Short-term effectiveness of ultrasound-guided Kirschner wire provocation technique in treatment of Salter-Harris types <b>Ⅰ</b> and <b>Ⅱ</b> periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

MA Hailong , ZHOU Zhilin ,  ZHANG Sicheng , LIU Fang , HUA Zhongtuo , SUN Xiwei , JIA Guoqiang , SUN Jun

Department of Orthopedics, Anhui Medical University Children’s Medical Center, Anhui Provincial Children’s Hospital, Hefei Anhui, 230051, P. R. China;

Corresponding?author：

ZHANG Sicheng, Email: zsc_zls@126.com

Keywords：

Distal tibial fracture; epiphyseal fracture; periosteal entrapment; ultrasound-guided; children; adolescents

DOI：

10.7507/1002-1892.202309047

Video：

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Objective To investigate the short-term effectiveness of ultrasound-guided closed reduction by Kirschner wire provocation technique in the treatment of Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents. Methods Between May 2019 and May 2022, 41 patients with Salter Harris types Ⅰ and Ⅱ distal tibial epiphyseal fractures were admitted, all of whom had periosteal entrapment on preoperative MRI, and 38 cases (92.7%) were confirmed to have periosteal entrapment by intraoperative ultrasound. There were 24 males and 14 females, the age ranged from 6.8 to 15.7 years, with an average of 10.7 years; and there were 20 cases of Salter Harris type Ⅰ and 18 cases of type Ⅱ. The time from injury to operation was 22-76 hours, with an average of 28.4 hours. The preoperative imaging examination showed excellent alignment in 4 cases, good in 20 cases, and poor in 14 cases. The ultrasound guided Kirschner wire provocation technique for closed reduction and percutaneous Kirschner wire internal fixation were performed. The operation time, intraoperative fluoroscopy frequency, fracture healing time, and complications were recorded. Anteroposterior and lateral X-ray films of the affected ankle joint were taken before operation, at 3 months after operation, and at last follow-up to observe the healing of the fracture, and anteroposterior X-ray films of the whole length of both lower limbs were taken to evaluate the alignment of the force lines of the affected limbs. The range of motion (ROM), visual analogue scale (VAS) score, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used to evaluate ankle function. The mechanical lateral distal tibia angle (mLDTA) and the anatomic anterior distal tibia angle (aADTA) were measured. Results The operation time ranged from 17 to 52 minutes, with an average of 22.6 minutes, and the intraoperative fluoroscopy frequency ranged from 3 to 11 times, with an average of 4.2 times. X-ray examination during operation and at 2 days after operation showed that anatomical reduction was achieved. All patients were followed up 10-24 months, with an average of 16.4 months. All fractures healed in 6.1-7.2 weeks, with an average of 6.3 weeks; no fracture displacement occurred, and the patients recovered to their pre-injury level of motion at 6 months after operation. Needle tail irritation occurred in 2 cases at 4 weeks after operation, and they recovered after symptomatic treatment. During the follow-up, there was no serious complication such as incision deep infection, bone nonunion, delayed union, and malunion. At last follow-up, the patients’ alignment were all excellent, and the difference was significant when compared with preoperative one (Z=–7.471, P<0.001). The VAS score, AOFAS ankle-hindfoot score, dorsiflexion-plantar flexion ROM, varus-valgus ROM, mLDTA, and aADTA significantly improved at 3 months after operation and last follow-up when compared with preoperative ones (P<0.05). Conclusion Ultrasound-guided closed reduction by Kirschner wire provocation technique for treating Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents is minimally invasive and safe.

