AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Triplane fractures of the distal tibia are generally sustained during adolescence and occur before complete closure of the distal tibial physis (growth plate). Incomplete closure of the tibial growth plate, as well as the stress forces applied during injury, are responsible for the unique occurrence of this fracture.

The fracture pattern extends through the transverse (growth plate), sagittal (epiphysis), and coronal (distal tibial metaphysis) anatomic planes, disrupting the tibial plafond intra-articularly.

Some practitioners prefer to call the fracture an adolescent tibial triplane fracture because this term is more descriptive of the age of occurrence, location, and fracture pattern.

History of the Procedure

What is now known as a triplane fracture is believed to have been first reported in 1957 by Johnson and Fahl. Ehalt, in 1961, and Titze, in 1967, described similar fractures of the distal lateral tibia and tibial epiphysis as transitional fractures.

In 1970, Marmor first described a fracture that involved the distal tibia and distal tibial epiphysis as having 3 separate fragments, including the anterolateral distal tibial epiphysis, the anteromedial and posterior portions of the distal tibial epiphysis with an attached posteromedial spike of the distal tibial metaphysis, and the remainder of the distal tibial metaphysis and shaft. This fracture pattern was recognized to have fracture lines in the transverse, coronal, and sagittal anatomic planes.

In 1972, Lynn first coined the term triplane fracture in his paper describing the reduction surgery in 2 patients with distal tibial epiphyseal injuries, both of whom had fractures in the sagittal, coronal, and transverse planes. In 1978, Cooperman reviewed 237 cases of distal tibial epiphyseal fractures. Fifteen (6%) were triplane fractures, of which 13 were treated by closed reduction.

In 1981, Denton and Fischer reported a triplane fracture that was unusual in that it was a medial triplane fracture. Von Laer (1985) and, later, Etrl (1988) continued investigations into the nature of the tibial triplane fracture.

Problem

Early discussions of distal tibial fractures occurring in adolescence lacked consistent and exact descriptions of the fracture fragments because plain radiographs were used to visualize and characterize the fragments. Additionally, involvement of the tibial growth plate in these fractures was suspected but not completely understood.

With the advent of computerized axial tomography (CT) and magnetic resonance imaging (MRI), delineating the exact anatomy, fracture lines, plane analysis, and other characteristics of the triplane fracture is now possible. In particular, any disruption that occurs at the growth plate, the anterior talofibular and tibiofibular ligament, and the talotibial articular plafond is visualized on CT scans.

Frequency

A review of the literature reveals epidemiologic characteristics of the triplane fracture as follows:

• Triplane fracture occurs most commonly in patients aged 12-15 years.
• It represents 5-10% of all pediatric intra-articular ankle injuries.
• Male-to-female frequency ratio varies in the literature from 1:1 to 2:1. In studies indicating a higher incidence in males, this is postulated to be caused by later closure of the lateral tibial growth plate in males than in females, thereby lengthening the period of vulnerability to injury for males.
• The right ankle is injured more often.
• Two-part triplane fractures occur more commonly and at a younger age than 3-part triplane fractures. This reflects the fact that relatively less closure of the tibial epiphysis exists in the 3-part group than in the 2-part group.
• Missed or incompletely diagnosed triplane fractures initially were evaluated with plain film radiography without further CT scan studies.
• Of the 8683 childhood and adolescent fractures evaluated by Landin (1983) over a 9-year study period, 4% (373) were ankle fractures.
  • More than 50% of ankle injuries were sustained during a fall.
  • Right-sided injury predominated almost 2:1.
  • Seasonally, over the 9-year study period, peak incidence was in April and September, with the lowest frequency in July and December.
  • Males sustained more ankle fractures than did females. For males, the incidence for each of the 2-year age groups studied was highest for those aged 15-16 years. For females, incidence was highest for those aged 13-14 years.
  • During the study period, the incidence of ankle injuries progressively increased. This may reflect the increasing popularity of roller skates, skateboards, and scooters.
• Devalentine (1987) indicated that upon review of 118 epiphyseal injuries in childhood, 25% involved the distal tibial or fibular epiphyses.
• Mac Nealy (1982) studied 194 cases of injuries of the distal tibial epiphysis and reported that 9.8% were triplane fractures.

