Adolescence is defined as a transition phase between childhood and adulthood. It encompasses puberty (a period of rapid growth and hormonal changes), which includes an acceleration phase of growth (for about two years), a peak (peak height velocity), and a deceleration phase (for one to two years). The mean age at the time of the peak height velocity is twelve years (typical range, ten to fourteen years) for girls and fourteen years (typical range, twelve to sixteen years) for boys. Typically, girls who are more than fourteen years of age and boys who are more than sixteen years of age are considered skeletally mature and can undergo treatment similar to that for their adult counterparts. For the sake of this article, girls from eight to fourteen years old and boys from ten to sixteen years old will be considered adolescents1,2.
The gold standard for fracture treatment in adults is often not applicable to an adolescent. Similarly, what is considered appropriate for a child is not considered acceptable for an adolescent; for example, the use of a hip spica cast is considered appropriate for a femoral shaft fracture in a child but not for one in an adolescent.
A primary difference between adults and skeletally immature patients is the quality of the bone. Because the bones of an adolescent are less mineralized, more vascular, more porous, and more elastic than the bones of an adult, the bones of an adolescent absorb more energy before they fracture, heal more quickly, and produce greater callus. The immature skeleton dissipates energy better than does the adult skeleton, and this decreases the severity of the comminution of fractures3. Physes are present in adolescents, and they are the weakest link in the bone. Physeal fractures occur in adolescents, while dislocations and ligamentous injuries would occur in adults. The pattern of physeal closure in adolescents determines the physeal fracture pattern, which explains the Tillaux fracture of the distal part of the tibia and tibial tuberosity avulsion in the proximal part of the tibia. It is essential to consider the presence of an open physis during the treatment of nonphyseal fractures in adolescents to avoid iatrogenic physeal injury and possible growth disturbances. Other issues, including compliance, emotional outbursts, peer pressure, aesthetics, and other psychosocial and behavioral elements, should be considered when treating an adolescent4,5.
Specific implants and instruments are now available to treat certain fractures in adolescents. However, this is not true for all fractures in adolescents, and it is not uncommon for fractures in adolescents to be fixed with the use of implants and instruments from an orthopaedic set meant for adults. Tibial nails have been used to treat femoral shaft fractures in adolescents, and the feasibility of using humeral nails for femoral and tibial shaft fractures has been explored6,7.
Chronological age does not necessarily correlate with skeletal maturity or allow sufficient prediction of remaining growth. Determination of skeletal age is the preferred method for the estimation of the years of growth remaining. Greulich's and Pyle's atlas8 (hand/wrist radiographs), Pyle's and Hoerr's atlas9 (knee radiographs), the Sauvegrain method10 (elbow radiographs), the Risser sign11 (iliac apophyseal ossification), the Oxford score12 (hip and pelvic radiographs), and the Tanner-Whitehouse-III RUS score13 (radiographs of the radius, ulna, and small bones of the hand) are all used to estimate skeletal age. We find it simple to use the method described by Sanders et al.14, which is based on a simplified Tanner-Whitehouse-III RUS maturity assessment. According to this method, if the physes of the distal phalanges of the hand are wide open, the patient is skeletally immature; if these physes are partially closed, the patient is approaching peak height velocity; and once these physes are closed, the patient has reached peak height velocity. Biologic age estimation with use of the traditional Tanner staging method or based on secondary sexual characteristics or menarche is important but less commonly used2,15.
Although each anatomic region has a separate fracture classification, all injuries around the physis can be classified with the commonly used Salter-Harris system16 (Fig. 1). Salter-Harris Types I and II are extra-articular fractures, Salter-Harris Types III and IV are intra-articular fractures, and Salter-Harris Type V is a retrospective diagnosis. Rang et al.17 described a Type-VI fracture, which involves injury to the perichondral ring of LaCroix. The other two commonly seen physeal fracture patterns not described by the Salter-Harris classification are the Peterson Type-I fracture (a fracture of the metaphysis extending into the physis) and the Peterson Type-VI fracture (a fracture with a portion of the physis missing)18. A Peterson Type-VI fracture is similar to a Rang Type-VI fracture. These classification systems help to predict the extent and prognosis of physeal injury, aid in decision-making for its management, and allow better communication for clinical and research purposes.
General principles of fracture imaging and the inclusion of joints above and below the fractures should be followed. Comparison views of the contralateral extremity may be useful for the evaluation of physeal fractures or minimally displaced or nondisplaced fractures, or to delineate ossification patterns. Stress radiographs are not recommended because of the pain involved and the risk of iatrogenic physeal injury. A computerized tomography (CT) scan is recommended for the evaluation of certain intra-articular fractures in the knee or ankle region to better define the fracture pattern and aid in management. Magnetic resonance imaging (MRI) is used for the evaluation of suspected ligamentous injuries, chondral injuries, and osteochondral injuries or to determine the "health" of physes3,19-21.
- Reduce displaced physeal fractures with traction and very gentle manipulation. Open reduction is better than multiple attempts at closed reduction to avoid iatrogenic physeal injury.
- Do not attempt to reduce a physeal fracture later than seven to ten days after injury, unless there is an intra-articular step-off of >2 mm.
- Pins or screws used for internal fixation should be parallel to the physis. Use smooth pins if they must cross the physis. Pins crossing the physis are removed as soon as early signs of fracture-healing appear.
- Arthroscopic examination during internal fixation of intra-articular fractures can improve the accuracy of a reduction.
- Resecting a small portion of periosteum on either side of the physis during an open fracture reduction requiring elevation of the periosteum near the physis reduces the risk of osseous bar formation across the physis.
- For an exposed or crushed physeal injury, an acute Langenskiöld procedure (use of free fat interpositional graft) can be performed to help prevent growth arrest22,23.
- Most physeal fractures heal in three weeks.
- Once a physeal fracture has healed, monitor the patient for growth disturbances for at least six months or until the patient is skeletally mature.
- Growth arrest lines (Park-Harris lines) are transverse lines seen in the metaphysis. Their orientation and relationship to the physis are used to assess growth24,25.
- The sequelae and complications of physeal fracture and their management is described in Figure 2. This algorithm is applicable when the patient has at least two years of growth remaining23,26-31.
- Following a fracture, the bone in adolescents does not remodel as it does in young children. The acceptable fracture reduction parameters in adolescents are similar to those used for adults.