Citation： MA Hailong, ZHOU Zhilin, ZHANG Sicheng, LIU Fang, HUA Zhongtuo, SUN Xiwei, JIA Guoqiang, SUN Jun. Short-term effectiveness of ultrasound-guided Kirschner wire provocation technique in treatment of Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(12): 1477-1481. doi: 10.7507/1002-1892.202309047 Copy

1.	Mizuta T, Benson WM, Foster BK, et al. Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop, 1987, 7(5): 518-523.
2.	Wuerz TH, Gurd DP. Pediatric physeal ankle fracture. J Am Acad Orthop Surg, 2013, 21(4): 234-244.
3.	Park J, Cha Y, Kang MS, et al. Fracture pattern and periosteal entrapment in adolescent displaced distal tibial physeal fractures: A magnetic resonance imaging study. J Orthop Trauma, 2019, 33(5): e196-e202.
4.	Su AW, Larson AN. Pediatric ankle fractures: Concepts and treatment principles. Foot Ankle Clin, 2015, 20(4): 705-719.
5.	Dugan G, Herndon WA, McGuire R. Distal tibial physeal injuries in children: a different treatment concept. J Orthop Trauma, 1987, 1(1): 63-67.
6.	Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop, 2003, 23(6): 733-739.
7.	Segal LS, Shrader MW. Periosteal entrapment in distal femoral physeal fractures: harbinger for premature physeal arrest? Acta Orthop Belg, 2011, 77(5): 684-690.
8.	Katzer C, Wasem J, Eckert K, et al. Ultrasound in the diagnostics of metaphyseal forearm fractures in children: A systematic review and cost calculation. Pediatr Emerg Care, 2016, 32(6): 401-407.
9.	伍興, 夏敬冬, 李雄濤, 等. 超聲和關節造影輔助下治療兒童肱骨遠端骨骺分離的臨床療效分析. 中華小兒外科雜志, 2022, 43(1): 50-55.
10.	郭美振, 黃瀠樂, 覃佳強, 等. 超聲引導下閉合復位內固定治療兒童JakobⅡ型肱骨外髁骨折的療效. 中華創傷雜志, 2020, 36(9): 785-790.
11.	Chambers G, Kraft J, Kingston K. The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries. Ultrasound, 2019, 27(1): 6-19.
12.	潘博文, 趙國強, 祝銘, 等. 超聲引導下經皮克氏針撬撥聯合髓內針內固定治療兒童橈骨頸骨折. 臨床小兒外科雜志, 2022, 21(2): 174-178.
13.	Duran JA, Dayer R, Kaelin A, et al. Intraoperative arthrography for the evaluation of closed reduction and percutaneous fixation of displaced MacFarland fractures: an alternative to open surgery. J Pediatr Orthop, 2011, 31(1): e1-e5.
14.	伍興, 夏敬冬, 李雄濤, 等. 超聲引導閉合復位經皮內固定治療兒童橈骨遠端骨骺骨折. 中華小兒外科雜志, 2020, 41(11): 1005-1009.
15.	Macaulay A, Nandyala SV, Miller CP, et al. Potential for bias and the American Orthopaedic Foot and Ankle Society Ankle-hindfoot scoring system. Foot Ankle Spec, 2018, 11(5): 416-419.
16.	Lesko PD, Georgis T, Slabaugh P. Irreducible salter-Harris type Ⅱ fracture of the distal radial epiphysis. J Pediatr Orthop, 1987, 7(6): 719-721.
17.	Phieffer LS, Meyer RA, Gruber HE, et al. Effect of interposed periosteum in an animal physeal fracture model. Clin Orthop Relat Res, 2000(376): 15-25.
18.	Crawford AH. Triplane and Tillaux fractures: is a 2 mm residual gap acceptable? J Pediatr Orthop, 2012, 32 Suppl 1: S69-S73.
19.	Russo F, Moor MA, Mubarak SJ, et al. Salter-Harris Ⅱ fractures of the distal tibia: does surgical management reduce the risk of premature physeal closure? J Pediatr Orthop, 2013, 33(5): 524-529.
20.	Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to the ankle. Foot Ankle, 1991, 11(6): 372-383.

