eMedicine Specialties > Orthopedic Surgery > Trauma

Triplane Fracture: Treatment

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

Treatment

Medical Therapy

Nondisplaced triplane fractures (< 2 mm displacement) and extra-articular fractures can be managed with immobilization in a short leg cast for 4-6 weeks. Serial radiographs are obtained at weekly intervals during the first 3 weeks to check for late displacement. For displaced fractures, closed reduction is attempted with general anesthesia.

Closed reduction

General anesthesia and, at times, skeletal muscle relaxation, is required to reduce the displacement. The mechanism of injury or the motion that produced the injury is reversed to obtain realignment. For medial fractures, the foot is positioned in external rotation; for lateral fractures, in internal rotation. Avoid more than 2 attempts at realignment, as each attempt causes additional trauma and bleeding and, possibly, further injury to the distal tibial growth plate. Closed reduction resulting in adequate fracture reduction in all planes is obtained in approximately 30-50% of triplane fractures.

Postreduction CT scans and serial radiographs are needed to assess adequacy of reduction and guard against loss of reduction in the cast.

Adequate closed reduction is followed by 4-6 weeks of above-the-knee casting. The cast then is replaced with a below-the-knee cast to allow limited weight bearing with crutches for an additional 4 weeks. Following removal of the final cast, progressive return to normal activity is encouraged with ongoing physical therapy and range-of-motion exercises.

Surgical Therapy

Open reduction and internal fixation

Open reduction and internal fixation for any triplane fracture demonstrating 2 mm or more of displacement after attempted closed reduction involves the following:

  • The surgical approach depends on the fracture planes and can be anterolateral for lateral fractures or anteromedial for medial fractures. Small stab incisions are often needed for the placement of screws, either solid or cannulated.
  • Reduction and fixation of the metaphyseal spike may be all the surgery that is needed. An alternative is the placement of epiphyseal screws parallel to the joint surface, avoiding the growth plate and the ankle joint. More than 1 screw is needed, and the primary goal is reduction of the physeal fracture and joint surface.
  • Intraoperative radiographs or fluoroscopy are needed to ensure that the fracture is reduced and that screw placement is satisfactory. Surgical fixation resulting in anatomic realignment of a triplane fracture can be viewed in Images 9-10.


Lateral view at 60 days postoperatively of this 3...

Lateral view at 60 days postoperatively of this 3-part triplane fracture in a 14-year-old male demonstrates accurate anatomic reduction. Two compression screws have been placed through a posterolateral incision. A vertical sclerotic line appears above, through, and below the screws, indicating healing of the realigned posterior metaphyseal spike. A 0.062 inch smooth Kirschner wire is observed (see Image 10).

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Lateral view at 60 days postoperatively of this 3...

Lateral view at 60 days postoperatively of this 3-part triplane fracture in a 14-year-old male demonstrates accurate anatomic reduction. Two compression screws have been placed through a posterolateral incision. A vertical sclerotic line appears above, through, and below the screws, indicating healing of the realigned posterior metaphyseal spike. A 0.062 inch smooth Kirschner wire is observed (see Image 10).



Anteroposterior view at 60 days postoperatively o...

Anteroposterior view at 60 days postoperatively of this 3-part triplane fracture demonstrates accurate anatomic reduction and 2 compression screws fixating the posterior metaphyseal spike. The horizontal 0.062 inch smooth Kirschner wire is accurately placed in the epiphysis from a medial approach through a single stab incision. Midway along the Kirschner wire a vertical line in the sagittal plane is observed, representing the original fracture through the epiphysis. Note that all fixation devices avoid the tibial growth plate.

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Anteroposterior view at 60 days postoperatively o...

Anteroposterior view at 60 days postoperatively of this 3-part triplane fracture demonstrates accurate anatomic reduction and 2 compression screws fixating the posterior metaphyseal spike. The horizontal 0.062 inch smooth Kirschner wire is accurately placed in the epiphysis from a medial approach through a single stab incision. Midway along the Kirschner wire a vertical line in the sagittal plane is observed, representing the original fracture through the epiphysis. Note that all fixation devices avoid the tibial growth plate.


  • The anterolateral epiphyseal fragment of a 3-part injury is reduced and held with either a screw or a K-wire. Before the patient leaves the operating room, a final set of postreduction radiographs is completed.
  • Arthroscopic reduction and internal fixation of 2-part triplane fractures has been described to have advantages over traditional open reduction and internal fixation.33,34,35,36

Preoperative Details

Preoperatively, it is essential to detect and address adequately all other injuries, as well as other comorbidities and preexisting medical conditions and needs.

In persons with open fractures, tetanus immunization should be updated preoperatively if needed, and prophylactic antistaphylococcal antibiotics should be administered.

Intraoperative Details

Portable or fixed overhead radiography or C-arm fluoroscopy is needed in the operating room to evaluate the results of internal fixation before the patient leaves the operating room.

Postoperative Details

Postoperatively, standard incision care and suture removal are performed as directed by the physician. An above-the-knee cast is used for 4-6 weeks, followed by a below-the-knee partial weightbearing cast. When internal fixation has been accomplished and early physical therapy and/or range-of-motion exercises are desired, the short leg cast may be replaced by a removable air splint.

Follow-up

All patients with triplane ankle fractures must be monitored closely for potential complications (see Complications). At discharge, the treating physician must make each patient aware of all of the follow-up requirements. Emphasis should be placed on the importance of patient involvement, as it has direct bearing on the likelihood of a favorable outcome.

Typically, the initial above-the-knee cast is replaced at 4-6 weeks postinjury, regardless of the treatment mode. This cast is replaced with a below-the-knee cast or a removable boot.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Ankle Fracture.

Complications

In general, young healthy adolescents do well following a triplane fracture, despite the fact that it is a serious injury.

Complications include the following:

  • Tibial length growth retardation or deformity around the ankle secondary to epiphyseal growth plate injury
  • Posttraumatic arthritis
  • Postoperative infection
  • Osteomyelitis
  • Pressure sores from the cast
  • Fracture blisters
  • Compartment syndrome

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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