Age / Sex : 8 / F

Age/Sex: an 8 year-old girl

Chief complaint: Right ankle pain

1) What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

* Send Application Answers to In Sook Lee, MD ([email protected])

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Salter-Harris type I injury

Discussion

Findings:

Anteroposterior and lateral radiographs of both ankles demonstrate diffuse widening of physis of right distal tibia, compared to that of contralateral side. Soft tissue swelling at right ankle is apparent.

Diffuse widening of physis with increased signal intensity is present in the distal tibia on T2 STIR coronal and T2-weighted sagittal image. Periosteal elevation with subperiosteal hemorrhage is noted in right distal tibia from the ankle joint. Additional fracture line extending either metaphysic or epiphysis is not seen. Also seen is severe soft tissue swelling.  

Diagnosis: Salter-Harris fracture of distal tibia, type 1

Discussion:

Fractures around the ankle often involve the growth plate in childhood. Physes and epiphyses are most susceptible to injury in children because the ligaments and joint capsule are two to five times stronger than the cartilage. Delayed diagnosis or inappropriate treatment can lead to premature closure of the physis, resulting in angular deformity and/or shortening of the extremities.

Salter-Harris classification describes the fracture through a growth plate and consists of five different types by the involvement of the physis, metaphysis, and epiphysis. The classification is important because it affects the treatment of the patient and provides clues to possible long-term complications.

Type 1 fractures are characterized by a line of cleavage confined to the zone of hypertrophic cells without involvement of either the metaphysis or epiphyseal ossification center. It is sometimes referred to as pure epiphyseal separations. The only radiographic evidence is a displacement of the epiphyseal ossification center. Identification of type 1 fracture with spontaneous reduction can be difficult. The prognosis is generally favorable.

References:

Radiology of Skeletal Trauma, 3^rd edition, Lee F.Rogers, Churchill Livingstone pp. 120 -125,

MacNealy GA, Injuries of the distal tibial epiphysis: systematic radiographic evaluation. Am J Roentgenol 1982;138:683-689.

Petit P, Panuel M, Faure F, jouve JL, Bourliere-Najean B, Devred P. Acute fracture of the distal tibial physis: Role of gradient-echo MR imaging versus Plain film examination. Am J Roentgenol 1996;166:1203-1206

Shi D, Zhu S, Li Y, Zheng J. Epiphyseal and physeal injury; comparison of conventional radiography and magnetic resonance imaging. Clinical Imaging 2009;33:379-383