- Besides age, the weight of the patient and the fracture characteristics help to determine the optimal fracture fixation method and postoperative management.
- For most displaced diaphyseal fractures of long bones, elastic stable intramedullary nails are the implants of choice.
- Locking plates are usually not needed.
- For most displaced metaphyseal fractures, percutaneous pin fixation is adequate. These pins can be cut and left outside the skin for later removal in the physician's office.
- Fracture fixation is usually supplemented by use of a splint, cast, or brace.
- Implant removal is optional, although it is recommended that elastic stable intramedullary nails be removed after the fracture heals.
The clavicle is the first bone to start the ossification process and the last to finish it32. The treatment of incomplete and minimally displaced fractures of the clavicle shaft is nonoperative. The healing and remodeling capacities of the clavicle are excellent, and this is a major reason for nonoperative care of nearly all clavicle fractures. However, it has been shown that the vast majority of clavicle growth has been completed by adolescence, with 80% of longitudinal growth completed by nine years of age in girls and by twelve years of age in boys; thus, the remodeling potential beyond these ages may be limited33. The discussion between the family and the pediatric orthopaedic surgeon regarding an adolescent with a completely displaced clavicle shaft fracture has changed substantially in the last several years. Recent published evidence regarding the treatment of adults with clavicle fractures34 has expanded the discussion of the treatment of completely displaced clavicle shaft fractures to include the possibility of open reduction and internal fixation35,36. Two centimeters or more of fracture fragment displacement has been suggested as an important threshold in adults. However, in the Level-I comparative study performed by the Canadian Orthopaedic Trauma Society that demonstrated superiority of treatment with open reduction and internal fixation with a plate and screws, the authors simply used "completely displaced" as a criterion for study entry34.
Currently the most common procedure for surgical treatment of a displaced clavicle shaft fracture in an adolescent is open reduction and internal fixation with a plate and screws. A transverse incision is placed near or slightly below the anticipated lower border of the reconstructed clavicle shaft. The surgical approach involves progressive exposure of the fracture fragments through subcutaneous tissue, platysma, and the clavipectoral fascia and periosteal layers, with protection of crossing branches of the supraclavicular nerve35,37. Standard fixation principles, including selective use of interfragmentary lag screws as indicated, are applied. Careful drilling and a depth gauge technique are advised for all portions of the procedure, but, more medially, the subclavian neurovascular bundle is only about 10 mm away from the clavicle38. Open reduction and plate fixation allows adolescents to return to full activities about four weeks sooner than would be possible with nonoperative treatment (i.e., at twelve weeks rather than sixteen weeks)36.
Forearm shaft fractures are the third most common fracture in children. The literature reflects a strong and positive precedent for nonoperative care, but the outcomes of many of the studies may be biased by the inclusion of very young patients and of distal metaphyseal radial fractures under the heading of "forearm fracture." Analysis of the outcomes of forearm shaft fractures in adolescents has shown that these fractures are more difficult to manage with nonoperative methods than has been generally believed39,40.
The shaft of the radius is that portion extending from the proximal base of the tubercle of Lister to the proximal base of the bicipital tuberosity, with the ulnar shaft defined in a similar manner. A practical classification of shaft fractures of the forearm in the pediatric population recognizes the existence of two bones, three levels (the proximal, middle, and distal thirds), and four fracture patterns (plastic deformation, greenstick, complete, and comminuted)41. Good-quality radiographs should be obtained in two orthogonal planes. If there is angulation in both planes, the true angulation will be greater than either single view reveals. The proximal and distal radioulnar joints should be carefully inspected in a patient who has what appears to be a single-bone shaft fracture.
Greenstick fractures have continuity of at least one cortex and may be reduced by derotating the forearm. A complete shaft fracture of both forearm bones in a child who is less than ten years of age can usually be successfully managed with closed methods. Angulation of more than 20° in the distal third, 15° in the middle third, or 10° in the proximal third is not acceptable even in patients younger than ten years of age42,43. Bayonet apposition is acceptable in these young patients provided that satisfactory angular, rotational, and interosseous space alignment is maintained. In children older than ten years of age, angulation of >10° is usually unacceptable. The most common indications for operative fixation are an open fracture and an inadequately reduced fracture involving both the radial and the ulnar shaft in an adolescent. Intramedullary flexible nails (elastic stable intramedullary nails) are the fixation implants of choice. A closed reduction and elastic nail fixation should be tried initially, but if this cannot be achieved within the first ten minutes, it should be converted to a minimally open reduction and elastic nail fixation. Elastic stable intramedullary nails (1.5 to 2.0 mm) are adequate, and, if needed, smaller smooth Steinmann pins are used. The radial nail is contoured to reestablish the radial bow, while the ulnar nail is minimally contoured. The narrowest portion of the intramedullary canal of the radius is central, near the isthmus, while the narrowest portion of the ulna is near its distal third. Internal fixation of the radius should be performed first. The radial entry point is the floor of the first dorsal compartment or the bare area just proximal to the Lister tubercle between the second and third dorsal compartments. Appropriate rotation of the contoured radial implant is necessary to properly restore the radial bow. The ulnar entry point is the "anconeus starting point" along the lateral edge of the proximal part of the ulna, just distal to the growth plate. The intramedullary fixation devices should not violate either of the physes, and the extensor tendons should be protected from the sharp edges of the distal aspect of the radial elastic nails. The intramedullary nails are removed after six or more months. The potential complications of elastic stable intramedullary nailing include nail migration, delayed union or nonunion, loss of reduction, loss of motion, infection, nerve injury, muscle entrapment, extensor tendon injury, a reoperation, physeal injury, and compartment syndrome (Fig. 3).
The goals of treatment of femoral shaft fractures are timely union, no rotational deformity, <2 cm of shortening, and angular alignment within the acceptable parameters of 10° to 20° in the sagittal plane and 5° to 10° in the frontal plane. Valgus and procurvatum are tolerated better than varus and recurvatum deformity. Numerous treatment options are available, and the surgeon must base his or her decision on a combination of patient factors, such as age and size, fracture morphology, and type and extent of other injuries and morbidities; surgeon factors, such as familiarity with and preference for a particular technique and availability of equipment; and social factors, such as the psychological impact on the patient, disruption to the family, loss of time from school, and cost.
