ABSTRACT

purpose. To review 28 cases of paediatric triplane
fractures of the distal tibia over a 7-year period in a
tertiary paediatric hospital.
Methods. Records of 21 boys and 7 girls aged 11 to
15 (mean, 13) years presented with triplane fractures
of the left (n=14) and right (n=14) ankles were
retrospectively reviewed.
results. Injury mechanism included low-energy
trauma (n=10) and moderate-energy trauma (n=18).
Fractures were 2-part in 20 patients, 3-part in 6,
and 4-part in 2. 11 patients had concomitant fbular
fractures. Articular displacement was <2 mm in
17 patients and ≥2 mm in 11 patients. 17 patients
were treated conservatively (cast immobilisation);
11 were treated surgically by closed reduction and
percutaneous pinning (n=1), open reduction and
percutaneous pinning (n=5), closed reduction and
internal fxation (n=3), or open reduction and internal
fxation (n=2). Transepiphyseal partially threaded
cannulated screws were used for fxation. The mean
Triplane fractures of the distal tibia in children
Adrian Chong Beng Tan, Roland Weng Wah Chong, Arjandas Mahadev
Department of Orthopaedics, KK Women’s and Children’s Hospital, Singapore
Address correspondence and reprint requests to: Dr Adrian Tan Chong Beng, KK Women’s and Children’s Hospital, 100 Bukit
Timah Road, Singapore 229899. Email: adrian_tan@mac.com
Journal of Orthopaedic Surgery 2013;21(1):55-9
period of casting was 5.8 weeks, and the mean non–
weight bearing period was 6.1 weeks. The mean
follow-up period was 14.2 (range, 9–20) weeks. All
patients had excellent outcome. No patient had any
infections, delayed or non-union. Six patients had
decreased range of motion and 4 had pain 4 weeks
after cast removal.
conclusion. Treatment outcome of triplane fractures
of the distal tibia in children is good when guidelines
are closely adhered to.
Key words: adolescent; ankle injuries; ankle joint;
fibula; talus; tibia; treatment outcome
introduction
The triplane fracture of the distal tibia is a multiplanar
injury with 3 possible fracture confgurations. The
fracture pattern extends through the transverse
(growth plate), sagittal (epiphysis), and coronal
(distal tibial metaphysis) anatomic planes, disrupting
the tibial articular surface of the ankle. Injury to the
epiphysis in adolescence results in specifc injury
56 ACB Tan et al. Journal of Orthopaedic Surgery
patterns owing to the change in biomechanics.
1