Etiology

Triplane fracture is the result of several factors that exist simultaneously, including the following:

• A partially open distal lateral tibial growth plate creates a plane of weakness when a shearing force is applied. This condition is most commonly found during adolescence.
• External rotation (eversion) of the foot on the tibia (horizontal plane influence), which creates stress along the open distal lateral tibial growth plate, is the essential force that initiates a triplane fracture.
• Exact fracture lines are further propagated through the coronal and sagittal planes as a result of the foot being in plantar flexion (most common) and the varying forces of axial loading.

Pathophysiology

Triplane fracture of the distal tibia rarely occurs outside of adolescence. This is directly related to the pattern of distal tibial growth plate closure as skeletal maturity is attained (see Images 1-2).

The distal tibial epiphysis begins to close with a centrally located epiphyseal hump and proceeds medially, with posterior closure occurring before anterior closure. Adolescent children are susceptible to a triplane fracture following medial physeal closure and before lateral physeal closure.

Following medial closure, the lateral tibial growth plate closes progressively from the posteromedial area to the anterolateral area. The anteromedial tibial growth plate is the last area to close; therefore, it is more prone to injury than any other area of the tibial growth plate.

The entire process of distal tibial growth plate closure (physiologic epiphysiodesis) usually spans a period of 18 months. This process generally occurs when the individual is aged 12-15 years (mean age is 13.5 y), with complete closure occurring earlier in girls than in boys.

Regardless of the age of the patient, it is important to remember that variation (age range is 10-18 y) exists around the mean age of expected closure of the tibial growth plate. Any time the lateral distal tibial growth plate is open (unfused), the patient is susceptible to a triplane fracture.

As previously reviewed, a triplane fracture involves fracture lines in the sagittal, coronal, and transverse planes (see Images 3-4); however, there are 3 types of triplane fractures—2-part triplane fractures, 3-part triplane fractures, and 4-part triplane fractures. Each type may have a coexisting fibular fracture as well, but this is not counted as a component part of the triplane fracture; only tibial fragments are counted as such. Other rare and unusual variants of the 2-part and 3-part triplane fracture have been reported, such as the medial triplane fracture by Denton, in 1981, and the triplane fracture described in Images 5-8.

In a 2-part triplane fracture, the first fracture line in the transverse (horizontal) plane is through the tibial epiphysis, leaving the anteromedial portion of the epiphysis attached to the distal tibia. The second fracture line is in the sagittal plane through the epiphysis, lateral to the original formation of the epiphyseal fusion hump. The third fracture line is in the coronal plane and courses superiorly through the posterior metaphysis, producing a posterior metaphyseal spike. The resulting 2 fragments are (1) the lateral portion of the epiphysis attached to a posterior metaphyseal spike and (2) the distal tibia with the anteromedial epiphysis attached (see Image 3).

In a 3-part triplane fracture, 3 fracture lines again are present in each of the 3 anatomic planes; however, the fracture line in the coronal plane is complete in its course through the epiphysis, as well as through the posterior metaphysis. The 3 fracture fragments produced are (1) a rectangular fragment of the anterolateral portion of the epiphysis, (2) the remainder of the epiphysis with an attached posterior spike of the distal tibial metaphysis, and (3) the tibial shaft with the anteromedial epiphysis (see Image 4).

The 4-part triplane fracture is similar to the 3-part fracture, with the exception that the fourth fragment consists of the medial malleolus. This is a result of the extension of the fracture forces projecting more medially in the horizontal plane.

Clinical

History

Recreating the action that led to the injury assists the practitioner in predicting the area of injury. In a triplane fracture of the ankle, nearly all cases involve an external rotation (eversion) of the foot on the tibia, creating stress along the distal lateral open tibial growth plate. Other contributing forces that propagate the fracture lines are axial loading in combination with the foot being in plantar flexion (most common) and supination, abduction, or pronation.

Patients are more likely to be adolescent males with right-sided ankle injuries.

Inquire about other areas of injury or pain. The pain of a triplane fracture is sufficient to distract attention from other areas, even when a significant injury is present.