For adolescents, surgical treatment of femoral shaft fractures is favored over nonsurgical treatment. The benefits of surgery are lower rates of malunion, shorter hospitalization, earlier mobilization, and better social acceptance and cost-effectiveness. The potential disadvantages are the risks of surgery, scars, infection, bleeding, the need for implant removal, and the risk of damage to the physis. The various surgical treatment options include external fixation, plating, the use of elastic stable intramedullary nails, and the use of rigid intramedullary nails. We are not aware of any prospective randomized trials comparing operative treatments, but the many retrospective studies of the various options all have demonstrated acceptable results44-60. Recently, the American Academy of Orthopaedic Surgeons (AAOS) published clinical practice guidelines for pediatric femoral fractures61. Use of elastic stable intramedullary nails is a treatment option for patients eleven years of age or less, whereas surgical treatment with elastic stable intramedullary nails, trochanteric antegrade nails, or plating are options for those eleven years of age or older.
External fixation is simple and quick to apply, it can be applied at the bedside if necessary, and the technique is familiar to most orthopaedic surgeons45,46,48,62,63. It is used primarily in patients with soft-tissue injury, multiple traumatic injuries, or severe shortening. Compared with some other treatment options, it is not as well accepted by patients and families, and the cosmetic appearance of the pin site scars can be an issue. Pin site irritation and infection are common, and a relatively high refracture rate and loss of knee range of motion and quadriceps strength have been reported64,65.
Plate and screw fixation is useful for very proximal or distal fractures, and when the medullary canal is too small for a nail44,49,54,59,66. The plate is inserted through a straight lateral approach. Alternatively, a minimally invasive technique with submuscular plating through small, transverse incisions may be utilized. Locking screws may be used for very proximal or distal fractures, to convert the construct to a fixed-angle construct. In a growing child, the plate generally must be removed before it is overgrown with bone. It is unclear whether or not the plate or screw holes act as a stress riser leading to an increased refracture rate in these patients.
Elastic stable intramedullary nails have become the treatment of choice for adolescent femoral fractures because they are simple and quick to insert, the incisions are small, and family acceptance is high52,55,56,60. The original indications for elastic stable intramedullary nails were Winquist Type-0 or 1, mid-diaphyseal fractures, but good results can be achieved when the devices are used for proximal, distal, and comminuted fractures. However, complications and loss of reduction are more likely in children who are eleven years of age or older, children heavier than 108 lb (49 kg), those with a distal or (especially) proximal fracture, and those with a comminuted or "length unstable" fracture67-71. Adjunctive immobilization or alternate treatment options should be considered in those cases. When flexible nails are chosen, the surgeon should always use two nails of the same diameter. Failure to do so will lead to angulation. The width of each nail should be 40% of the diameter of the diaphysis at its narrowest point. The canal should never be >80% filled. The nails are bent before insertion, such that the apex of the bend is at the fracture site. For mid-diaphyseal fractures being treated with retrograde insertion, the nails should be contoured into two "c" shapes. For proximal fractures being treated with antegrade insertion, the medial nail should be contoured into a "c" and the lateral nail, into an "s." The nails should be removed six months to one year after insertion. Overgrowth at the fracture site has not been a substantial problem with the use of elastic stable intramedullary nails. Complications include irritation at the insertion sites, the tendency for the fracture to fall into varus, and the potential for intra-articular nail penetration.
Trochanteric antegrade nails can be used in older, heavier children, and for unstable fracture patterns47,53,58,72-75. The technique is generally familiar to orthopaedists who treat adults, although there are some variations among available systems. These variations include cannulated versus non-cannulated nails, universal versus right and left nails, and nails that are prebent versus those requiring custom bending. The differences are not critical, but the surgeon should know the details of the system being used. Trochanteric antegrade nails generally do not require reaming; however, the nails are typically wider proximally than distally, and the proximal part of the canal may need to be reamed to accommodate this. Complications include potential harm to the hip abductors, potential osteonecrosis of the greater trochanter, and "explosion" of the proximal part of the femur during insertion76-81. The piriformis entry point is reserved for patients with closed physes, as cases of osteonecrosis of the femoral head have been reported in children with open physes76,80,81.
Distal femoral fractures in adolescents are due either to high-energy trauma or a sports-related injury82-86. A careful neurovascular examination of the injured extremity is necessary. Fractures of the distal part of the femur are either metaphyseal or physeal.
Metaphyseal fractures are classified by the direction of the apex of angulation. The gastrocnemius muscles pull the distal fragment posteriorly, producing an apex-posterior angulation. In patients who are less than ten years of age, closed reduction, percutaneous cross-pin fixation, and a long leg cast are satisfactory treatment. Loss of reduction is a risk, and the patient should be evaluated every week for at least the first three weeks. In patients ten years of age or older or those with a comminuted and/or unstable fracture, submuscular plating or external fixation is recommended. For distal fractures, locking screws may be used with the submuscular plate to achieve a fixed-angle device. For open fractures, patients with multiple injuries, or a floating knee, external fixation should be used.
Physeal fractures of the distal part of the femur are classified with the Salter-Harris system83,84,86. For intra-articular fractures, a CT scan may help to identify fracture lines and aid in preoperative planning. Vascular and nerve injuries are not infrequent. CT angiography is recommended if a vascular injury is suspected. Reduction of the fracture into anatomic alignment and maintenance of reduction are the goals of treatment for displaced fractures. For nondisplaced Salter-Harris Type-I and II physeal fractures, a long leg cast is usually adequate. If a cast alone is inadequate, stabilization with percutaneously placed, crossed, transphyseal, smooth pins is recommended; this is similar to the treatment for displaced Salter-Harris Type-I or II fractures with a small metaphyseal fragment after closed reduction. A long leg cast and close follow-up is recommended. The pins are removed at approximately four weeks. A Salter-Harris Type-II fracture with a large metaphyseal fragment can be stabilized with cannulated screws through the metaphyseal fragment into the metaphyseal bone and application of a long leg cast, avoiding transphyseal fixation. Displaced Salter-Harris Type-III and IV fractures should be anatomically reduced and internally fixed with cannulated compression screws placed across the fracture and parallel to the physis. All patients with a fracture of the distal femoral physis should remain non-weight-bearing until the fracture has healed. About 50% of all distal femoral physeal fractures lead to a growth disturbance, and patients with a Salter-Harris Type-II injury have the greatest risk of limb-length inequality or angular deformity87,88 (Fig. 4). Other potential complications include nonunion, which is treated with bone graft and rigid fixation, and arthrofibrosis, which is treated with knee manipulation and aggressive physical therapy after the fracture heals89,90.
