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Proximal Pediatric Tibial Metaphyseal Fractures

- Discussion:
    - frx of proximal tibial metaphysis are rare;
    - valgus greenstick fractures usually occur between 3-6 yrs of age;
    - cortex is slightly opened on the medial side;
    - distal fragment is angulated lateralward;

- Non Operative Treatment:
    - usually treated with closed methods;
    - frx is reduced before immobilization in cast;
    - place leg in long leg cast in extension for 6 weeks w/ documented varus molding;
    - ensure that valgus angulation is not present w/ knee in extension (either clinically or radiographically);
          - any valgus angulation must be corrected by closed manipulation under anesthesia and a long leg cast w/ knee in extension for 6 weeks;
    - inform patient's family of possibility of delayed vaglus angulation;

- Operative Treatment:
    - if closed reduction is impossible because of soft-tissue interposition, open anatomical reduction rarely may be indicated.

- Complications

- Delayed Valgus Angulation:
    - one complication unique to frxs of proximal metaphysis is valgus angulation;
    - frx may appear benign, with little or no angulation, but after healing occurrs, limb may drift into progressive valgus angulation;
    - natural history:
             - in the report by Muller, et al (2002), the authors determining the extent of the two typical
                    outcomes (valgus deformity and leg overgrowth) following proximal tibial fractures in children;
             - 7 children were retrospectively re-examined by their medical records and roentgenograms;
             - ages ranged from from 1 year 10 months to 10 years 2 months;
             - all the patients experienced a subjective recovery, with the exception of one child who had minor functional problems;
             - 6 patients developed a genu valgum (proximal tibia angle between 6 degrees and 16 degrees) and each of them was treated conservatively;
             - only two patients - both under the age of 5 - experienced a partial spontaneous correction;
             - overgrowth on the side of the fracture was observed in four cases, varying from 0.5 cm to 1.5 cm, most pronounced after
                      complete reduction and stable osteosynthesis;
             - the authors concluded that surgical correction and osteosynthesis as the preferred method of treatment, even with the increased likelihood of overgrowth;
              - Results of proximal metaphyseal fractures in children.
    - proposed causes of this angulation:
          - unrecognized valgus at time of original injury or overgrowth;
          - angulation may result from overgrowth of tibia w/o overgrowth of fibula;
          - presence greenstick fracture of proximal tibia w/ slight medial opening may contribute to progressive valgus deformity;
          - interposition of flap of fibrous tissue consisting of periosteum, MCL, & pes anserinus results in failure of medial gap to close;
                - normal growth may occur after removal of offending tissue;
          - increased vascular response resulting in asymmetrical growth stimulation of medial portion of the proximal tibial physis;
    - treatment of delayed valgus angulation:
          - spontaneous correction usually occurs with time;
          - therefore, it is generally advised to continue w/ non operative treatment, until natural history is clear;
          - increase in valgus angulation may occur for as long as 17 mo followed by spontaneous improvement w/ in 1-2 years;
          - deformity may improve over 5-10 years;
          - in the study by Tuten HR, et al (1999), 7 patients w/ post traumatic tibia valga were followed until deformity resolution;
                 - average age of injury was 4 years;
                 - the deformity typically occurred with 12 months of injury;
                 - resolution of the defomrity took, on average, 39 months;
                 - once the deformity had corrected, the affected limb was an average of 9 mm longer than the opposite;
                 - Posttraumatic tibia valga in children. A long-term follow-up note.
    - surgical treatment:
          - indications:
                 - failure to reduce fully any medial tibial cortical gap mandates surgical exploration and removal of interposed soft-tissue flap;
                 - if deformity is not sufficiently corrected by age of ten to twelve yrs, tibial osteotomy or hemiepiphyseodesis can then be performed if necessary;
          - surgical treatment:
                 - stapling of medial portion of physis or proximal tibial osteotomy;
                 - note that recurrence of valgus deformity is frequent after osteotomy in skeletally immature patients

Physeal arrest about the knee associated with non-physeal fractures in the lower extremity.

Fibrous interposition causing valgus deformity after fracture of the upper tibial metaphysis in children.

Spontaneous improvement in post traumatic valga.  

Acquired valgus deformity of the tibia in children.  

Genu valgum following fractures of the proximal tibial metaphyseal in children.  DH Bahnson and WW Lovell. Orthop Trans. 1980;4:306.