Document other chronic medical conditions (eg, prior injury or surgery; orthopedic hardware in the affected area of injury; diabetes; peripheral vascular disease; metabolic bone disease).

Determine current and recent medication use, including corticosteroids.

Physical

Patients with a triplane fracture of the ankle present with the following:

• Pain
• Swelling
• Possible ecchymosis
• Possible ankle deformity
• Inability to freely bear weight on the injured ankle

Observe all areas for evidence of open injury, including lacerations and abrasions. Ask the patient to demonstrate any ankle motion that can be performed voluntarily without assistance.

Check for posterior tibial and dorsalis pedis pulses, and compare these to the pulses on the uninjured side. Note that up to 15% of the population has a congenital absence of the dorsalis pedis artery. Check for adequate distal capillary artery refill—that is, 2 seconds or less.

Check for distal sensation and evidence of compartment syndrome tingling, decreased sensation, swelling, pale skin, diminished pulses, and severe pain with passive dorsiflexion of the foot.

Examine the knee and foot for tenderness, ecchymosis, and swelling. Radiographs of the knee and foot are needed if there are positive findings. Pay careful attention to the fibula, which must also be palpated and inspected along its entire length. Fibular fractures are commonly associated with triplane fractures. A fibular fracture likely to be missed upon initial evaluation is the Maisonneuve fracture of the proximal fibula, as reported by Healy in 1996.

Inspect and palpate other areas at high risk for fracture, the calcaneus, and the proximal fifth metatarsal. Cup the calcaneus as if it were a tennis ball, and gently compress it. If pain is elicited, be highly suspicious of a calcaneal fracture.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Surgical fixation of a triplane fracture should be undertaken if the residual fracture gap is 2 mm or greater after attempted closed reduction and casting.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Triplane fracture of the ankle involves the bony structures and their associated ligamentous supports as follows (see Image 2):

• The tibia is the main weight-bearing bone of the lower leg.
• Tibial metaphysis consists of the distal quarter of the tibia, excluding the tibial growth plate and epiphysis.
• The distal tibial physis, also called the growth plate, is located between the tibial metaphysis and the epiphysis.
• The distal tibial epiphysis is bordered proximally by the physeal growth plate and distally by its articulation with the articular surface of the talar dome.
• The fibula is situated laterally along the length of the tibia in the lower leg giving stability to the lateral ankle joint and serving in a non–weight-bearing role.

The ankle joint bears more weight per surface unit area than any other joint in the body. The ankle joint is formed by the fibula (laterally), the tibia (superiorly and medially), and the dome of the talus (inferiorly). The joint is saddle shaped. The dome of the talus becomes wider anteriorly, such that when the foot is in dorsiflexion, the talus is situated more snugly in the tibiofibular saddle than when the foot is plantar flexed. Thus, plantar flexion (a position contributing to the triplane fracture) is a less stable position of the ankle than is dorsiflexion.

The only pure motions of the ankle joint are dorsiflexion and plantar flexion. Inversion and eversion of the ankle joint take place at the subtalar joint formed by the opposition of the talus and the inferiorly situated calcaneus. The talus always moves in the same direction as the calcaneus in normal gait.

Ankle injuries typically follow forces that are directed perpendicularly (inversion or eversion) to the normal motion of the ankle. That motion is perpendicular to the motions of dorsiflexion and plantar flexion that occur in the sagittal plane.

Ligamentous support of the ankle is extensive. Ligaments situated laterally consist of anterior and posterior talofibular and tibiofibular ligaments. The strong deltoid ligament is located medially and is the only ligament of the ankle containing elastic fibers.

The tibia and fibula are joined by the anterior and posterior talofibular ligaments distally and the interosseous membrane more proximally.

Knowledge of the anatomic planes of the body is essential to understanding the lines, planes, and fragments produced in a triplane fracture. In the anatomic position (ie, with the person standing, palms forward), these 2-dimensional planes are as follows:

• The horizontal plane passes horizontally through the body.
• The coronal plane passes through the body from one shoulder to the other.
• The sagittal plane passes through the body from front to back, dividing it into equal right and left halves.

