eMedicine Specialties > Orthopedic Surgery > Trauma

Triplane Fracture: Follow-up

Author: John L Abt, DO, FACEP, FACFE, Clinical Associate Professor and Senior Consulting Staff, Department of Emergency Medicine, Mount Sinai Medical Center of Miami
Coauthor(s): Vinod K Panchbhavi, MD, FRCS, FACS, Associate Professor, Chief, Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch School of Medicine
Contributor Information and Disclosures

Updated: Jun 12, 2009

Outcome and Prognosis

The outcome and long-term prognosis for individuals with triplane fracture are related primarily to concerns in 2 areas, as follows:

  • Posttraumatic arthritis: When fracture fragment reduction is inadequate, either by closed or open reduction, the long-term prognosis is less than favorable. Posttraumatic arthritis may take years to be appreciated fully. Recent studies support the contention that the development of posttraumatic arthritis is related primarily to inadequate realignment of the inferior surface of the epiphysis as it articulates with the talar dome.
  • Tibial length growth retardation secondary to epiphyseal growth plate injury: This is a lesser concern, as most triplane fractures in adolescents occur at a time when at least medial growth plate closure has occurred, leaving only the lateral growth plate open.
  • Intraoperatively, it is important not to place compression screws or other hardware that exert compression forces on the growth plate. Such compression exacerbates premature growth plate closure and tibial growth retardation. Also, any physeal gaps lead to bony bridge formation and therefore require perfect reduction.
  • Rotational malalignment, which most often manifests as external rotation deformity, will adversely affect the foot progression angle.37

Additional concerns include the following:

  • Postoperative infection and osteomyelitis are uncommon complications. Either may be attributed to a lack of patient cleanliness and compliance or to poor surgical technique, or may result from a highly contaminated open fracture.
  • Pressure sores may result from localized swelling, a cast that gets wet and expands, or a cast that is fitted improperly. In all such cases, the patient develops point tenderness that was not present previously under the cast. Remove the cast, and inspect and palpate the entire area to identify the location and cause of the pain. If the pain is caused by pressure alone, a new cast is applied with extra padding in the area of pain and attention to avoiding all pressure to the area. If a pressure sore (skin breakdown) is noted, standard wound therapy, which may include oral antibiotics, should be initiated. The cast is reapplied as above, with the addition of a cast window. This allows ongoing wound checks and dressing changes until the wound resolves, while avoiding frequent cast changes for wound care.
  • Fracture blisters are caused by blood accumulating under the skin in an area of swelling that accompanies a fracture. This can result in skin breakdown and ulceration. Care of fracture blisters is similar to that for pressure sores. It is imperative that no surgical therapy for the fracture, initial or delayed, should be attempted at a site with fracture blisters because of the high risk of wound complications in the affected area.
  • Compartment syndrome may affect any of the 4 compartments of the lower leg or the deep plantar compartment of the foot. This may manifest as pain or burning, which may be severe at rest or with passive dorsiflexion of the foot. Sensation is affected first, then motor function. Commonly, the anterior tibial compartment is affected with resultant increasing compartment pressure on the superficial peroneal nerve, which results in heightened pain on passive motion of the toes followed by decreased sensation in the first and second webspaces of the toes. The foot and/or lower leg may be tense and hard. Compare findings with those of the unaffected limb. If compartment syndrome is confirmed by measurement of compartment pressures, immediate operative intervention is required.

Future and Controversies

With the advent and greater use of spiral CT and ultrafast CT scans, and the declining costs of this technology, these scans will likely become the imaging modalities of choice for complex multipart and triplane ankle fractures. These scans will also guide approaches to further open intraoperative intervention.

Future intraoperative CT C-arm or navigation technology will be more readily available and increase the accuracy of placement of screws and internal fixation in these complex fractures.

The strength of operative screws and pins has increased progressively, while the diameters of operative screws have decreased. Titanium-based materials of greater diameter may be replaced by composite materials of lesser diameter, thus lessening the trauma associated with their operative placement.

 


More on Triplane Fracture

Overview: Triplane Fracture
Workup: Triplane Fracture
Treatment: Triplane Fracture
Follow-up: Triplane Fracture
Multimedia: Triplane Fracture
References
Further Reading
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Keywords

triplane fracture, transitional fracture, ankle fracture, Marmor-Lynn fracture, multiplane fracture, multipart fracture, adolescent tibial triplane fracture, tibial fracture, tibia fracture, tibial epiphysis, tibial growth plate, growth plate, epiphyseal fracture, epiphyseal growth plate, physis, physeal fracture, distal tibia, distal tibial epiphysis, distal tibial metaphysis, tibia, Maisonneuve fibular fracture, distal fibula, proximal fibula, fibula fracture, fibular fracture

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Contributor Information and Disclosures

Author

John L Abt, DO, FACEP, FACFE, Clinical Associate Professor and Senior Consulting Staff, Department of Emergency Medicine, Mount Sinai Medical Center of Miami
John L Abt, DO, FACEP, FACFE is a member of the following medical societies: American College of Emergency Physicians, American College of Forensic Examiners, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Vinod K Panchbhavi, MD, FRCS, FACS, Associate Professor, Chief, Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch School of Medicine
Vinod K Panchbhavi, MD, FRCS, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Foot and Ankle Society, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center
John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, and Texas Medical Association
Disclosure: Zimmer Inc Consulting fee Consulting; Smith Nephew Consulting fee Consulting; AO North America Honoraria Speaking and teaching; Osteotech Consulting fee Consulting; Stryker Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center
Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

 
 
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