Triplane Fracture
Salter-Harris type-IV fracture of distal tibia. Three fracture planes:
- Sagittal (vertical) - Epiphysis
- Transverse (horizontal) - Physis
- Coronal - Metaphysis
Occur in adolescents as distal tibial physis closing. Suspect it if see fracture line on AP in Tibial metaphysis and second fracture line or step in articular surface on lateral. VERY easy to not appreciate severity of injury on plane radiographs.
CT scan is indicated if suspect triplane fracture and to detect amount of displacement.
Two patterns
Lateral triplane - metaphyseal fragment posterolateral
Medial triplane - metaphyseal fragment medial
Treatment
As for Tillaux fracture problem is not growth disturbance but congruity of articular surface.
Articular
step-off of >2 mm or a fracture gap of >2 to 4 mm is an indication for open
reduction and fixation.
Reduce by internal rotation
Hold with percutaneous screws if adequate closed reduction
Convert to tillaux type by securing metaphyseal fragments with anterior metaphyseal lag screws, then secure tillaux fragment with oblique epiphyseal metaphyseal screw directed postero medially (plan trajectory of screws with CT scans)
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| Coronal CT slice showing - Fracture in Sagital plane in Epiphysis | Sagital CT showing - Fracture in Coronal plane, posterior metaphyseal fragment | Axial CT showing fracture configuration in Epiphysis |
Third plane of triplane not depicted above, in horizontal plane in plane of Physis
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Triplane fixed |
References
L von Laer Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia; JBJS - Am 1985 67: 687-698
John M. Flynn, David Skaggs, Paul D. Sponseller, Theodore J. Ganley, Robert M. Kay, and K. Kellie Leitch; The Operative Management of Pediatric Fractures of the Lower Extremity; JBJS - Am 2002 84: 2288-2300.