Lower Tibial Shaft Spiral Fracture Concurrent with Distal Tibial Tri- plane Fracture

Background: The clinical and imaging features of lower tibial shaft spiral fracture con-current with distal tibial triplane fracture are not clear. Introduction: This study was conducted to investigate these features for correct diagnosis, treat-ment and prevention of possible premature physeal arrest or angular deformation. Methods: Patients with lower tibial shaft spiral fracture concurrent with distal tibial triplane frac-ture were enrolled, and the clinical, imaging, treatment and follow-up data were analyzed. Results: Five patients with lower tibial shaft spiral fracture concurrent with distal tibial triplane fracture were found including four men and one woman with an age range of 12-15 years (mean 13.6). Injury to the distal tibial epiphysis was missed in the diagnosis in plain radiography reports, but careful reevaluation confirmed distal tibial epiphysis fracture in four cases including Salter-Har-ris type II in three cases and type III in one case. The remaining case had no apparent distal tibial epiphysis injury in the plain radiograph. CT scan revealed that all five patients had distal tibial tri-plane fracture of the lateral type including two fragments in three cases and three fragments in two cases. The fracture was divided into type I (within the articular weight-bearing line) in three cases, type II (outside the articular weight-bearing line) in two cases based on the involvement of the artic-ular surface by the fracture line. For the lower tibial fracture, one patient was treated with closed re-duction and fixation with an elastic nail, three patients had internal plate fixation, and the remain-ing patient had cast immobilization. Followed up for 3-11 months (mean 7), all the distal tibial frac-tures and the triplane fractures were healed without varus or valgus deformity in the ankle. Conclusion: Distal tibial triplane fracture can be readily missed in plain radiography and should be suspected in patients with distal tibial spiral fracture which should be evaluated with a computed to-mographic scan.