In adolescents, tibial spine fractures occur with hyperextension of the knee, typically during bicycling. The pull of the anterior cruciate ligament (ACL) leads to an avulsion fracture of the tibial spine, which may extend into the medial or lateral tibial plateau. Pain, swelling due to hemarthrosis, and a positive Lachman test are present. The avulsed tibial spine fracture is best seen on the lateral radiograph. An MRI may be necessary for a patient younger than ten years of age, as much of the eminence is still cartilaginous. Tibial eminence fractures were classified by Meyers and McKeever into three types91. Type I is minimally displaced, Type II is displacement of the anterior part of the tibial spine with an intact posterior hinge, and Type III is complete separation of the avulsed fragment from the proximal tibial epiphysis. Zaricznyj92 described a Type-IV fracture, which is a comminuted tibial spine fracture fragment (Fig. 5). Type I is managed with a long leg cast with the limb flexed approximately 10° to 15° to avoid excessive tension on the ACL and further displacement of the tibial spine. If anatomic reduction of a Type-II fracture can be achieved by aspiration of the hemarthrosis and extension of the leg, then, like Type-I fractures, the Type-II fracture can be treated with a long leg cast, with weekly radiographs to ensure maintenance of reduction. For irreducible Type-II and Type-III fractures, arthroscopic or open reduction is recommended. An entrapped meniscus may be seen during arthroscopic surgery93. We prefer arthroscopic epiphyseal or transphyseal screw fixation for Type-II and Type-III fractures with a large fracture fragment, and we recommend suture fixation woven through the base of the ACL and tied over the metaphyseal bridge on the proximal part of the tibia for treatment of a Type-IV or small fracture fragment94. A transphyseal screw, if used, should be removed after three months to prevent growth disturbances95. The ACL may be stretched during this injury, but symptomatic instability is uncommon. Other potential complications include nonunion, malunion with resultant notch impingement, and arthrofibrosis.
Proximal tibial physeal fractures are categorized with the Salter-Harris classification. In adolescents, these fractures occur during sports activities or motor-vehicle accidents, with a valgus or a hyperextension force on a fixed knee83,86,96. A CT scan is recommended for complex, high-energy injuries such as Salter-Harris Type-III and IV fractures involving the tibial plateau. Neurovascular injuries and compartment syndromes are not uncommon, and the possibility that they are present should be considered for every patient. The principles of treatment for proximal tibial physeal fractures are similar to those for distal femoral physeal fractures. Potential complications include neurovascular injuries, compartment syndrome, and growth disturbances.
Metaphyseal fractures of the proximal part of the tibia are usually treated with closed reduction and a long leg cast. With low-energy fractures in patients less than ten years old, so-called Cozen fractures97, the most common complication is genu valgum in the first six to twelve months after the fracture due to medial proximal tibial overgrowth. No treatment is needed for this deformity, as it usually corrects spontaneously. For high-energy fractures in patients ten years of age or older, closed or open reduction and internal fixation with buttress plates and/or interfragmentary compression screws is used if the reduction cannot be held with a cast or if the patient cannot be treated with a long leg cast. Neurovascular injuries, compartment syndrome, and malunion are potential complications.
Tibial tubercle fractures occur most commonly in teenaged males who participate in repetitive jumping sports, and these injuries usually cause pain, swelling, and an inability to extend the knee against gravity. The fractures are classified according to the Watson-Jones classification, as modified by Ogden et al.98 (Fig. 6). Nondisplaced Type-I fractures without an extensor lag can be treated in a cylinder cast with the knee in extension for four to six weeks, followed by rehabilitation. All displaced fractures (Types II, III, and IV) require open anatomic reduction and internal fixation with 4.5 or 6-mm screws. For Type-III fractures, arthroscopic or open joint visualization should be performed to ensure adequate joint-surface reduction. Type-IV fractures are similar to Salter-Harris Type-I or II fractures of the proximal part of the tibia, with a potential for neurovascular injuries. For Type-V fractures, the periosteal sleeve should be reattached with use of sutures or suture anchors. Prophylactic anterior compartment fasciotomy should be performed. Postoperatively, the knee should be immobilized until the bone heals. Potential complications include prominent implants requiring removal, compartment syndrome, and genu recurvatum due to premature closure of the tibial apophysis.
Physeal injuries to the ankle account for 15% to 38% of all physeal injuries99-102. The distal tibial physis appears by one year of age and closes by twelve to fourteen years of age in girls and by fifteen to eighteen years of age in boys. The distal fibular physis appears by two years of age and closes somewhat later than the distal tibial physis—i.e., by the age of nineteen to twenty. The medial malleolus projection appears by the age of seven and is fully formed by the age of ten. Ankle physeal injury patterns are partly due to the physeal anatomy as it relates to the patient's age. The distal tibial physis closes in a circular pattern that proceeds from the center to medial to lateral, and the fracture patterns reflect the areas of the physis that are still open. A CT scan is recommended for intra-articular fractures to evaluate for articular displacement, physeal congruity, and surgical planning103,104. A CT scan is also recommended after initial reduction if there are concerns about persistent or recurrent displacement. The ankle fracture classifications commonly used for adults, such as the Weber105,106 and Lauge-Hansen107-110 systems, are not useful for adolescents. The Dias-Tachdjian111 classification incorporates the Salter-Harris classification; the first word in each descriptor indicates the position of the foot, and the second indicates the direction of the force. The Vahvanen-Aalto112 classification stratifies physeal ankle fractures into two groups: group I comprises low-risk avulsion fractures and epiphyseal separations and group II, high-risk transphyseal fractures.