Motions of the ankle and foot are described by a number of interchangeable terms, including the following:

• Eversion - External rotation
• Inversion - Internal rotation
• Dorsiflexion - Extension
• Plantar flexion - Flexion
• Abduction - Lateral deviation of the proximal foot on a longitudinal axis through the tibia
• Adduction - Medial deviation of the proximal foot on a longitudinal axis through the tibia
• Supination - Adduction and inversion
• Pronation - Abduction and eversion

Neurovascular structures in the area of the ankle and foot include the following:

• Medially, both the posterior tibial artery and tibial nerve pass directly below the flexor retinaculum spanning between the distal tibia and the calcaneus.
• Dorsally and proximally, the anterior tibial artery and the deep fibular (peroneal) nerve pass directly below the flexor hallucis longus tendon.
• Dorsally and distally, the dorsalis pedis artery and the medial branch of the deep fibular (peroneal) nerve are situated laterally to the flexor hallucis longus tendon.
• Arterial pulses of the foot and ankle should be checked in any injury to the region and are readily palpable at the posterior tibial artery area medially and the dorsalis pedis artery area on the dorsum of the foot.

No major superficial neurovascular structures exist on the plantar or lateral surfaces of the foot or on the lateral lower leg.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

It is imperative that no surgical therapy for the fracture, initially or delayed, be attempted at the site of an existing or preexisting fracture blister because there is great risk of complications related to skin healing in the affected area (see Outcome and Prognosis).

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Lab Studies

• Laboratory studies performed in anticipation of the operating room depend on the age of the patient, the extent of all injuries, and other comorbid conditions. Triplane fractures most commonly occur in healthy adolescents. CBC, sequential multiple analysis (SMA7), urinalysis, and blood type and screen are reasonable, but not mandatory, preoperative studies.

Imaging Studies

• Plain film radiography of the ankle (distal tibia, fibula, and talus): If the patient demonstrates localized pain, inability to fully bear weight, ankle deformity, confounding variables (eg, patient age <18 y), underlying neurologic deficits affecting the lower limbs, altered mental status, and/or multisystem trauma, or if the patient otherwise meets the Ottawa rules indicating that radiologic evaluation should be performed, obtain anteroposterior (AP), lateral, and ankle mortise views with the foot in 15° of internal rotation.
• • The saddle or headset sign should be observed. The saddle (or telephone headset), consisting of the tibia and fibula, should lie equally above and around the talus (the horse or the telephone base).
  • The space between the talar dome and a curved line running along the internal surfaces of the distal tibia and fibula (ankle mortise space) should be equal throughout its length. Lack of symmetry suggests ankle mortise disruption due to ligamentous injury or bony fracture.
• Plain film radiography of the foot
• • Indications for radiologic studies of the foot include localized pain, deformity, or the inability to completely bear weight.
  • Obtain AP and lateral foot films.
  • Direct attention to high-risk areas (eg, proximal fifth metatarsal, navicular, cuboid, medial cuneiform, calcaneal bones).
• Plain film radiography of the fibula and tibia
• • Triplane and other ankle fractures are frequently associated with fibula fractures. As a result, forces are transmitted to the fibula in a lateral, medial, or spiral (twisting) motion.
  • Spiral stresses, in particular, may result in a Maisonneuve fracture of the proximal fibula. These are easily missed if the knee and proximal fibula are not examined at the time the ankle and foot are examined.
  • If pain or tenderness is present anywhere along the length of the fibula, x-ray the fibula. This applies equally to any area of the tibia not apparently associated with the primary area of injury.
• Other x-rays performed in anticipation of the operating room depend on the age of the patient, the extent of all injuries, and other comorbid conditions. Triplane fractures most commonly occur in healthy adolescents. Chest x-ray is a reasonable, but not mandatory, preoperative study.
• CT scan
• • CT scanning is not indicated for routine evaluation of common ankle fractures; however, it is commonly employed and is advised in complex multipart and/or multiplane fractures of the ankle.
  • CT scanning demonstrates all fracture lines present and intra-articular injuries involving the ankle mortise. In anticipation of internal fixation procedures, use CT scanning to accurately demonstrate the orientation and displacement of fragments.
  • CT scanning is particularly useful to evaluate fractures through the tibial epiphysis and tibial growth plate (growth center) and should follow any attempts at closed reduction to ensure accurate anatomic fracture realignment and restoration of articular surfaces.
• Stress radiographs: These images may be obtained when plain film evaluation reveals no obvious fractures. Preferably, these radiographs are obtained following orthopedic consultation, as stress films lend little to the management of ankle injuries by emergency department physicians.

