for all practical purposes. At age 14 she may be treated surgically as needed, and hopefully a closed reduction will suffice. Jim Carr

James B. Carr, MD
Premier Orthopedic Specialists
Columbia, SC 29203

Date: Mon, 30 Aug 2004 19:59:55 +0100

From: Chris Wilson

This injury is a fracture through the physis including the secondary ossification centre of the tubercle.It is not covered by the Ogden system,which is the usual one for classifying tubercle separations in adolescents,and it has been proposed( see reference below) that this be added to the Watson-Jones classification as a type 4. We have seen 2 of these in 2 years here and treated one in POP after manipulation under anaesthetic,and a second with screw fixation of the tuberosity to prevent it hinging backwards again,as it was very unstable.I suggest a manipulation with xray screening and conservative treatment if it is stable.  

Am J Orthop. 2003 Dec;32(12):604-7.; Combined physeal/apophyseal fracture of the proximal tibia with anterior angulation from an indirect force: report of 2 cases.; Donahue JP, Brennan JF, Barron OA.


Chris Wilson