Patients with a nondisplaced Salter-Harris Type-I or II fracture should be treated with a below-the-knee walking cast for three to four weeks. Patients with a displaced Salter-Harris Type-I or II fracture should have a closed reduction under appropriate sedation followed by application of a well-molded above-the-knee cast, which can be switched to a below-the-knee cast after three weeks. If there is a physeal gap or translation of >2 mm after a closed reduction, an open reduction and fixation is indicated. A periosteal flap often prevents an anatomic reduction and, if it is not removed, there is a 60% incidence of premature physeal closure113. In children less than ten years of age, the acceptable reduction parameters are <10° of flexion or extension and <20° of varus or valgus angulation. In children ten years or older, no more than 5° of angulation in any direction should be accepted. Most Salter-Harris Type-III and IV fractures require open reduction and internal fixation to obtain and maintain an anatomic reduction and joint congruity. An accurate reduction helps prevent premature growth arrest99,112,114,115. Pins or screws can be used for fixation. Transphyseal fixation should be avoided if possible, but, if transphyseal fixation is necessary, smooth pins should be used and should be removed at three to four weeks. Use of a short leg cast or splint for four to six weeks is recommended. Once the cast is removed, motion and proprioception exercises should be performed before the patient returns to full activity. Radiographs should be obtained at three-month intervals for at least a year to check for growth arrest116-118.
The Tillaux fracture is a Salter-Harris Type-III fracture of the anterolateral portion of the distal tibial epiphysis, which is the final tibial physeal area to close119. It appears on the anteroposterior radiograph as a vertical line through the epiphysis. The appropriate closed reduction maneuver is internal rotation of the foot; however, these fractures may require open reduction to restore the joint surface and prevent articular degeneration. One or two pins or screws placed through the epiphysis are usually sufficient. Tillaux fractures occur toward the conclusion of physeal closure, and symptomatic growth arrest is rare.
A triplane fracture is a multiplanar Salter-Harris Type-IV fracture120, which appears as a Salter-Harris Type-II fracture on the lateral radiograph and a Salter-Harris Type-III fracture on the anteroposterior radiograph. Patients with such a fracture are usually younger than those who have a Tillaux fracture and more of the physis is open, but a growth arrest is clinically unimportant. These fractures are usually described as being in two or three parts, but they may also be in four parts. Because these patterns are so complicated, a CT scan helps one assess the fracture pattern, and it is suggested that CT be performed before surgery.
The closed reduction maneuver for a typical triplane fracture is flexion of the knee to 90°, and plantar flexion and internal rotation of the foot, with the patient under adequate sedation or general anesthesia. Multiple or forceful reduction attempts should be avoided. If the reduction is acceptable, the limb is immobilized in a long leg cast for three weeks, after which a short leg cast is worn for three weeks. If there is a concern about redisplacement, percutaneous screw fixation in a medial-lateral plane in the epiphysis and in the anterior-posterior plane in the metaphysis should be performed at the time of the initial reduction. If closed reduction is unacceptable, open reduction should be performed with use of an anterolateral or anteromedial incision and a posterolateral or posteromedial incision. The goal of open reduction is to obtain a congruous joint surface.
The challenges in the management of fractures in adolescents are unique and should be recognized. These fractures should not be grouped with pediatric fractures, for which nonoperative treatment often suffices. The presence of physes and unique bone characteristics should differentiate the fracture management in adolescents from that of their adult counterparts.
Dimeglio
A. Growth in pediatric orthopaedics. J Pediatr Orthop.
2001;21:549-55.[PubMed]
Tanner
JM;
Whitehouse
RH. Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty. Arch Dis Child.
1976;51:170-9.[PubMed]
Rathjen
KE;
Birch
JG. Physeal injuries and growth disturbances. : Beaty
JH;
Kasser
JR, . Rockwood and Wilkins’ fractures in children. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p 99-131.
Pattussi
MP;
Lalloo
R;
Bassani
DG;
Olinto
MT. The role of psychosocial, behavioural and emotional factors on self-reported major injuries in Brazilian adolescents: a case-control study. Injury.
2008;39:561-9.[PubMed]
Valovich McLeod
TC;
Bay
RC;
Parsons
JT;
Sauers
EL;
Snyder
AR. Recent injury and health-related quality of life in adolescent athletes. J Athl Train.
2009;44:603-10.[PubMed]
Bienkowski
P;
Harvey
EJ;
Reindl
R;
Berry
GK;
Benaroch
TE;
Ouellet
JA. The locked flexible intramedullary humerus nail in pediatric femur and tibia shaft fractures: a feasibility study. J Pediatr Orthop.
2004;24:634-7.[PubMed]
Mehlman
CT;
Bishai
SK. Tibial nails for femoral shaft fractures in large adolescents with open femoral physes. J Trauma.
2007;63:424-8.[PubMed]
Greulich
WW;
Pyle
SI. Radiographic atlas of skeletal development of the hand and wrist. 2nd ed. Stanford: Stanford University Press; 1959.
Pyle
SI;
Hoerr
NL. Radiographic atlas of skeletal development of the knee; a standard of reference. Springfield: Charles C. Thomas; 1955.
Diméglio
A;
Charles
YP;
Daures
JP;
de Rosa
V;
Kaboré
B. Accuracy of the Sauvegrain method in determining skeletal age during puberty. J Bone Joint Surg Am.
2005;87:1689-96.[PubMed]
Risser
JC. The iliac apophysis; an invaluable sign in the management of scoliosis. Clin Orthop.
1958;11:111-9.[PubMed]
Acheson
RM. The Oxford method of assessing skeletal maturity. Clin Orthop.
1957;10:19-39.[PubMed]
Tanner
JM;
Healy
MJR;
Goldstein
H;
Cameron
N. Assessment of skeletal maturity and prediction of adult height (TW3 method). 3rd ed. London: WB Saunders; 2001.
Sanders
JO;
Khoury
JG;
Kishan
S;
Browne
RH;
Mooney
JF
3rd;
Arnold
KD;
McConnell
SJ;
Bauman
JA;
Finegold
DN. Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence. J Bone Joint Surg Am.
2008;90:540-53.[PubMed]
Sanders
JO. Maturity indicators in spinal deformity. J Bone Joint Surg Am.
2007;89
Suppl 1:14-20.[PubMed]
Salter
RB;
Harris
WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am.
1963;45:587-622.
Rang
M;
Pring
ME;
Wenger
DR. Rang's children's fractures. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2005.
Peterson
HA. Physeal fractures: part 2. Two previously unclassified types. J Pediatr Orthop.
1994;14:431-8.[PubMed]
Boutis
K;
Narayanan
UG;
Dong
FF;
Mackenzie
H;
Yan
H;
Chew
D;
Babyn
P. Magnetic resonance imaging of clinically suspected Salter-Harris I fracture of the distal fibula. Injury.
2010;41:852-6.[PubMed]
Carey
J;
Spence
L;
Blickman
H;
Eustace
S. MRI of pediatric growth plate injury: correlation with plain film radiographs and clinical outcome. Skeletal Radiol.
1998;27:250-5.[PubMed]
Havránek
P;
Lizler
J. Magnetic resonance imaging in the evaluation of partial growth arrest after physeal injuries in children. J Bone Joint Surg Am.