Other Tests

• Other tests performed in anticipation of the operating room depend on the age of the patient, the extent of all injuries, and other comorbid conditions. As stated above, triplane fractures most commonly occur in healthy adolescents.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Medical therapy

Closed reduction

Closed reduction resulting in adequate fracture reduction in all planes can be obtained in approximately 30-50% of triplane fractures. Generally, the motion that produced the injury, when reversed and in combination with distal axial traction, results in realignment. Avoid more than 2 attempts at realignment, as each attempt creates additional trauma, bleeding, and possible further injury to the distal tibial growth plate.

Adequate closed reduction is followed by 4-6 weeks of above-the-knee casting. The cast then is replaced with a below-the-knee cast to allow limited weight-bearing with crutches for an additional 4 weeks. Following removal of the final cast, progressive return to normal activity is encouraged with ongoing physical therapy and range-of-motion exercises.

Surgical therapy

Open reduction and internal fixation

Open reduction and internal fixation for any triplane fracture demonstrating 2 mm or more of displacement after closed reduction is attempted involves the following steps:

• The surgical approach is to reduce the fracture, and incisions can be anterior or anterolateral. Small stab incisions are often needed for the placement of screws, either solid or cannulated.
• Reduction and fixation of the metaphyseal spike may be all the surgery that is needed. An alternative is the placement of epiphyseal screws parallel to the joint surface, avoiding the growth plate and the ankle joint. More than one screw is needed, and the primary goal is reduction of the physeal fracture and joint surface.
• Intraoperative radiographs or fluoroscopy are needed to ensure that the fracture is reduced and that screw placement is satisfactory. The surgical fixation resulting in anatomic realignment of a triplane postoperatively can be viewed in Images 9-10.
• The anterolateral epiphyseal fragment of a 3-part injury is reduced and held with either a screw or a K-wire. Before the patient leaves the operating room, a final set of postreduction radiographs is completed.

Preoperative details

It is essential to preoperatively detect and adequately address all other injuries as well as other comorbidities and preexisting medical conditions and needs.

In persons with open fractures, preoperative tetanus immunization should be updated if needed, and prophylactic antistaphylococcal antibiotics should be administered.

Intraoperative details

Portable or fixed overhead radiography or C-arm fluoroscopy is needed in the operating room to evaluate the results of internal fixation prior to the patient leaving the operating room.

Postoperative details

Postoperatively, standard incision care and suture removal are performed as directed by the physician. An above-the-knee cast is used for 4-6 weeks, followed by a below-the-knee partial weight-bearing cast. When internal fixation has been accomplished and early physical therapy and/or range-of-motion exercises are desired, the short leg cast may be replaced by a removable air splint.

Follow-up

All patients with triplane ankle fractures must be monitored closely for potential complications (see Complications). The patient must be made aware of all of the follow-up requirements outlined by the treating physician at the time of discharge following initial care of the fracture. Emphasis should be placed on patients' participation in their own care, as it relates to the most favorable outcome.

Typically, all patients undergo replacement of the initial above-the-knee cast at 4-6 weeks postinjury, regardless of the treatment mode. This cast is replaced with a below-the-knee cast or a removable air splint.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Ankle Fracture.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

In general, young healthy adolescents do well following a triplane fracture, despite the fact that it is a serious injury.

Complications include the following:

• Tibial length growth retardation secondary to epiphyseal growth plate injury
• Posttraumatic arthritis
• Postoperative infection
• Osteomyelitis
• Pressure sores from the cast
• Fracture blisters
• Compartment syndrome

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

The outcome and long-term prognosis for individuals with triplane fracture are primarily related to concerns in 2 areas, as follows:

• Posttraumatic arthritis: When fracture fragment reduction is inadequate, either by closed or open reduction, long-term prognosis is less than favorable. Posttraumatic arthritis may take years to be appreciated fully. Recent studies support the contention that the development of posttraumatic arthritis is primarily related to inadequate realignment of the inferior surface of the epiphysis as it articulates with the talar dome.
• Tibial length growth retardation secondary to epiphyseal growth plate injury: This is a lesser concern, as most triplane fractures in adolescents occur at a time when at least medial growth plate closure has occurred, leaving only the lateral growth plate open. Intraoperatively, it is important not to place compression screws or other hardware that exert compression forces on the growth plate. Such compression exacerbates premature growth plate closure and tibial growth retardation.

