Case report 227
Triplane fracture of distal radius treated surgically: case report and review of the literature Juan Mingo-Robinet, Miguel Torres-Torres and Manuel Gonzalez-Rodriguez Only four cases of triplane distal radius fracture have been described in the literature. We report the first that has been treated with open reduction and internal fixation. A 15-yearold boy sustained a triplane fracture of the distal radius. After an unsuccessful attempt at closed reduction, open reduction and internal fixation were performed. Six months after injury, the patient is asymptomatic, but radiographs show a partial growth arrest. The goal of treatment is to achieve anatomic reduction of the articular surface. In this case interposed periosteum prevented anatomic reduction, requiring open reduction and internal fixation. Because of the patient’s advanced age the partial physeal arrest should advance to complete arrest before length
impairment or occurrence of angular deformity. J Pediatr c 2014 Wolters Kluwer Health | Orthop B 23:227–230 Lippincott Williams & Wilkins.
Introduction
slightly displaced fracture of the distal radius, through the radial portion of the physis extending across the epiphysis in the sagittal plane (Salter–Harris type III fracture, Fig. 1a). The lateral view revealed slight displacement of a fracture of the volar metaphysis attached to the epiphysis (Salter–Harris type II fracture, Fig. 1b). An oblique view showed a displacement of the fracture of more than 2 mm (Fig. 1c). An unsuccessful attempt at closed reduction and casting was carried out, and to achieve an anatomical reduction of the intra-articular surface, surgical treatment was indicated.
Triplane fractures, first described by Johnson and Fahl [1], are defined as fractures that occur in three planes (coronal, sagittal and transverse) through the epiphyseal plate of a long bone. Radiographically, these type of fractures look like a Salter–Harris type III injury on the anteroposterior view and a Salter–Harris type II on the lateral view. In 1972, Lynn [2] coined the term ‘triplane fracture’, and since then these fractures have been widely described in the literature. The distal tibia is by far the most common site for a triplane fracture, and, even if other cases have been described in the upper limb [3–8], these are extremely rare. Triplane fractures typically occur in late childhood, and are often associated with beginning normal symmetric fusion of the physis [9]. By their nature, they are intraarticular fractures, and the goal of treatment is to achieve an anatomic reduction of the physis and the articular surface. Four cases of triplane distal radius fracture have been described in the literature, one by Peterson [4], two by Garcia Mata et al. [6,7] and one by Pearce and Chung [8], all treated by closed reduction and casting. We report a new case of a displaced triplane fracture of the distal radius, the first reported that has been treated with open reduction and internal fixation.
Journal of Pediatric Orthopaedics B 2014, 23:227–230 Keywords: distal radius, fracture, intra-articular, open reduction, partial growth arrest, triplane Department of Orthopaedics and Traumatology, Complejo Hospitalario de Palencia, Palencia, Spain Correspondence to Juan Mingo-Robinet, MD, Department of Orthopaedics and Traumatology, Complejo Hospitalario de Palencia, Avd. Donantes de sangre s/n, 34005 Palencia, Spain Tel: + 34 656 19 73 54; fax: + 34 979167014; e-mail: [email protected]
Under general anaesthesia, closed reduction was again attempted, without a good reduction in the oblique view, and therefore a distal radius volar approach was used: a 6-cm-long incision was made over the flexor carpi radialis tendon, and the space between the flexor tendons and the volar surface of the pronator quadratus was developed. The pronator quadratus was released and lifted by subperiosteal dissection to expose the fracture site. Triplane fracture was reduced after cleaning the fracture of the interposed periosteum, and temporarily fixed with two smooth wires. An image intensifier was used to confirm reduction and two screws were used to fix the fracture, one cannulated partially threaded screw from anterior to posterior in the metaphyseal part of the fracture, and one percutaneous headless screw from radial to ulnar in the epiphysis (Fig. 2a–c). The patient was immobilized in a cast for 4 weeks after surgery, and was then allowed free active mobilization.
Methods A 15-year-old boy was admitted to hospital after falling off his bicycle onto his right hand. On physical examination he had a swollen and painful wrist, without neurovascular abnormality. Anteroposterior radiograph revealed a c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
Results Three months after injury, a radiograph showed radiological union of the fracture (Fig. 3), and the patient was back to full activities with no pain. Anteroposterior DOI: 10.1097/BPB.0000000000000011
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
228 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
Fig. 1
(a–c) Initial anteroposterior, lateral and oblique radiographs of right wrist.
Fig. 2
(a–c) Immediate postoperatory anteroposterior, lateral and oblique radiographs.