1991;73:1234-41.[PubMed]
Foster
BK;
John
B;
Hasler
C. Free fat interpositional graft in acute physeal injuries: the anticipatory Langenskiöld procedure. J Pediatr Orthop.
2000;20:282-5.[PubMed]
Langenskiöld
A. The possibilities of eliminating premature partial closure of an epiphyseal plate caused by trauma or disease. Acta Orthop Scand.
1967;38:267-79.
Lee
TM;
Mehlman
CT. Hyphenated history: Park-Harris growth arrest lines. Am J Orthop (Belle Mead NJ).
2003;32:408-11.[PubMed]
Ogden
JA. Growth slowdown and arrest lines. J Pediatr Orthop.
1984;4:409-15.[PubMed]
Anderson
M;
Messner
MB;
Green
WT. Distribution of lengths of the normal femur and tibia in children from one to eighteen years of age. J Bone Joint Surg Am.
1964;46:1197-202.[PubMed]
Menelaus
MB. Correction of leg length discrepancy by epiphysial arrest. J Bone Joint Surg Br.
1966;48:336-9.[PubMed]
Moseley
CF. A straight-line graph for leg-length discrepancies. J Bone Joint Surg Am.
1977;59:174-9.[PubMed]
Ogden
JA. The evaluation and treatment of partial physeal arrest. J Bone Joint Surg Am.
1987;69:1297-302.[PubMed]
Paley
D;
Bhave
A;
Herzenberg
JE;
Bowen
JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am.
2000;82:1432-46.[PubMed]
Peterson
HA. Partial growth plate arrest and its treatment. J Pediatr Orthop.
1984;4:246-58.[PubMed]
Mehlman
CT. Injuries to the lateral end of the clavicle and AC joint: a pediatric perspective. J Am Osteo Acad Orthop.
1996;33:82-3, .
McGraw
MA;
Mehlman
CT;
Lindsell
CJ;
Kirby
CL. Postnatal growth of the clavicle: birth to 18 years of age. J Pediatr Orthop.
2009;29:937-43.[PubMed]
Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am.
2007;89:1-10.
Mehlman
CT;
Yihua
G;
Bochang
C;
Zhigang
W. Operative treatment of completely displaced clavicle shaft fractures in children. J Pediatr Orthop.
2009;29:851-5.[PubMed]
Vander Have
KL;
Perdue
AM;
Caird
MS;
Farley
FA. Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents. J Pediatr Orthop.
2010;30:307-12.[PubMed]
Altamimi
SA;
McKee
MD; Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. Surgical technique. J Bone Joint Surg Am.
2008;2(
Pt 1):1-8.
Qin
D;
Zhang
Q;
Zhang
YZ;
Pan
JS;
Chen
W. Safe drilling angles and depths for plate-screw fixation of the clavicle: avoidance of inadvertent iatrogenic subclavian neurovascular bundle injury. J Trauma.
2010;69:162-8.[PubMed]
Mehlman
CT;
Wall
EJ. Injuries to the shafts of the radius and ulna. : Beaty
JH;
Kasser
JR, . Rockwood and Wilkins’ fractures in children. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p
399-441.
Price
CT;
Scott
DS;
Kurzner
ME;
Flynn
JC. Malunited forearm fractures in children. J Pediatr Orthop.
1990;10:705-12.[PubMed]
Mehlman
CT;
Wall
EJ. Injuries to the shafts of the radius and ulna. : Beaty
JH;
Kasser
JR, . Rockwood and Wilkins’ fractures in children. 7th ed. Philadelphia: Lippincott, Williams & Wilkins; 2010. p
347-402.
Younger
AS;
Tredwell
SJ;
Mackenzie
WG;
Orr
JD;
King
PM;
Tennant
W. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop.
1994;14:200-6.[PubMed]
Zionts
LE;
Zalavras
CG;
Gerhardt
MB. Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents. J Pediatr Orthop.
2005;25:507-12.[PubMed]
Agus
H;
Kalenderer
O;
Eryanilmaz
G;
Omeroglu
H. Biological internal fixation of comminuted femur shaft fractures by bridge plating in children. J Pediatr Orthop.
2003;23:184-9.[PubMed]
Aronson
J;
Tursky
EA. External fixation of femur fractures in children. J Pediatr Orthop.
1992;12:157-63.[PubMed]
Bar-On
E;
Sagiv
S;
Porat
S. External fixation or flexible intramedullary nailing for femoral shaft fractures in children. A prospective, randomised study. J Bone Joint Surg Br.
1997;79:975-8.[PubMed]
Beaty
JH;
Austin
SM;
Warner
WC;
Canale
ST;
Nichols
L. Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: preliminary results and complications. J Pediatr Orthop.
1994;14:178-83.[PubMed]
Blasier
RD;
Aronson
J;
Tursky
EA. External fixation of pediatric femur fractures. J Pediatr Orthop.
1997;17:342-6.[PubMed]
Caird
MS;
Mueller
KA;
Puryear
A;
Farley
FA. Compression plating of pediatric femoral shaft fractures. J Pediatr Orthop.
2003;23:448-52.[PubMed]
Czertak
DJ;
Hennrikus
WL. The treatment of pediatric femur fractures with early 90-90 spica casting. J Pediatr Orthop.
1999;19:229-32.[PubMed]
Ferguson
J;
Nicol
RO. Early spica treatment of pediatric femoral shaft fractures. J Pediatr Orthop.
2000;20:189-92.[PubMed]
Flynn
JM;
Hresko
T;
Reynolds
RA;
Blasier
RD;
Davidson
R;
Kasser
J. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop.
2001;21:4-8.[PubMed]
Kanellopoulos
AD;
Yiannakopoulos
CK;
Soucacos
PN. Closed, locked intramedullary nailing of pediatric femoral shaft fractures through the tip of the greater trochanter. J Trauma.
2006;60:217-23.[PubMed]
Kregor
PJ;
Song
KM;
Routt
ML
Jr;
Sangeorzan
BJ;
Liddell
RM;
Hansen
ST
Jr. Plate fixation of femoral shaft fractures in multiply injured children. J Bone Joint Surg Am.
