Triplane Fracture Workup

Updated: Apr 23, 2020
  • Author: John L Abt, DO, FACEP, FACFE; Chief Editor: Jeffrey D Thomson, MD  more...
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Workup

Approach Considerations

Early discussions of distal tibial fractures occurring in adolescence lacked consistent and exact descriptions of the fracture fragments because plain radiographs were used to visualize and characterize the fragments. Additionally, involvement of the tibial growth plate in these fractures was suspected but not understood completely.

The advent of computed tomography (CT) and magnetic resonance imaging (MRI) made it possible to delineate the exact anatomy, fracture lines, plane analysis, and other characteristics of the triplane fracture. In particular, any disruption that occurs at the growth plate, the anterior talofibular and tibiofibular ligament, and the talotibial articular plafond is visualized on CT.

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Laboratory Studies

The laboratory studies performed in patients with triplane fractures depend on the age of the patient, the extent of all injuries, and other comorbid conditions. Triplane fractures most commonly occur in healthy adolescents. Reasonable, though not mandatory, preoperative studies include the following:

  • Complete blood count (CBC)
  • Sequential multiple analysis (SMA7)
  • Urinalysis
  • Blood type and screen
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Radiography

Plain radiography

Ankle (distal tibia, fibula, and talus)

If the patient demonstrates localized pain, inability to fully bear weight, ankle deformity, confounding variables (eg, patient age < 18 years), underlying neurologic deficits affecting the lower limbs, altered mental status, and/or multisystem trauma, or if the patient otherwise meets the Ottawa rules indicating that radiologic evaluation should be performed, obtain anteroposterior (AP), lateral, and ankle mortise views with the foot in 15° of internal rotation.

The saddle or headset sign should be observed. The saddle (or telephone headset), consisting of the tibia and fibula, should lie congruently above and around the talus (the horse or the telephone base).

The space between the talar dome and a curved line running along the internal surfaces of the distal tibia and fibula (ankle mortise space) should be equal throughout its length. Lack of symmetry suggests ankle mortise disruption due to ligamentous injury or bony fracture.

Foot

Indications for radiologic studies of the foot include localized pain, deformity, or the inability to bear weight completely. Obtain AP and lateral foot films. Direct attention to areas at high-risk for associated injuries (eg, proximal fifth metatarsal, navicular, cuboid, medial cuneiform, calcaneal bones).

Fibula and tibia

Triplane and other ankle fractures are frequently associated with fibula fractures (see the images below). As a result, forces are transmitted to the fibula in a lateral, medial, or spiral (twisting) motion. Spiral stresses, in particular, may result in a Maisonneuve fracture of the proximal fibula. These are easily missed if the knee and proximal fibula are not examined at the time the ankle and foot are examined.

Lateral radiograph of a triplane fracture illustra Lateral radiograph of a triplane fracture illustrates the following: Yellow arrows indicate the horizontal component of the fracture through the physis (growth plate), red arrows indicate the vertical fracture line in the coronal plane involving the metaphyseal spike complex, black arrows point to the posterior margin of the metaphyseal spike, and purple arrows indicate the associated fibular fracture. This image represents one of the first known published images of this type of 2-part triplane fracture.
Radiograph of a triplane fracture. The anterior-po Radiograph of a triplane fracture. The anterior-posterior view of the distal tibia and epiphysis is illustrated as follows: Yellow arrows indicate the horizontal fracture component through the growth plate, white arrows indicate the vertical fracture through the epiphysis in the sagittal plane, and black arrows outline the superior edges of the posterior metaphyseal spike. An associated fibula fracture is present. In this left-sided 2-part triplane fracture, medial is to the viewer's left, and lateral is to the right. This image represents one of the first known published images of this type of 2-part triplane fracture.

If pain or tenderness is present anywhere along the length of the fibula, x-ray the fibula. This applies equally to any area of the tibia not apparently associated with the primary area of injury.

Other x-rays performed in anticipation of the operating room depend on the age of the patient, the extent of all injuries, and other comorbid conditions. Triplane fractures most commonly occur in healthy adolescents. Chest x-ray is a reasonable, but not mandatory, preoperative study.

Stress radiography

These images may be obtained when plain film evaluation reveals no obvious fractures. Preferably, these radiographs are obtained following orthopedic consultation; stress films lend little to the management of ankle injuries by emergency department physicians.

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Computed Tomography

CT is not indicated for routine evaluation of common ankle fractures, but it is required to assess complex multipart or multiplane fractures of the ankle. [34, 35]  CT demonstrates fracture lines, fracture segments, and intra-articular extent and enables the accurate measurement of displacement. If surgery is being contemplated, it helps with planning the surgical incisions and the direction and orientation of implants such as screws for internal fixation.

In a study designed to assess the utility of radiography, with or without CT, for fracture classification, displacement measurement, and treatment planning in children with triplane fractures, Eismann et al found that the addition of CT had a definite positive impact with respect to all three parameters, which suggested that this modality is a potentially valuable adjunct to radiography in the management of pediatric triplane fractures. [36]

With the advent and greater use of spiral (helical) CT (see the images below) and ultrafast CT scans, as well as 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.

Digital 3-dimensional helical CT scan reconstructi Digital 3-dimensional helical CT scan reconstruction of a rare type of triplane fracture. The image shown is of the inferior surface of the tibial epiphysis. Medially (viewer's left) is the distal tibial malleolus. Laterally (viewer's right) is the distal fibula/lateral malleolus. Fracture lines exist through the tibial epiphysis in the coronal, sagittal, and horizontal planes. The posterolateral fragment of the epiphysis is attached to the posterior metaphyseal spike rather than the more common anterolateral segment of the epiphysis. This image represents one of the first known published images of this type of 2-part triplane fracture.
Two-dimensional helical CT scan image prior to 3-d Two-dimensional helical CT scan image prior to 3-dimensional reconstruction. PLEF represents the posterolateral epiphyseal fragment. DF is the distal fibula. The posteromedial and the entire portion of the anterior epiphysis are intact. This image represents one of the first known published images of this type of 2-part triplane fracture.
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Magnetic Resonance Imaging

Park et al used MRI to investigated the incidence and location of periosteal entrapment in 50 adolescent distal tibial physeal fractures (15 Salter-Harris type II, 12 type III [four malleolar, eight Tillaux], and 23 type IV [two malleolar, 21 triplane]) and the angle of the fracture plane of metaphyseal fragments on the axial plane. [37] In all, 36 (72.0%) presented with periosteal entrapment. In all type II and triplane fractures, periosteal entrapment was observed in the anterolateral corner when there was any displacement on that corner, whereas only one Tillaux fracture presented with periosteal entrapment. In almost all supinated foot injuries of type II and triplane fractures, the metaphyseal fracture line was parallel to the intermalleolar axis on the axial plane.

The authors concluded that Salter-Harris type II and triplane fractures have a high risk of periosteal entrapment, especially in the anterolateral corner. [37] Therefore, even without preoperative MRI, surgical repositioning of entrapped periosteum should be considered after failed closed reduction. In cases of supinated foot injuries of type II or triplane fractures requiring surgical fixation, a metaphyseal fracture plane parallel to the oblique coronal plane connecting the medial and lateral malleoli may facilitate appropriate metaphyseal fixation.

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