Fig. 3
Radiological union of the fracture after 3 months.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Triplane fracture of distal radius Mingo-Robinet et al. 229
Fig. 4
(a)
(b)
(c)
R R
R pa
Lat Oblicua
(a–c) Anteroposterior, lateral and oblique radiographs after 9 months showing partial growth arrest of the lateral and volar portions of the physis.
Fig. 5
(a–d) Clinical result with full range of movement.
radiographs of the wrist after 9 months showed that the fracture had healed, but also partial growth arrest of the radial and volar portions of the physis (Fig. 4a–c, arrows), and the patient remained asymptomatic, with full range of movement (Fig. 5a–d).
Discussion Triplane fractures are usually reported in the distal tibia, and their management is well described in the literature. These fractures are common in the distal tibia due to the way that the physis fuses and the torsional forces are involved in the injury [8]. However, these fractures can also involve the upper limb [3–8], even if they are rare, as the physis fusion is more uniform and injury is caused by axial rather than torsional forces [8]. Asymmetric closure of the physis is the cause of these fractures, where fusion initiates centrally and progresses
ulnar and radially, even if the ulnar side fuses first. As in our patient, all cases reported previously show this pattern, with the ulnar side attached to the metaphysis and displacement of the radial epiphysis [4,6–8]. Three previous cases presented evident fragment displacement [4,7,8], and all three were successfully treated by closed reduction and casting. Review of the cases reported led us to consider that in the absence of displacement, treatment should be the same as in normal one-plane fractures, with only immobilization with a cast. If initial displacement is appreciated, we could also expect good results with closed reduction and immobilization without pinning. In all triplane fractures the goal is anatomic reduction of both the physis and the articular surface. As most triplane fractures occur in older children with beginning physeal
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
230
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
closure, physeal closure secondary to the fracture rarely leads to angular deformity or length discrepancy. Thus, the goal of achieving anatomic reduction of the articular surface becomes more important. We followed the same principle in our patient, in whom closed reduction was unsuccessful. Surgery achieved an anatomical reduction of the articular surface and a good clinical result, and therefore we could add to the previous statements about the management of these fractures that if anatomical reduction is not achieved by closed means, open reduction and internal fixation might be good options for treatment.
managed by closed means, even if open reduction and internal fixation might be necessary if anatomic reduction of the articular surface is not accomplished. Oblique radiograph views might be useful for the exact determination of the displacement of the fracture. As most triplane fractures occur in older children with beginning normal physeal closure, any physeal closure due to the fracture rarely (if ever) leads to angular deformity or length discrepancy. Nevertheless, all physeal fractures should be followed until complete physeal closure.
Previous cases show various degrees of displacement of the fracture, but none of them show oblique radiograph views. The case presented in this paper suggests that oblique views may show greater displacement than originally appreciated in the common anteroposterior and lateral views.
Conflicts of interest
Growth deformity should not be a problem in these patients, as this mostly occurs close to the physiological growth plate fusion. In previous papers, partial growth arrest is described by Peterson [4] and by Garcia Mata et al. [6,7] in their two patients. However, Pearce and Chung [8] report no growth abnormalities at final followup. Our case also suggests that partial growth arrest is a common complication of these rare fractures.
Acknowledgements There are no conflicts of interest.
References 1 2 3 4 5 6 7 8
Conclusion
On the basis of our case and the previous literature, we conclude that triplane fractures of the distal radius can be
9
Johnson EW Jr, Fahl JC. Fractures involving the distal epiphysis of the tibia and fibula in children. Am J Surg 1957; 93:778–781. Lynn MD. The triplane distal tibial epiphyseal fracture. Clin Orthop Relat Res 1972; 86:187–190. Peterson HA. Triplane fracture of the distal humeral epiphysis. J Pediatr Orthop 1983; 3:81–84. Peterson HA. Triplane fracture of the distal radius: case report. J Pediatr Orthop 1996; 16:192–194. Chin KR, Jupiter JB. Treatment of triplane fractures of the head of the proximal phalanx. J Hand Surg Am 1999; 24:1263–1268. Garcia Mata S, Hidalgo Ovejero A, Martinez Grande M. Triplane fractures in the hand. Am J Orthop (Belle Mead NJ) 1999; 28:125–127. Garcia Mata S, Hidalgo Ovejero A. Triplane fracture of the distal radius. J Pediatr Orthop B 2006; 15:298–301. Pearce C, Chung R. Triplane fracture of the distal radius. Clin Pract 2011; 1:e75.155–e75.156. Tanner J, Healy M, Goldstein H, Cameron N. Assessment of skeletal maturity and prediction of adult height (TW3) method. 3rd ed. London: W.B. Saunders; 2001. pp. 62–63.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Triplane fracture of distal radius treated surgically: case report and review of the literature Juan Mingo-Robinet, Miguel Torres-Torres and Manuel Gonzalez-Rodriguez Only four cases of triplane distal radius fracture have been described in the literature. We report the first that has been treated with open reduction and internal fixation. A 15-yearold boy sustained a triplane fracture of the distal radius. After an unsuccessful attempt at closed reduction, open reduction and internal fixation were performed. Six months after injury, the patient is asymptomatic, but radiographs show a partial growth arrest. The goal of treatment is to achieve anatomic reduction of the articular surface. In this case interposed periosteum prevented anatomic reduction, requiring open reduction and internal fixation. Because of the patient’s advanced age the partial physeal arrest should advance to complete arrest before length
impairment or occurrence of angular deformity. J Pediatr c 2014 Wolters Kluwer Health | Orthop B 23:227–230 Lippincott Williams & Wilkins.
