Triplane Fractures - Types, Symptoms, Diagnosis, and Treatment

Introduction

The term triplane fracture refers to fractures occurring in three planes, vertical, horizontal, and transverse planes. It is usually noted in children and adolescents. The common site of occurrence is usually in the distal part of the tibia and the ankle. It involves the cartilaginous growth plate, which is the weakest part of the bone. These fractures occur secondary to ankle trauma and affect the distal part of the tibia.

Who Are Prone to Triplane Fractures?

Triplane fractures usually occur in children and adolescents between the ages of 10 to 17 years. In these individuals, the growth plates are still active. As a result, there is the presence of cartilage between the calcified bone, typically in the physis region. When any external trauma results in a forced external rotation, it results in a triplane fracture. It usually occurs secondary to ankle fractures.

What Are the Symptoms of a Triplane Fracture?

The symptoms seen in the case of triplane fractures are as follows:

1. Pain and swelling in the affected area.

2. Abnormal sensation or paresthesia.

3. Petechiae and ecchymosis (the presence of bleeding spots over the injury site).

4. Ankle deformity.

5. Growth retardation of the tibia.

How Are Triplane Fractures Diagnosed?

• The extent of the fracture cannot be determined with plain radiographs.

• The anteroposterior and lateral views have to also be taken into consideration for a proper diagnosis.

• Other than radiographs, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans are also necessary to identify the extent of the fracture, the angle of its deformity, and the status of the surrounding soft tissue.

What Are the Type of Triplane Fractures?

Triplane fractures are classified according to the following;

1. The Number of Fragments:

Two-Part Fractures:

• Anterolateral or posterior epiphyseal fractures.

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• Anteromedial epiphyseal fractures.

Three-Part Fractures:

• Anterolateral epiphyseal fracture.

• Posterior epiphyseal fracture.

• Anteromedial epiphyseal fracture.

Four-Part Fractures:

• Comminuted fractures.

2. The Pattern of the Fracture:

• Lateral Fracture:

  • Sagittal Plane: Epiphysis.

  • Axial Plane: Physis.

  • Coronal Plane: Metaphysis.

• Medial Fracture:

  • Sagittal Plane: Epiphysis.

  • Axial Plane: Physis.

  • Coronal Plane: Metaphysis.

• Intra Malleolar Fracture:

  • Type I: Intra-articular fractures involving the weight-bearing surfaces.

  • Type II: Intra-articular fractures not involving the weight-bearing surfaces.

  • Type III: Extra-articular fractures.

What Are the Treatment Modalities for Triplane Fractures?

The treatment of triplane fractures depends upon several factors, as enlisted below;

1. The extent of the fracture.

2. The amount of displaced fragments of the fractured components.

3. The degree of articular step-off is observed in the CT scan.

The treatment may either be non-surgical or surgical, depending upon the aforementioned factors.

Non-surgical Treatment:

Non-surgical treatments are for those fractures that show displacement of less than 2 mm. The procedure involves the following steps;

• After assessing the displacement and degrees of articular step-off, the bone is subjected to maneuvers to be put back to its original position.

• This is achieved by an internal rotation of the ankle to align the bone into place.

• The leg is then kept immobilized using a long leg cast.

• Postoperative CT scans are then performed to assess the residual displacement of the bones.

Surgical Treatment:

Surgical treatment is usually done in cases where;

• The fracture fragment displacement is more than 2 mm.

• Loss of fracture reduction after initial non-surgical treatment.

One or two screws are placed parallel to the physis to achieve bone fixation. The placement of the screws can be in the metaphysis, epiphysis, or both depending upon the fracture pattern. The types of screws that are utilized for fixation vary widely. The screws in fixation may be several types depending upon their design:

1. Cannulated and non-cannulated.

2. Fully threaded and partially threaded.

• The articular surface must be restored to congruence to optimize the outcomes of the treatment. Care is necessary to place screws perpendicularly as possible to fracture lines to maximize compression and maintain reduction. Clinicians and researchers have described both closed-reduction and open-reduction techniques with universally good outcomes.

• Several doctors are of the opinion that percutaneous reduction via small incisions and fixation with one or two non-cannulated partially threaded 3.5 mm screws placed parallel to the physis is a very effective process. The epiphyseal fracture is usually amenable to anterolateral to posteromedial placed screws, while the metaphyseal fragment usually gets captured with direct anterior to posterior based screws.

• It is also necessary to ensure all screw threads are past the fracture if using partially threaded screws.

• Postoperative care involves the immobilization of the region, along with follow-up CT scans to assess the recovery of the fractured bone. Pain management is usually done using non-steroidal anti-inflammatory drugs (NSAIDs), and opioids are rarely given to children. This is followed up with physical and occupational therapy.

What Are the Postoperative Care Necessary Following Surgical Treatment?

Usually, one to two weeks of in-hospital stay is necessary after a triplane fracture surgery, with the recovery period being relatively less due to children having a faster healing capability as compared to adults. In addition, physical and occupational therapy is also done to help regain strength and functionality faster. The patient may also require the use of specially designed orthopedic shoes called orthotics.

Can the Surgery Be Minimally-Invasive?

Yes. Minimally invasive surgery aims to impact minimally on the adjacent healthy tissue such as bone, muscle, nerves, and blood vessels.

The advantages are as follows:

• Lower risk of muscle damage.

• Less pain.

• Quicker and easier recovery.

• Less limping.

• Shorter hospital stay.

What Are the Postoperative Complications Following Surgical Treatment?

Like any other surgical procedure, triplane fracture surgery also has certain risks associated with it. The potential complications are enlisted as follows:

• Loss of reduction that requires operative fixation.

• Nonunion of fracture fragments.

• Malunion.

• Persistent pain.

• Bleeding at the surgical site.

• Infection of the surgical site.

• Early closure of the growth plate results in stunted growth of the bone.

• Transient neuropathy, resulting in abnormal sensations or paresthesia.

How Is the Postoperative Prognosis?

As per the studies conducted in the past, non-surgical fracture reductions show excellent healing in almost all cases. However, in surgical cases, the patient may develop a limp, an ankle deformity, or in rare cases, stunted growth due to early closure of the growth plates in the physeal region.

Conclusion

Triplane fractures are usually seen in children and adolescents between the ages of 10 to 17 years. Non-surgical treatments are for those fractures that show displacement less than 2 mm, whereas those with greater displacement require surgical management. Treatment strategies for triplane fractures depend on the residual displacement following reduction.