Abstract
Introduction
Diagnosis of Triplane fractures remains difficult in common practice. Aim of the study was the evaluation of the fracture pattern and the benefit of cross-sectional imaging in classification of Triplane-fractures.
Material and Methods
A total of 27 pediatric patients treated for ankle fractures were identified from patient charts. Radiographic images of epiphyseal fractures (X-rays and additional cross-sectional imaging) were blinded evaluated by 13 observers to answer a specific questionnaire regarding type or fracture and treatment suggestion.
Results
There were seven Triplane-I and eight Triplane-II fractures. The other physeal ankle fracture group consisted of four patients with a Twoplane-fracture, five Salter-and-Harris (SH) II, one SH-III, and two SH-IV fracture. Accuracy of classification improved considerably depending on the experience of the observer in pediatric trauma care. Surgeons specialized in pediatric trauma care classified correctly with conventional X-rays in 48.1 % of all cases presented versus 31.5 % appropriate diagnosis by younger fellows. Accuracy in exact specification of Triplane-fractures was comparable lesser in younger fellows (31.1 vs. 22 %). Cross-sectional imaging improved classification of all fractures in both groups (75.6 % specialized vs. 47.3 % non specialized). Whereas availability of cross-sectional imaging improved treatment recommendation in specialized surgeons this benefit was not detectable for the doctors without specialization. Evaluation of fracture pattern showed a relatively stereotypical fracture pattern in Triplane-II fractures, whereas Triplane-I fractures were more variable.
Conclusion
The additional information of cross-sectional imaging seems helpful for any physician in finding the right classification of a pediatric ankle fracture. However, the additive information appears especially viable for experienced surgeons to suggest the appropriate treatment.
Similar content being viewed by others
References
Petit P, Panuel M, Faure F, et al. Acute fracture of the distal tibial physis: role of gradient-echo MR imaging versus plain film examination. Am J Roentgenol. 1996;166:1203–6.
Lohman M, Kivisaari A, Kallio P, et al. Acute paediatric ankle trauma: MRI versus plain radiography. Skel Radiol. 2001;30:504–11.
Kay RM, Matthys GA. Paediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9:268–78.
von Laer L, Kraus R, Linhart WE. Frakturen und Luxationen im Wachstumsalter. Stuttgart: Thieme; 2007.
Landin LA, Danielsson LG, Jonsson K, Pettersson H. Late results in 65 physeal ankle fractures. Acta Orthop Scand. 1986;57:530–4.
Karrholm J, Hansson LI, Svensson K. Incidence of tibio-fibular shaft and ankle fractures in children. J Pediatr Orthop. 1982;2:386–96.
Cooperman DR, Spiegel PG, Laros GS. Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture. J B Jt Surg Am. 1978;60:1040–6.
Mac Nealy GA, Rogers LF, Hernandez R, Poznanski AK. Injuries of the distal tibial epiphysis: systematic radiographic evaluation. Am J Roentgenol. 1982;138:683–9.
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 B Jt Surg Am. 1978;60:1046–50.
Rapariz JM, Ocete G, Gonzalez-Herranz P, et al. Distal tibial triplane fractures: long-term follow-up. J Pediatr Orthop. 1996;16:113–8.
Feldman DS, Otsuka NY, Hedden DM. Extra-articular triplane fracture of the distal tibial epiphysis. J Pediatr Orthop. 1995;15:479–81.
Ho-Fung V, Pollock A. Triplane fracture. Pediatr Emerg Care. 2011;27:70–2.
O’Connor DK, Mulligan ME. Extra-articular triplane fracture of the distal tibia: a case report. Pediatr Radiol. 1998;28:332–3.
Clement DA, Worlock PH. Triplane fracture of the distal tibia. A variant in cases with an open growth plate. J B Jt Surg Br. 1987;69:412–5.
Cone RO III, Nguyen V, Flournoy JG, et al. Triplane fracture of the distal tibial epiphysis: radiographic and CT studies. Radiology. 1984;153:763–7.