Introduction
slightly displaced fracture of the distal radius, through the radial portion of the physis extending across the epiphysis in the sagittal plane (Salter–Harris type III fracture, Fig. 1a). The lateral view revealed slight displacement of a fracture of the volar metaphysis attached to the epiphysis (Salter–Harris type II fracture, Fig. 1b). An oblique view showed a displacement of the fracture of more than 2 mm (Fig. 1c). An unsuccessful attempt at closed reduction and casting was carried out, and to achieve an anatomical reduction of the intra-articular surface, surgical treatment was indicated.
Triplane fractures, first described by Johnson and Fahl [1], are defined as fractures that occur in three planes (coronal, sagittal and transverse) through the epiphyseal plate of a long bone. Radiographically, these type of fractures look like a Salter–Harris type III injury on the anteroposterior view and a Salter–Harris type II on the lateral view. In 1972, Lynn [2] coined the term ‘triplane fracture’, and since then these fractures have been widely described in the literature. The distal tibia is by far the most common site for a triplane fracture, and, even if other cases have been described in the upper limb [3–8], these are extremely rare. Triplane fractures typically occur in late childhood, and are often associated with beginning normal symmetric fusion of the physis [9]. By their nature, they are intraarticular fractures, and the goal of treatment is to achieve an anatomic reduction of the physis and the articular surface. Four cases of triplane distal radius fracture have been described in the literature, one by Peterson [4], two by Garcia Mata et al. [6,7] and one by Pearce and Chung [8], all treated by closed reduction and casting. We report a new case of a displaced triplane fracture of the distal radius, the first reported that has been treated with open reduction and internal fixation.
Journal of Pediatric Orthopaedics B 2014, 23:227–230 Keywords: distal radius, fracture, intra-articular, open reduction, partial growth arrest, triplane Department of Orthopaedics and Traumatology, Complejo Hospitalario de Palencia, Palencia, Spain Correspondence to Juan Mingo-Robinet, MD, Department of Orthopaedics and Traumatology, Complejo Hospitalario de Palencia, Avd. Donantes de sangre s/n, 34005 Palencia, Spain Tel: + 34 656 19 73 54; fax: + 34 979167014; e-mail: [email protected]
Under general anaesthesia, closed reduction was again attempted, without a good reduction in the oblique view, and therefore a distal radius volar approach was used: a 6-cm-long incision was made over the flexor carpi radialis tendon, and the space between the flexor tendons and the volar surface of the pronator quadratus was developed. The pronator quadratus was released and lifted by subperiosteal dissection to expose the fracture site. Triplane fracture was reduced after cleaning the fracture of the interposed periosteum, and temporarily fixed with two smooth wires. An image intensifier was used to confirm reduction and two screws were used to fix the fracture, one cannulated partially threaded screw from anterior to posterior in the metaphyseal part of the fracture, and one percutaneous headless screw from radial to ulnar in the epiphysis (Fig. 2a–c). The patient was immobilized in a cast for 4 weeks after surgery, and was then allowed free active mobilization.
Methods A 15-year-old boy was admitted to hospital after falling off his bicycle onto his right hand. On physical examination he had a swollen and painful wrist, without neurovascular abnormality. Anteroposterior radiograph revealed a c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
Results Three months after injury, a radiograph showed radiological union of the fracture (Fig. 3), and the patient was back to full activities with no pain. Anteroposterior DOI: 10.1097/BPB.0000000000000011
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
228 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
Fig. 1
(a–c) Initial anteroposterior, lateral and oblique radiographs of right wrist.
Fig. 2
(a–c) Immediate postoperatory anteroposterior, lateral and oblique radiographs.