1. Mizuta T, Benson WM, Foster BK, et al. Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop, 1987, 7(5): 518-523.
2. Wuerz TH, Gurd DP. Pediatric physeal ankle fracture. J Am Acad Orthop Surg, 2013, 21(4): 234-244.
3. Park J, Cha Y, Kang MS, et al. Fracture pattern and periosteal entrapment in adolescent displaced distal tibial physeal fractures: A magnetic resonance imaging study. J Orthop Trauma, 2019, 33(5): e196-e202.
4. Su AW, Larson AN. Pediatric ankle fractures: Concepts and treatment principles. Foot Ankle Clin, 2015, 20(4): 705-719.
5. Dugan G, Herndon WA, McGuire R. Distal tibial physeal injuries in children: a different treatment concept. J Orthop Trauma, 1987, 1(1): 63-67.
6. Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop, 2003, 23(6): 733-739.
7. Segal LS, Shrader MW. Periosteal entrapment in distal femoral physeal fractures: harbinger for premature physeal arrest? Acta Orthop Belg, 2011, 77(5): 684-690.
8. Katzer C, Wasem J, Eckert K, et al. Ultrasound in the diagnostics of metaphyseal forearm fractures in children: A systematic review and cost calculation. Pediatr Emerg Care, 2016, 32(6): 401-407.
9. 伍興, 夏敬冬, 李雄濤, 等. 超聲和關節造影輔助下治療兒童肱骨遠端骨骺分離的臨床療效分析. 中華小兒外科雜志, 2022, 43(1): 50-55.
10. 郭美振, 黃瀠樂, 覃佳強, 等. 超聲引導下閉合復位內固定治療兒童JakobⅡ型肱骨外髁骨折的療效. 中華創傷雜志, 2020, 36(9): 785-790.
11. Chambers G, Kraft J, Kingston K. The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries. Ultrasound, 2019, 27(1): 6-19.
12. 潘博文, 趙國強, 祝銘, 等. 超聲引導下經皮克氏針撬撥聯合髓內針內固定治療兒童橈骨頸骨折. 臨床小兒外科雜志, 2022, 21(2): 174-178.
13. Duran JA, Dayer R, Kaelin A, et al. Intraoperative arthrography for the evaluation of closed reduction and percutaneous fixation of displaced MacFarland fractures: an alternative to open surgery. J Pediatr Orthop, 2011, 31(1): e1-e5.
14. 伍興, 夏敬冬, 李雄濤, 等. 超聲引導閉合復位經皮內固定治療兒童橈骨遠端骨骺骨折. 中華小兒外科雜志, 2020, 41(11): 1005-1009.
15. Macaulay A, Nandyala SV, Miller CP, et al. Potential for bias and the American Orthopaedic Foot and Ankle Society Ankle-hindfoot scoring system. Foot Ankle Spec, 2018, 11(5): 416-419.
16. Lesko PD, Georgis T, Slabaugh P. Irreducible salter-Harris type Ⅱ fracture of the distal radial epiphysis. J Pediatr Orthop, 1987, 7(6): 719-721.
17. Phieffer LS, Meyer RA, Gruber HE, et al. Effect of interposed periosteum in an animal physeal fracture model. Clin Orthop Relat Res, 2000(376): 15-25.
18. Crawford AH. Triplane and Tillaux fractures: is a 2 mm residual gap acceptable? J Pediatr Orthop, 2012, 32 Suppl 1: S69-S73.
19. Russo F, Moor MA, Mubarak SJ, et al. Salter-Harris Ⅱ fractures of the distal tibia: does surgical management reduce the risk of premature physeal closure? J Pediatr Orthop, 2013, 33(5): 524-529.
20. Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to the ankle. Foot Ankle, 1991, 11(6): 372-383.

Chinese Journal of Reparative and Reconstructive Surgery

Short-term effectiveness of ultrasound-guided Kirschner wire provocation technique in treatment of Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents

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