Anatomic reduction is necessary to prevent
malalignment and subsequent early degenerative
changes.
2
We review 28 cases of paediatric triplane
fractures of the distal tibia over a 7-year period in a
tertiary paediatric hospital.
Materials and Methods
Between January 2002 and January 2009, records of 21
boys and 7 girls aged 11 to 15 (mean, 13) years with
triplane fractures of the left (n=14) and right (n=14)
ankles were retrospectively reviewed. Patient age,
gender, mechanism of injury, diagnosis, management,
cast immobilisation duration, treatment outcome,
and complications (pain, restricted range of motion
or functional defcits) were recorded, as were the
number and displacement of fragments. Computed
tomography was performed in 2 patients for further
evaluation (Figs. 1 and 2).
Triplane fractures with articular displacements
of <2 mm were treated with cast immobilisation,
whereas those with >2 mm displacement were treated
with closed reduction and internal fxation. Open
reduction was performed when the displacement
was >2 mm after closed reduction.
Fracture union, presence of a deformity,
premature closure of the growth plate, and post-
traumatic arthritis were assessed on radiographs.
Treatment outcome (pain, activity, function of ankle
joint, walking ability, and radiographic result)
was evaluated using a modifed Weber protocol as
excellent, good, fair, or poor.
3
Scores for each item
could range from 1 to 4.
results
Injury mechanism included low-energy trauma
(n=10) such as walking, and falling off a low bed or
chair, and moderate-energy trauma (n=18) such as
soccer injuries (n=4), falling from a height of >1 m
(n=3), skateboarding (n=3), running (n=2), martial
arts training (n=2), ice-skating (n=2), bicycling (n=1),
and playing softball (n=1) [Table].
Figure 1 A 12-year-old boy with a 3-part triplane fracture of the left ankle: (a) radiographs and (b) computed tomography
showing a sagittal split through the epiphysis, a coronal split through the distal tibial metaphysis, and a transverse split through
the growth plate, (c) 3-dimensional reconstruction of the fractures, and (d) good healing and congruent articular surface 4
months after conservative treatment.
(a)
(c) (d)
(b)
Vol. 21 No. 1, April 2013 Triplane fractures of the distal tibia in children 57
Fractures were 2-part in 20 patients, 3-part in
6 (Fig. 1), and 4-part in 2 (Fig. 2). 11 patients had
concomitant fbular fractures. Articular displacement
was <2 mm in 17 patients and ≥2 mm in 11 patients.
17 patients were treated conservatively with cast
immobilisation (Fig. 1); 11 were treated surgically by
closed reduction and percutaneous pinning (n=1),
open reduction and percutaneous pinning (n=5),
closed reduction and internal fxation (n=3), or open
reduction and internal fxation (n=2). Transepiphyseal
partially threaded cannulated screws were used for
fxation (Fig. 2).
The mean period of casting was 5.8 weeks, and
the mean non–weight bearing period was 6.1 weeks.
For patients treated conservatively, the mean non–
weight bearing period was 6.7 weeks. For those
treated surgically, the mean period of casting was 4.6
weeks and the mean non–weight bearing period was
5.3 weeks.
The mean follow-up period was 14.2 (range,
Figure 2 An 11-year-old girl with a 4-part triplane fracture of the
left ankle: (a) radiographs and (b) computed tomography showing a
sagittal split through the epiphysis, a coronal split through the distal
tibial metaphysis and epiphysis, and a transverse split through the
growth plate, (c) 3-dimensional reconstruction of the fractures, (d) a
small articular gap is seen after screw fixation owing to comminution,
(e) healing of the articular gap at month 3, and (f) screw removal at
month 4.
(a)
(c)
(f)
(d) (e)
(b)
58 ACB Tan et al. Journal of Orthopaedic Surgery
* CRPP denotes closed reduction and percutaneous pinning, CRIF closed reduction and internal fixation, ORPP open reduction
and percutaneous pinning, and ORIF open reduction and internal fixation
Sex/age
(years)
Injury mechanism Fracture parts/
side
Displacement
(mm)
Management
*
Cast duration
(weeks)
Outcome
M/14 Softball 3/R 4 ORPP 5 Excellent
M/13 Low-energy trauma 2/R 0 Conservative 6 Excellent
M/13 Soccer 2/R 1 Conservative 6 Excellent
M/13 Soccer 3/L 2 CRPP 5 Excellent
M/15 Soccer 3/L 2 ORPP 4 Excellent
M/12 Skateboarding 4/R 3 ORPP 8 Excellent
M/11 Biking 2/L 1 Conservative 6 Excellent
M/14 Low-energy trauma 2/L 2 ORIF 4 Excellent
M/13 Low-energy trauma 2/L 0 Conservative 6 Excellent
M/14 Low-energy trauma 2/L 1 Conservative 6 Excellent
F/11 Low-energy trauma 2/R 0 Conservative 6 Excellent
M/14 Soccer 2/R 3 ORPP 6 Excellent
F/11 Low-energy trauma 2/R 1 Conservative 6 Excellent
M/12 Low-energy trauma 3/L 1 Conservative 8 Excellent
F/12 Low-energy trauma 2/L 1 Conservative 6 Excellent
M/14 Fall from height 2/R 0 Conservative 6 Excellent
F/14 Skating 2/L 0 Conservative 6 Excellent
M/14 Height 2/R 3 ORIF 0 Excellent
M/14 Martial Arts 2/L 0 Conservative 6 Excellent
M/12 Running 2/L 0 Conservative 8 Excellent
M/12 Fall from height 2/L 0 Conservative 12 Excellent
M/13 Skateboarding 2/R 0 Conservative 5 Excellent
M/13 Martial Arts 3/R 2 CRIF 2 Excellent
F/11 Running 2/R 0 Conservative 7 Excellent
F/11 Low-energy trauma 4/L 2 CRIF 6 Excellent
M/13 Skateboarding 2/R 0 Conservative 7 Excellent
F/14 Skating 2/R 3 CRIF 5 Excellent
M/14 Low-energy trauma 3/L 3 ORPP 5 Excellent
Table
Patient characteristics and outcomes
9–20) weeks. All patients had excellent outcome. No
patient had any infections, delayed or non-union. Six
patients had decreased range of motion and 4 had
pain 4 weeks after cast removal.
discussion
The paediatric triplane ankle fracture is a transitional
injury. Physeal closure of the distal tibia begins
centrally and extends medially and then laterally.
The anterolateral quadrant of the physis closes last.
This gradual and asymmetric closure occurs over 18
months to 2 years and explains its specifc fracture
patterns.
4

Triplane ankle fractures represent 5% to 10% of
paediatric intra-articular ankle injuries, and typically
occur in children aged 12 to 15 years (more commonly
in boys than girls). Undisplaced triplane fractures
can be managed with immobilisation in a long-leg
cast. Displaced fractures can be treated with closed
or open reduction and internal fxation through an
anterolateral or anteromedial approach. Although
triplane fractures are not associated with growth
arrest as most of the physis has closed, they may lead
to early arthritis owing to joint surface disruption
or joint malalignment.
2
Intra-articular reduction
to within 2 mm is necessary for optimal outcome;
residual displacement of >2 mm necessitates surgical
treatment.
1,5,6
Fixation devices can be percutaneous
wires or cannulated cancellous transepiphyseal
screws, depending on the surgeon’s preference.
Computed tomography and 3-dimensional
reconstruction improve understanding of injury
patterns and assist in the management decision.
7

This further delineates epiphyseal and physeal
involvement, the number of fragments, the
appearance of the Salter-Harris fracture in each
plane, and the degree of separation of the epiphyseal
fragments. Meticulous placement of cannulated
screws is necessary to avoid penetrating both the
articular surface and physis.
For severely displaced fractures, articular
reduction through an open approach can be extensive.
Vol. 21 No. 1, April 2013 Triplane fractures of the distal tibia in children 59
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Arthroscopy-assisted methods facilitate anatomic
reduction and minimal soft-tissue disruption,
8–10
and
may be augmented by intra-operative intensifed
imaging.
The modifed Weber protocol has been used for
evaluation of treatment outcome of ankle fractures
in adults
3,11
and triplane fractures in children.
12

Treatment outcome is good when guidelines are
closely adhered to.
disclosure
No conficts of interest were declared by the authors.