Fig. 3
Radiological union of the fracture after 3 months.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Triplane fracture of distal radius Mingo-Robinet et al. 229
Fig. 4
(a)
(b)
(c)
R R
R pa
Lat Oblicua
(a–c) Anteroposterior, lateral and oblique radiographs after 9 months showing partial growth arrest of the lateral and volar portions of the physis.
Fig. 5
(a–d) Clinical result with full range of movement.
radiographs of the wrist after 9 months showed that the fracture had healed, but also partial growth arrest of the radial and volar portions of the physis (Fig. 4a–c, arrows), and the patient remained asymptomatic, with full range of movement (Fig. 5a–d).
Discussion Triplane fractures are usually reported in the distal tibia, and their management is well described in the literature. These fractures are common in the distal tibia due to the way that the physis fuses and the torsional forces are involved in the injury [8]. However, these fractures can also involve the upper limb [3–8], even if they are rare, as the physis fusion is more uniform and injury is caused by axial rather than torsional forces [8]. Asymmetric closure of the physis is the cause of these fractures, where fusion initiates centrally and progresses
ulnar and radially, even if the ulnar side fuses first. As in our patient, all cases reported previously show this pattern, with the ulnar side attached to the metaphysis and displacement of the radial epiphysis [4,6–8]. Three previous cases presented evident fragment displacement [4,7,8], and all three were successfully treated by closed reduction and casting. Review of the cases reported led us to consider that in the absence of displacement, treatment should be the same as in normal one-plane fractures, with only immobilization with a cast. If initial displacement is appreciated, we could also expect good results with closed reduction and immobilization without pinning. In all triplane fractures the goal is anatomic reduction of both the physis and the articular surface. As most triplane fractures occur in older children with beginning physeal
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
230
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
closure, physeal closure secondary to the fracture rarely leads to angular deformity or length discrepancy. Thus, the goal of achieving anatomic reduction of the articular surface becomes more important. We followed the same principle in our patient, in whom closed reduction was unsuccessful. Surgery achieved an anatomical reduction of the articular surface and a good clinical result, and therefore we could add to the previous statements about the management of these fractures that if anatomical reduction is not achieved by closed means, open reduction and internal fixation might be good options for treatment.
managed by closed means, even if open reduction and internal fixation might be necessary if anatomic reduction of the articular surface is not accomplished. Oblique radiograph views might be useful for the exact determination of the displacement of the fracture. As most triplane fractures occur in older children with beginning normal physeal closure, any physeal closure due to the fracture rarely (if ever) leads to angular deformity or length discrepancy. Nevertheless, all physeal fractures should be followed until complete physeal closure.
Previous cases show various degrees of displacement of the fracture, but none of them show oblique radiograph views. The case presented in this paper suggests that oblique views may show greater displacement than originally appreciated in the common anteroposterior and lateral views.
Conflicts of interest
Growth deformity should not be a problem in these patients, as this mostly occurs close to the physiological growth plate fusion. In previous papers, partial growth arrest is described by Peterson [4] and by Garcia Mata et al. [6,7] in their two patients. However, Pearce and Chung [8] report no growth abnormalities at final followup. Our case also suggests that partial growth arrest is a common complication of these rare fractures.
Acknowledgements There are no conflicts of interest.
References 1 2 3 4 5 6 7 8
Conclusion
On the basis of our case and the previous literature, we conclude that triplane fractures of the distal radius can be
9
Johnson EW Jr, Fahl JC. Fractures involving the distal epiphysis of the tibia and fibula in children. Am J Surg 1957; 93:778–781. Lynn MD. The triplane distal tibial epiphyseal fracture. Clin Orthop Relat Res 1972; 86:187–190. Peterson HA. Triplane fracture of the distal humeral epiphysis. J Pediatr Orthop 1983; 3:81–84. Peterson HA. Triplane fracture of the distal radius: case report. J Pediatr Orthop 1996; 16:192–194. Chin KR, Jupiter JB. Treatment of triplane fractures of the head of the proximal phalanx. J Hand Surg Am 1999; 24:1263–1268. Garcia Mata S, Hidalgo Ovejero A, Martinez Grande M. Triplane fractures in the hand. Am J Orthop (Belle Mead NJ) 1999; 28:125–127. Garcia Mata S, Hidalgo Ovejero A. Triplane fracture of the distal radius. J Pediatr Orthop B 2006; 15:298–301. Pearce C, Chung R. Triplane fracture of the distal radius. Clin Pract 2011; 1:e75.155–e75.156. Tanner J, Healy M, Goldstein H, Cameron N. Assessment of skeletal maturity and prediction of adult height (TW3) method. 3rd ed. London: W.B. Saunders; 2001. pp. 62–63.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