Additional concerns include the following:

• Postoperative infection and osteomyelitis are uncommon complications. Either may be attributed to patient cleanliness and compliance, surgical technique, or the result of a highly contaminated, originally open fracture.
• Pressure sores may result from localized swelling, a cast that gets wet and expands, or a cast that is improperly fitted. In all such cases, the patient will, after a period of time, develop point tenderness in an area below the cast that was not present previously. Remove the cast, and inspect and palpate the entire area to identify the location and cause of the pain. If the pain is caused by pressure alone, the new cast is applied with extra padding placed in the area of pain. Attention is given during cast reapplication to avoid all pressure to the area. If the pain is caused by pressure and a localized sore (skin breakdown) is noted, standard wound therapy, which may include oral antibiotics, should be initiated. The cast is reapplied as above with the addition of a cast window, which allows for frequent and ongoing wound checks and dressing changes until the wound resolves, to avoid having to change the cast each time.
• Fracture blisters result from blood accumulating under the skin in the area of a fracture accompanied by swelling. This results in skin breakdown and ulcerations. These are attended to in the same manner described above for pressure sores. It is imperative that no surgical therapy for the fracture, initially or delayed, be attempted at the site of an existing or preexisting fracture blister because there is great risk of complications related to skin healing in the affected area.
• Compartment syndrome may affect any of the 4 compartments of the lower leg or the deep plantar compartment of the foot. This may manifest as pain or burning, which may be severe at rest or passive dorsiflexion of the foot. Sensation is affected first, then motor function. Commonly, the anterior tibial compartment is affected with resultant increasing compartment pressure on the superficial peroneal nerve, which results in heightened pain on passive motion of the toes followed by decreased sensation in the first and second webspaces of the toes. The foot and/or lower leg may be tense and hard. Compare findings with those of the unaffected limb. If compartment syndrome is confirmed by measurement of compartment pressures, immediate operative intervention is required.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

With the advent and greater use of spiral CT and ultrafast CT scans and the declining costs of this technology, these scans will likely become the imaging modality of complex multipart and triplane ankle fractures. These scans will also guide approaches to further open intraoperative intervention.

It is possible that intraoperative spiral CT and ultrafast CT scans will be available in the operating room suite, particularly in centers routinely treating athletes and Olympians.

In recent years, the strength of operative screws and pins has increased progressively, and operative screws have decreased in diameter. Titanium-based materials of greater diameter may be replaced by composite materials of lesser diameter, thus lessening trauma in their intraoperative placement.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Media file 1:  (A) The distal tibial growth plate begins to close with a centrally located epiphyseal hump and proceeds medially, with posterior closure occurring before anterior closure. Following medial closure, the lateral tibial growth plate then closes progressively from the posteromedial area (B) to the anterolateral area (C, D). The entire process of physeal closure usually spans a period of 18 months. This process generally occurs when the individual is aged 12-15 years (mean age is 13.5 years, age range is 10-18 years), with complete closure occurring earlier in girls than in boys.
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Media type:  Image

Media file 2:  Triplane fracture involves the tibial metaphysis, tibial growth plate (physis), and the epiphysis. This image depicts each of the involved anatomic areas. It is important to recall the structural lines of development and maturation of the metaphysis, physis, and epiphysis, as they relate to the triplane fracture. Note that forces transmitted to the physis and epiphysis create fracture lines consistent with the maturity of these structures. For an unfused growth plate, separation is likely to occur here. When the growth plate is fused (closed), the avulsed portion is likely the most recent portion of the growth plate that has fused. This part represents the weakest (least calcified and least matured) portion of the physis. Frequently this involves the anterolateral growth plate.
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Media type:  Image