Dailiana ZH, Malizos KN, Zacharis K, et al. Distal tibial epiphyseal fractures in adolescents. Am J Orthop (Belle. Mead NJ). 1999;28:309–12.
El-Karef E, Sadek HI, Nairn DS, et al. Triplane fracture of the distal tibia. Injury. 2000;31:729–36.
Dias LS, Giegerich CR. Fractures of the distal tibial epiphysis in adolescence. J B Jt Surg Am. 1983;65:438–44.
Evans MC, Graham HK. Olecranon fractures in children: part 1: a clinical review; part 2: a new classification and management algorithm. J Pediatr Orthop. 1999;19:559–69.
Jarvis JG, Miyanji F. The complex triplane fracture: ipsilateral tibial shaft and distal triplane fracture. J Trauma. 2001;51:714–6.
Kim JR, Song KH, Song KJ, et al. Treatment outcomes of triplane and Tillaux fractures of the ankle in adolescence. Clin Orthop Surg. 2010;2:34–8.
Peiro A, Aracil J, Martos F, et al. Triplane distal tibial epiphyseal fracture. Clin Orthop Relat Res. 1981;160:196–200.
Shin AY, Moran ME, Wenger DR. Intramalleolar triplane fractures of the distal tibial epiphysis. J Pediatr Orthop. 1997;17:352–5.
Karrholm J. The triplane fracture: 4 years of follow-up of 21 cases and review of the literature. J Pediatr Orthop B. 1997;6:91–102.
Ertl JP, Barrack RL, Alexander AH, et al. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J B Jt Surg Am. 1988;70:967–76.
von Laer L. Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia. J B Jt Surg Am. 1985;67:687–98.
von Laer L. Epiphyseal fractures. Zentralbl Chir. 1986;111:1217–27.
Brown SD, Kasser JR, Zurakowski D, Jaramillo D. Analysis of 51 tibial triplane fractures using CT with multi-planar reconstruction. AJR Am J Roentgenol. 2004;183:1489–95.
Marmor L. An unusual fracture of the tibial epiphysis. Clin Orthop Relat Res. 1970;73:132–5.
Rogers L. The ankle. Philadelphia, PA: Churchill Livingstone; 2002
van Laarhoven CJ, Severijnen RS, van der Werken C. Triplane fractures of the distal tibia. J Foot Ankl Surg. 1995;34:556–9.
Crawford AH. Triplane and tillaux fractures: is a 2 mm residual gap acceptable? J Pediatr Orthop. 2012;32(Suppl 1):S69–73.
Nenopoulos SP, Papavasiliou VA, Papavasiliou AV. Outcome of physeal and epiphyseal injuries of the distal tibia with intra-articular involvement. J Pediatr Orthop. 2005;25:518–22.
Jones S, Phillips N, Ali F, et al. Triplane fractures of the distal tibia requiring open reduction and internal fixation. Pre-operative planning using computed tomography. Injury. 2003;34:293–8.
Spiegel PG, Mast JW, Cooperman DR, Laros GS. Triplane fractures of the distal tibial epiphysis. Clin Orthop Relat Res. 1984;188:74–89.
Lemburg SP, Lilienthal E, Heyer CM. Growth plate fractures of the distal tibia: is CT imaging necessary? Arch Orthop Trau Surg. 2010;130:1411–7.
Conflict of interest
The authors declare that they have no conflicts of interest.
Author information
Authors and Affiliations
Corresponding author
Additional information
D. Schneidmueller and A. L. Sander contributed equally to this work.
Rights and permissions
About this article
Cite this article
Schneidmueller, D., Sander, A.L., Wertenbroek, M. et al. Triplane fractures: do we need cross-sectional imaging?. Eur J Trauma Emerg Surg 40, 37–43 (2014). https://doi.org/10.1007/s00068-013-0338-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00068-013-0338-7