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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Triplane Fracture


- Discussion:
    - name derives from the fact that the fracture exists in the frontal, lateral, and transverse planes;
    - frx tends to occur in older children and young adolescents during an 18 month window, prior to physeal closure;
          - lateral portion of epiphysis is the last to close leaving it vulnerable to injury;
    - epiphyseal arrest and angular deformity are uncommon;
    - there are 3 types of frxs: two-part, three-part frx, and four part;
          - note that this fracture does not fit well into the Salter-Harris classification and is considered an atypical fractures;
    - mechanism:
          - occurs due to external rotation forces;
          - this injury most commonly occurs just before epiphyseal closure & mechanism of injury is forced external rotation.
          - anterior part of frx begins intra-articularly in saggital plane;
          - when frx reaches epiphyseal plate, it courses laterally in horizontal plane, and posterior portion changes direction upward in saggital plane;
    - two part frx: (most common)
          - type of SH type IV frx;
          - occurs when the medial portion of of the distal tibial epiphysis is closed;
          - lateral view: shows Salter type IV frx;
          - posterior plafond fragment extends across epiphyseal plate to involve metaphysis of the tibia;
          - may be comminuted w/ separation of posterior half from lateral three fourths;
          - reference:
                    - The medial triplane fracture: report of an unusual injury.

    - three part frx:
           - combination of SH types II & III frx;
           - occurs when only the middle portion of the distal tibial epiphysis is closed;
           - appears as SH type III frx on AP view & type II on lateral;
           - frx of anterolateral portion of epiphysis of distal tibia (similar to Tillaux frx);
           - frx of large posterior fragment comprised of posterior & medial portions of tibial epiphysis plus a large metaphyseal fragment of variable size;
           - medial one fourth of plafond and medial malleolus are left intact;
           - fibula may also be fractured;


- Radiology:

    - three part frx appears as SH type III frx on AP view & type II on lateral;
    - look for associated spiral frx of fibula (frx occurs in 50% of patients);
    - CT scan:
         - there is usually more deformity of articular surface than would be anticipated from radiographs;
    - tomograms may be useful to determine extent of injury & displacement;


- Non Operative Treatment:
    - most indicated for extra-articular fractures;
    - most two part triplane frx, can be treated by closed reduction under GEA;
    - closed reduction is successful when frxs is displaced < 2 mm & when joint surface is congruous;
    - closed reduction is achieved by internal rotation of foot & long leg cast for 4 weeks followed by short leg casting for 2-3 weeks;
    - these frxs are often assoc w/ significant soft-tissue swelling, which makes maintenance of reduction w/ cast somewhat difficult;
         - it is not unusual for reduction obtained to slip once swelling has subsided;


- Indications for Operative Treatment:

    - any significant displacement ( > 3 mm) requires surgical fixation;
    - most often, 3 part frx will require ORIF;

- Surgical Technique:
    - because of complex frx pattern, adequate reduction may be difficult;
    - wide dissection may be necessary to achieve reduction;
    - surgical technique depends on whether frx is two part or three part frx
    - screws used to provide fixation should not cross growth plate, unless patient is nearing the end of growth.
    - technique for three part frx:
          - open reduction of both SH type II & type III components is necessary & requires adequate exposure;
          - implants:
                - stabilization w/ two screws, placed percutaneously, obliquely through anterolateral epiphyseal fragment, & an AP screw to stabilize posterior metaphyseal fragment;
          - incision: anterolateral incision;
          - anterolateral fragment is identified and displaced to allow for visualization of posteromedial fragment;
          - reduction of posteromedial fragment is achieved under direct vision thru internal rotation and dorsiflexion of foot;
          - posteromedial fragment is fixed w/ K wire or cancellous screws in an AP direction from anterior aspect of distal tibia into posterior fragment;
          - associated fibular frx is subsequently reduced and fixed;
          - at this point, the frx has been essential converted to a Tillaux frx;
          - anterolateral fragment is reduced and fixed w/ K wires or cancellous screw;
          - other surgeons advocate fixing the anterolateral fragment first (through an anterolateral approach), then fixing the posteromedial fragment (w/ reduction achieved using dorsiflexion and internal rotation of the foot);
          - controversies: ankle arthroscopy to evaluate for articular incongruity;
                  - reference:
                         - Arthroscopically assisted percutaneous fixation of triplane fracture of the distal tibia.

- Complications:
    - growth deformities are uncommon because frx occurs at end period of skeletal maturity


Triplane fracture of the distal tibial epiphysis. Long-term follow-up.

Triplane fractures of the distal tibial epiphysis.

Operative treatment of ankle fractures in children.

Pronation injuries of the ankle in children. Retrospective study of  radiographical classification and treatment.

Team physician #4. Avulsion fracture of the distal tibial epiphysis in  skeletally immature athletes (juvenile Tillaux fracture).

Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus.

Fractures of the distal tibial epiphysis in adolescence.

Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture.

Late results in 65 physeal ankle fractures.

Changes in tibiofibular relationships due to growth disturbances after ankle fractures in children.

Children's ankle fractures. Classification and epidemiology.

Prediction of growth pattern after ankle fractures in children.

Supination-adduction injuries of the ankle in children--radiographical classification and treatment.

Roentgen stereophotogrammetric analysis of growth pattern after pronation ankle injuries in children.

Roentgen stereophotogrammetric analysis of growth pattern after supination-adduction ankle injuries in children.

Roentgen stereophotogrammetric analysis of growth pattern after supination--eversion ankle injuries in children.

Avulsion fracture of the lateral malleolus in children.

Classification of ankle fractures in children.

Physeal injuries of the ankle in children: classification.

Triplane fracture of the distal tibial epiphysis. Long-term follow-up.

Triplane fracture of the distal tibia.

Intramalleolar triplane fractures of the distal tibial epiphysis.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, December 10, 2012 3:13 pm