Media file 3:  In a 2-part triplane fracture, 3 fracture lines are identified in each of the transverse, coronal, and sagittal planes. The first fracture line in the transverse (horizontal) plane is through the growth plate (physis), leaving the anteromedial portion of the physis attached to the distal tibia. The second fracture line is in the sagittal (anteroposterior) plane through the epiphysis, lateral to the original formation of the epiphyseal fusion hump. The third fracture line is in the coronal plane and courses superiorly through the posterior metaphysis, producing a posterior metaphyseal spike. The resulting 2 fragments are (1) a fragment consisting of the posteromedial and lateral portions of the epiphysis attached to a posterior metaphyseal spike and (2) the distal tibia, with the anteromedial epiphysis attached.
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Media type:  Image

Media file 4:  In a 3-part triplane fracture, the 3 fracture lines noted in Image 2 are present in each of the 3 anatomic planes; however, the fracture line in the coronal plane is complete in its course through the epiphysis and posterior metaphysis. The 3 fracture fragments thus produced are (1) a rectangular fragment of the anterolateral portion of the epiphysis, (2) the remainder of the epiphysis with an attached posterior spike of the distal tibial metaphysis, and (3) the tibial shaft with the proximal metaphysis and anteromedial epiphysis.
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Media type:  Image

Media file 5:  Lateral radiograph of a triplane fracture illustrates the following: Yellow arrows indicate the horizontal component of the fracture through the physis (growth plate), red arrows indicate the vertical fracture line in the coronal plane involving the metaphyseal spike complex, black arrows point to the posterior margin of the metaphyseal spike, and purple arrows indicate the associated fibular fracture. This image represents one of the first known published images of this type of 2-part triplane fracture.
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Media type:  Photo

Media file 6:  Radiograph of a triplane fracture. The anterior-posterior view of the distal tibia and epiphysis is illustrated as follows: Yellow arrows indicate the horizontal fracture component through the growth plate, white arrows indicate the vertical fracture through the epiphysis in the sagittal plane, and black arrows outline the superior edges of the posterior metaphyseal spike. An associated fibula fracture is present. In this left-sided 2-part triplane fracture, medial is to the viewer's left, and lateral is to the right. This image represents one of the first known published images of this type of 2-part triplane fracture.
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Media type:  X-RAY

Media file 7:  Digital 3-dimensional helical CT scan reconstruction of a rare type of triplane fracture. The image shown is of the inferior surface of the tibial epiphysis. Medially (viewer's left) is the distal tibial malleolus. Laterally (viewer's right) is the distal fibula/lateral malleolus. Fracture lines exist through the tibial epiphysis in the coronal, sagittal, and horizontal planes. The posterolateral fragment of the epiphysis is attached to the posterior metaphyseal spike rather than the more common anterolateral segment of the epiphysis. This image represents one of the first known published images of this type of 2-part triplane fracture.
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Media type:  CT

Media file 8:  Two-dimensional helical CT scan image of the fracture observed in Image 3 prior to 3-dimensional reconstruction. PLEF represents the posterolateral epiphyseal fragment. DF is the distal fibula. The posteromedial and the entire portion of the anterior epiphysis are intact. This image represents one of the first known published images of this type of 2-part triplane fracture.
	View Full Size Image
Media type:  CT

Media file 9:  Lateral view at 60 days postoperatively of this 3-part triplane fracture in a 14-year-old male demonstrates accurate anatomic reduction. Two compression screws have been placed through a posterolateral incision. A vertical sclerotic line appears above, through, and below the screws, indicating healing of the realigned posterior metaphyseal spike. A 0.062 inch smooth Kirschner wire is observed (see Image 10).
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Media type:  X-RAY

Media file 10:  Anteroposterior view at 60 days postoperatively of this 3-part triplane fracture demonstrates accurate anatomic reduction and 2 compression screws fixating the posterior metaphyseal spike.The horizontal 0.062 inch smooth Kirschner wire is accurately placed in the epiphysis from a medial approach through a single stab incision. Midway along the Kirschner wire a vertical line in the sagittal plane is observed, representing the original fracture through the epiphysis. Note that all fixation devices avoid the tibial growth plate.
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Media type:  X-RAY

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

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Article Last Updated: Jan 26, 2007