1993;75:1774-80.[PubMed]
Ligier
JN;
Metaizeau
JP;
Prévot
J;
Lascombes
P. Elastic stable intramedullary pinning of long bone shaft fractures in children. Z Kinderchir.
1985;40:209-12.[PubMed]
Ligier
JN;
Metaizeau
JP;
Prévot
J;
Lascombes
P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br.
1988;70:74-7.[PubMed]
Stans
AA;
Morrissy
RT;
Renwick
SE. Femoral shaft fracture treatment in patients age 6 to 16 years. J Pediatr Orthop.
1999;19:222-8.[PubMed]
Townsend
DR;
Hoffinger
S. Intramedullary nailing of femoral shaft fractures in children via the trochanter tip. Clin Orthop Relat Res.
2000;376:113-8.[PubMed]
Ward
WT;
Levy
J;
Kaye
A. Compression plating for child and adolescent femur fractures. J Pediatr Orthop.
1992;12:626-32.[PubMed]
Ziv
I;
Blackburn
N;
Rang
M. Femoral intramedullary nailing in the growing child. J Trauma.
1984;24:432-4.[PubMed]
Kocher
MS;
Sink
EL;
Blasier
RD;
Luhmann
SJ;
Mehlman
CT;
Scher
DM;
Matheney
T;
Sanders
JO;
Watters
WC
3rd;
Goldberg
MJ;
Keith
MW;
Haralson
RH
3rd;
Turkelson
CM;
Wies
JL;
Sluka
P;
Hitchcock
K. Treatment of pediatric diaphyseal femur fractures: guideline and evidence report. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009.
Domb
BG;
Sponseller
PD;
Ain
M;
Miller
NH. Comparison of dynamic versus static external fixation for pediatric femur fractures. J Pediatr Orthop.
2002;22:428-30.[PubMed]
Nork
SE;
Hoffinger
SA. Skeletal traction versus external fixation for pediatric femoral shaft fractures: a comparison of hospital costs and charges. J Orthop Trauma.
1998;12:563-8.[PubMed]
Miner
T;
Carroll
KL. Outcomes of external fixation of pediatric femoral shaft fractures. J Pediatr Orthop.
2000;20:405-10.[PubMed]
Skaggs
DL;
Leet
AI;
Money
MD;
Shaw
BA;
Hale
JM;
Tolo
VT. Secondary fractures associated with external fixation in pediatric femur fractures. J Pediatr Orthop.
1999;19:582-6.[PubMed]
Eren
OT;
Kucukkaya
M;
Kockesen
C;
Kabukcuoglu
Y;
Kuzgun
U. Open reduction and plate fixation of femoral shaft fractures in children aged 4 to 10. J Pediatr Orthop.
2003;23:190-3.[PubMed]
Flynn
JM;
Luedtke
L;
Ganley
TJ;
Pill
SG. Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. Am J Orthop (Belle Mead NJ).
2002;31:71-4.[PubMed]
Luhmann
SJ;
Schootman
M;
Schoenecker
PL;
Dobbs
MB;
Gordon
JE. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop.
2003;23:443-7.[PubMed]
Moroz
LA;
Launay
F;
Kocher
MS;
Newton
PO;
Frick
SL;
Sponseller
PD;
Flynn
JM. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br.
2006;88:1361-6.[PubMed]
Rohde
RS;
Mendelson
SA;
Grudziak
JS. Acute synovitis of the knee resulting from intra-articular knee penetration as a complication of flexible intramedullary nailing of pediatric femur fractures: report of two cases. J Pediatr Orthop.
2003;23:635-8.[PubMed]
Wall
EJ;
Jain
V;
Vora
V;
Mehlman
CT;
Crawford
AH. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am.
2008;90:1305-13.[PubMed]
Jencikova-Celerin
L;
Phillips
JH;
Werk
LN;
Wiltrout
SA;
Nathanson
I. Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures. J Pediatr Orthop.
2008;28:864-73.[PubMed]
Keeler
KA;
Dart
B;
Luhmann
SJ;
Schoenecker
PL;
Ortman
MR;
Dobbs
MB;
Gordon
JE. Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. J Pediatr Orthop.
2009;29:345-51.[PubMed]
Momberger
N;
Stevens
P;
Smith
J;
Santora
S;
Scott
S;
Anderson
J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop.
2000;20:482-4.[PubMed]
Timmerman
LA;
Rab
GT. Intramedullary nailing of femoral shaft fractures in adolescents. J Orthop Trauma.
1993;7:331-7.[PubMed]
Buckaloo
JM;
Iwinski
HJ;
Bertrand
SL. Avascular necrosis of the femoral head after intramedullary nailing of a femoral shaft fracture in a male adolescent. J South Orthop Assoc.
1997;6:97-100.[PubMed]
González-Herranz
P;
Burgos-Flores
J;
Rapariz
JM;
Lopez-Mondejar
JA;
Ocete
JG;
Amaya
S. Intramedullary nailing of the femur in children. Effects on its proximal end. J Bone Joint Surg Br.
1995;77:262-6.[PubMed]
Gordon
JE;
Swenning
TA;
Burd
TA;
Szymanski
DA;
Schoenecker
PL. Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am.
2003;85:1295-301.[PubMed]
Letts
M;
Jarvis
J;
Lawton
L;
Davidson
D. Complications of rigid intramedullary rodding of femoral shaft fractures in children. J Trauma.
2002;52:504-16.[PubMed]
Mileski
RA;
Garvin
KL;
Huurman
WW. Avascular necrosis of the femoral head after closed intramedullary shortening in an adolescent. J Pediatr Orthop.
1995;15:24-6.[PubMed]
Raney
EM;
Ogden
JA;
Grogan
DP. Premature greater trochanteric epiphysiodesis secondary to intramedullary femoral rodding. J Pediatr Orthop.
1993;13:516-20.[PubMed]
Riseborough
EJ;
Barrett
IR;
Shapiro
F. Growth disturbances following distal femoral physeal fracture-separations. J Bone Joint Surg Am.
1983;65:885-93.[PubMed]
Edwards
PH
Jr;
Grana
WA. Physeal fractures about the knee. J Am Acad Orthop Surg.
