Triplane fracture

Fig. 3.3. Parasagittal MPR image showing a triplane fracture of the distal tibia. The axial component of the fracture line with widening of the growth plate is particularly well demonstrated on this view...

Fig. 3.4. a Posterior 3D VR image of a triplane fracture (same patient as in Fig. 3.3). Involvement of the medial malleolus can also be seen on this view, along with an incomplete, angulated libular diaphyseal fracture (b). The fibular has been removed from the image, using the scalpel tool. The tibial component of the fracture can now be viewed on the CT workstation from all directions (lateral...

Fig. 15.3a,b. Extra-articular triplane fracture. The sagittal plane component exits through the medial malleolus... 

Fig. 15.4a-h. Three-part triplane fracture, a-c AP, lateral and mortise views d,e axial and sagittal CT f CT3D reconstruction g,h post internal fixation... 

Many of the studies reporting good outcome following intra-articular fractures of the distal tibial physis are of short follow-up. In triplane fractures there does appear to be a symptomatic deterioration... 

Type III and IV tibial fractures with < 2mm displacement Triplane fractures... 

Dias LS, Tachdjian MO (1978) Physeal injuries ofthe ankle in children classification. Clin Orthop 136 230-233 Ertl JP, Barrack RL, Alexander AH et al (1988) Triplane fracture of the distal tibial epiphysis long term follow-up. J Bone Joint Surg 70A 967-976 Farley FA, Kuhns L, Jacobson JA et al (2001) Ultrasound examination of ankle injuries in children. J Pediatr Orthop 21 604-607... 

Feldman F, Singson RD, Rosenberg ZS et al (1987) Distal tibial triplane fractures diagnosis with CT. Radiol 164 429-435... 

The distal tibial epiphysis ossifies between 6 and 24 months of age. The medial malleolus appears at 7-8 years and is complete at 10 years. It usually ossifies as a downward extension of the distal tibial ossific nucleus but may develop as a separate centre of ossification and thus be mistaken for a fracture line. The distal tibial physis closes first centrally, then medially and finally anterolaterally (Fig. 15.1), with the entire process lasting about 18 months. This sequence of closure of the distal tibial physis is important in the pattern of transitional fractures (triplane and juvenile Tillaux). Completion of distal tibial physeal closure is at around 14 years in girls and 16 years in boys. 

The first part of the name refers to the position of the foot at the moment of the injury. The second part indicates the direction of the abnormal force applied to the ankle. A further four types of fracture - juvenile Tillaux, triplane, axial compression and miscellaneous physeal injuries - were added later to complete the classification. Whilst this classification is useful in understanding the deforming forces of the fracture, and hence the type of manoeuvre needed to achieve a satisfactory closed reduction, the Salter-Harris classification is easier to commit to memory and provides a better predictor of outcome in terms of complications (Spiegel et al. 1978). 

Computerised tomography (CT) is particularly valuable in the assessment of transitional (triplane, juvenile Tillaux) and intraarticular fractures wdiere the magnitude of displacement - both fracture gap and intraarticular or physeal step - is critical in determining whether or not operative intervention is required. CT is also extremely useful in helping the surgeon to plan the surgical approach in these situations. 

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