title: Salter-Harris II fractures of the distal tibia: does surgical management reduce the risk of premature physeal closure?
abstract: BACKGROUND
  Premature physeal closure (PPC) is a common complication resulting from the management of a displaced Salter-Harris II (SH II) fracture of the distal tibia. The purpose of this study was to evaluate our institution's treatment approach to assess PPC and complication rates of fractures treated both surgically and nonsurgically.
  
  
  METHODS
  We performed a retrospective review of all patients presenting with a displaced SH II fracture between 2004 and 2010. Initial treatment was closed reduction in the emergency department. Further treatment and subsequent categorization was based on amount of residual displacement. Patients with <2 mm of postreduction displacement were treated with a non-weight-bearing long-leg cast (LLC; group 1), patients with residual displacement between 2 and 4 mm were treated with one of 2 approaches based on surgeon preference: either LLC (group 2) or open reduction and internal fixation (ORIF) with removal of any interposed tissue (group 3). Patients with >4 mm of residual displacement were treated with ORIF (group 4). Follow-up radiographs were performed for a minimum of 6 months. If there was clinical concern about PPC, computed tomography imaging was performed to assess for a bony bar.
  
  
  RESULTS
  In total, 96 patients with a mean age of 12.6 years at presentation were included in the study. Among the 14 patients with <2 mm of postreduction displacement, 29% had a PPC and 7% had to undergo a subsequent procedure (epiphsyiodesis, osteotomy, etc.). Of the 33 patients with 2 to 4 mm of displacement who were treated with a LLC, 33% had a PPC and 15% had to undergo a subsequent procedure. Of the 11 patients with 2 to 4 mm of displacement treated with ORIF 46% had a PPC and 18% had a second procedure. Finally, 38 patients with >4 mm of displacement treated with ORIF had a PPC rate of 55% and 23% had a subsequent procedure. No statistical differences in PPC (P=0.19) or subsequent surgeries (P=0.57) were observed between groups. Among those with 2 to 4 mm of postreduction displacement, patient age (P=0.36), sex (P=0.39), mechanism of injury (P=0.13), time to fracture management (P=0.51), amount of initial displacement (P=0.34), number of reduction attempts (P=0.43), and operative treatment (P=0.47) did not significantly influence PPC.
  
  
  CONCLUSIONS
  Patients with displaced SH II distal tibia fractures pose a challenging problem for the treating physician with a high rate of PPC (43% overall). Although surgical fixation with anatomic reduction and removal of interposed tissue may be necessary to improve joint alignment, it does not reduce the incidence of PPC and may increase the need for subsequent surgeries.
authors.affiliation: Department of Orthopedic Surgery, Rady Children's Hospital, University of California-San Diego, San Diego, CA 92123, USA.
authors.forename: Franco
authors.initials: F
authors.lastname: Russo
authors.forename: Molly A
authors.initials: MA
authors.lastname: Moor
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Mubarak
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Pennock
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002370:Casts, Surgical; D002648:Child; D004838:Epiphyses / Q000000981:diagnostic imaging / Q000473:pathology*; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing / Q000502:physiology*; D006801:Humans; D008297:Male; D061646:Operative Time; D012189:Retrospective Studies; D012737:Sex Factors; D013978:Tibial Fractures / Q000601:surgery* / Q000628:therapy; D013997:Time Factors; D014057:Tomography, X-Ray Computed