1995;3:63-9.[PubMed]
Eid
AM;
Hafez
MA. Traumatic injuries of the distal femoral physis. Retrospective study on 151 cases. Injury.
2002;33:251-5.[PubMed]
Sferopoulos
NK. Concomitant physeal fractures of the distal femur and proximal tibia. Skeletal Radiol.
2005;34:427-30.[PubMed]
Zionts
LE. Fractures around the knee in children. J Am Acad Orthop Surg.
2002;10:345-55.[PubMed]
Basener
CJ;
Mehlman
CT;
DiPasquale
TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma.
2009;23:663-7.[PubMed]
Ilharreborde
B;
Raquillet
C;
Morel
E;
Fitoussi
F;
Bensahel
H;
Penneçot
GF;
Mazda
K. Long-term prognosis of Salter-Harris type 2 injuries of the distal femoral physis. J Pediatr Orthop B.
2006;15:433-8.[PubMed]
Goldberg
BA;
Mansfield
DS;
Davino
NA. Nonunion of a distal femoral epiphyseal fracture-separation. Am J Orthop (Belle Mead NJ).
1996;25:773-7.[PubMed]
Hart
AJ;
Eastwood
DM;
Dowd
GS. Fixed flexion deformity of the knee following femoral physeal fracture: the Inverted Cyclops lesion. Injury.
2004;35:1330-3.[PubMed]
Meyers
MH;
McKeever
FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am.
1959;41:209-22.[PubMed]
Zaricznyj
B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am.
1977;59:1111-4.[PubMed]
Kocher
MS;
Micheli
LJ;
Gerbino
P;
Hresko
MT. Tibial eminence fractures in children: prevalence of meniscal entrapment. Am J Sports Med.
2003;31:404-7.[PubMed]
Hirschmann
MT;
Mayer
RR;
Kentsch
A;
Friederich
NF. Physeal sparing arthroscopic fixation of displaced tibial eminence fractures: a new surgical technique. Knee Surg Sports Traumatol Arthrosc.
2009;17:741-7.[PubMed]
Kocher
MS;
Saxon
HS;
Hovis
WD;
Hawkins
RJ. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group. J Pediatr Orthop.
2002;22:452-7.[PubMed]
Mubarak
SJ;
Kim
JR;
Edmonds
EW;
Pring
ME;
Bastrom
TP. Classification of proximal tibial fractures in children. J Child Orthop.
2009;3:191-7.[PubMed]
Cozen
L. Fracture of the proximal portion of the tibia in children followed by valgus deformity. Surg Gynecol Obstet.
1953;97:183-8.[PubMed]
Ogden
JA;
Tross
RB;
Murphy
MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am.
1980;62:205-15.[PubMed]
Kay
RM;
Matthys
GA. Pediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg.
2001;9:268-78.[PubMed]
Mann
DC;
Rajmaira
S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop.
1990;10:713-6.[PubMed]
Rogers
LF. The radiography of epiphyseal injuries. Radiology.
1970;96:289-99.[PubMed]
Crawford
AH;
Al-Sayyad
MJ;
Mehlman
CT. Fractures and dislocations of the foot and ankle. : Green
NE;
Swiontkowski
MF, . Skeletal trauma in children. 4th ed. Philadelphia: Saunders; 2008. 507-84.
Cutler
L;
Molloy
A;
Dhukuram
V;
Bass
A. Do CT scans aid assessment of distal tibial physeal fractures?J Bone Joint Surg Br.
2004;86:239-43.[PubMed]
Horn
BD;
Crisci
K;
Krug
M;
Pizzutillo
PD;
MacEwen
GD. Radiologic evaluation of juvenile Tillaux fractures of the distal tibia. J Pediatr Orthop.
2001;21:162-4.[PubMed]
Weber
BG. Die Verletzungen des oberen Sprunggelenkes. Bern: Huber; 1966.
Danis
R. Les fractures malleolaires. : Danis
R, . Théorie et pratique de l'osteosynthese. Paris: Masson; 1949.
Lauge-Hansen
N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg.
1950;60:957-85.[PubMed]
Lauge-Hansen
N. Fractures of the ankle. IV. Clinical use of genetic roentgen diagnosis and genetic reduction. AMA Arch Surg.
1952;64:488-500.[PubMed]
Lauge-Hansen
N. Fractures of the ankle. V. Pronation-dorsiflexion fracture. AMA Arch Surg.
1953;67:813-20.[PubMed]
Lauge-Hansen
N. Fractures of the ankle. III. Genetic roentgenologic diagnosis of fractures of the ankle. Am J Roentgenol Radium Ther Nucl Med.
1954;71:456-71.[PubMed]
Dias
LS;
Tachdjian
MO. Physeal injuries of the ankle in children: classification. Clin Orthop Relat Res.
1978;136:230-3.[PubMed]
Vahvanen
V;
Aalto
K. Classification of ankle fractures in children. Arch Orthop Trauma Surg.
1980;97:1-5.[PubMed]
Barmada
A;
Gaynor
T;
Mubarak
SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop.
2003;23:733-9.[PubMed]
Kling
TF
Jr.;
Bright
RW;
Hensinger
RN. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am.
1984;66:647-57.[PubMed]
Spiegel
PG;
Cooperman
DR;
Laros
GS. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of two hundred and thirty-seven cases in children. J Bone Joint Surg Am.
1978;60:1046-50.[PubMed]
Berson
L;
Davidson
RS;
Dormans
JP;
Drummond
DS;
Gregg
JR. Growth disturbances after distal tibial physeal fractures. Foot Ankle Int.
2000;21:54-8.[PubMed]
Kärrholm
J;
Hansson
LI;
Laurin
S;
Selvik
G. Post-traumatic growth disturbance of the ankle treated by the Langenskiöld procedure. Evaluation by radiography, roentgen stereophotogrammetry, scintimetry and histology: case report. Acta Orthop Scand.
1983;54:721-9.[PubMed]
Leary
JT;
Handling
M;
Talerico
M;
Yong
L;
Bowe
JA. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop.
2009;29:356-61.[PubMed]
Kleiger
B;
Mankin
HJ. Fracture of the lateral portion of the distal tibial epiphysis. J Bone Joint Surg Am.
1964;46:25-32.[PubMed]
Cooperman
DR;
Spiegel
PG;
Laros
GS. Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture. J Bone Joint Surg Am.
1978;60:1040-6. [PubMed]