Transitional fracture

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The transition fracture is a special bone fracture in pediatric trauma that only occurs in the transition age from adolescent to adult, when the growth plate is already partially closed. Most often it occurs on the shin above the upper ankle joint (distal tibia). It is always a joint fracture , i. H. the fracture extends into the joint.

The term transitional fracture is also used for periprosthetic fractures .

root cause

From around the age of 10, the distal growth plate on the shin begins to slowly ossify from the medial side. The ossification of the growth plate then gradually spreads laterally in the front (ventral) and rear (dorsal), finally the growth plate ossifies in the area of ​​the anterior syndesmosis . With the onset of ossification, a typical supination injury with shear effect then leads to a child's epiphyseal detachment laterally, but the course of the fracture is stopped at the ossification and then bends into the epiphysis and thus to the upper ankle .

Classification

Depending on the course of the fracture and the number of fragments, a distinction is made between three types of transitional fracture on the distal tibia, which are primarily dependent on the mechanism of the accident:

  • Two-plane fracture: purely epiphyseal fragment. When ossification begins at around 10-11 years of age, almost the entire epiphysis can be involved and the fracture gap is far medial (intramalleolar). As the joint closes, the mostly sagittal fracture gap becomes increasingly more lateral. Finally, there is only a bony syndesmosis avulsion with a ventrolateral fragment. This last form is also called the Tillaux or Kleiger fracture .
  • Triplane I fracture: In addition to the epiphyseal fracture, there is a metaphyseal wedge on the lateral fragment. However, the metaphyseal fracture line does not extend through the epiphysis .
  • Triplane II fracture: As with the Triplane I fracture, there is an additional metaphyseal wedge fracture, but this continues into the epiphysis and thus leads to two epiphyseal fragments. The second fragment lies dorsally and corresponds to a Volkmann fracture from adult traumatology.

Diagnostics and therapy

Since the epiphyseal fracture is often only vaguely visible on the ap x-rays , it is occasionally overlooked. In the case of a metaphyseal wedge (triplane fracture), it is important to look for a dorsal epiphyseal (Volkmann-like) fragment, as this must be treated surgically. If necessary, oblique exposures or, in rare cases, a CT examination must be performed. If the fracture gap gapes by> 2 mm, the danger is later osteoarthritis or instability. If the fragments are not dislocated, conservative therapy in a lower leg cast is possible for usually four weeks with follow-up controls. The rare dislocated fractures and dorsal epiphyseal fragments (Triplane-II) should be surgically reduced and fixed. Usually lag screws are used for this . In the case of the two-plane fracture, a screw lying horizontally in the epiphysis is necessary, in the case of triplane fractures, a metaphyseal screw, which is usually anterior to the dorsal, is also necessary.

swell

  • L. von Laer: Fractures and dislocations in growing age . 3. Edition. Thieme-Verlag, Stuttgart 1996, ISBN 3-13-674303-2 .
  • B. Weigel, M. Nerlich: Praxisbuch Unfallchirurgie . Springer-Verlag, Berlin 2005, DNB 972622020 .