ORIGINAL ARTICLE
Premature Physeal Closure
Following Distal Tibia Physeal Fractures
A New Radiographic Predictor
Adam Barmada, MD, Tracey Gaynor, MA, and Scott J. Mubarak, MD
Abstract: The incidence and predictors of premature physeal clo-
sure (PPC) after pediatric distal tibial fractures were investigated.
PPC was defined as evidence of growth plate disturbance on the in-
jured side compared with the uninjured side. Ninety-two fractures
were reviewed with at least 1 year of follow-up, or until physiologic
closure of the growth plates. Twenty-five fractures (27.2%) were
complicated by PPC, as confirmed by CT scan in most cases. Salter-
Harris III and IV (medial malleolar type) fractures resulted in the
highest percentage of PPC by fracture type (38%). Salter-Harris I and
II fractures resulted in PPC in 36% of cases, followed by triplane
fractures (21%) and Tillaux fractures (0%). Initial displacement,
number of reduction attempts, or treatment method did not signifi-
cantly affect the incidence of PPC. More anatomic reductions resulted
in a statistically significant decrease in PPC rates. Residual physeal
gap (>3 mm) following reduction was determined from radiographs
in Salter-Harris I and II fractures. If a residual gap was seen on the
radiograph, the incidence of PPC increased to 60%; if no gap was
present, the incidence decreased to 17%. Open reduction was per-
formed in five Salter-Harris II fractures that had a residual gap. Peri-
osteum was entrapped in the physis in all of these cases. Residual gaps
in the physis following closed reduction may represent entrapped
periosteum in Salter-Harris I and II fractures. This can lead to a higher
incidence of PPC, suggesting that open reduction and removal of the
entrapped periosteum may be beneficial.
Key Words: distal tibia fracture, physeal closure, growth plate, peri-
osteum, pediatric ankle
(J Pediatr Orthop 2003;23:733–739)
P hyseal fractures of the distal tibia represent a significant
percentage of long bone physeal injuries, second only to
distal radius physeal fractures.11,12,16,23 The incidence of pre-
Study conducted at Children’s Hospital and Health Center, San Diego, Cali-
fornia.
From Portland Bone & Joint Center, LLC, Portland, Oregon (Dr Barmada) and
Children’s Hospital and Health Center, San Diego, California (Ms Gaynor,
Dr Mubarak).
Supported by the Children’s Hospital-San Diego Orthopedic Research and
Education Fund.
Reprints: Scott J. Mubarak, MD, 3030 Children’s Way, Suite 410, San Diego,
CA 92123 (e-mail: pedsortho@chsd.org).
Copyright © 2003 by Lippincott Williams & Wilkins.
J Pediatr Orthop • Volume 23, Number 6, November/December 2003
mature physeal closure (PPC) in distal tibia physeal fractures
has been reported as low as 2% to 5%.2,15 Factors proposed as
influencing rates of growth disturbances include fracture type
and location, displacement, energy of injury, quality of reduc-
tion, number of reduction attempts, and method of treat-
ment.1,2,7–9,20,21 Salter-Harris (SH) type I and II fractures have
been considered low-risk injuries.20,23 The importance of ana-
tomic reduction to decrease the potential of future growth dis-
turbances has been debated.7,16,21 Several authors have sug-
gested that growth disturbances in distal tibia SH II fractures
may be more common than previously realized.9,21 Interposi-
tion of periosteum and other soft tissues is occasionally re-
sponsible for creating a block to reduction in these injuries.8,23
Researchers have found that periosteum folded into a physeal
defect in sheep results in physeal growth arrest.24 Others dis-
covered that periosteum after fractures could form bone, car-
tilage, or fibrous tissue, cause resorption of bone, and lead to
increased rates of growth plate disturbances in rat models.5,18
This theory has not been demonstrated in humans.
Medial malleolar (SH III and IV) fractures have resulted
in higher complication rates. Consequently, anatomic reduc-
tion is recommended for preservation of the physis and the
articular surface.1,8,9,20,21,23 Triplane (SH IV) and Tillaux (SH
III) fractures occur closer to skeletal maturity, and PPC has not
been considered a problem. Anatomic reduction in these inju-
ries is recommended for articular surface congruity.
MATERIALS AND METHODS
The records of 92 patients treated for distal tibia physeal
fractures at San Diego Children’s Hospital between 1991 and
2000 were reviewed. All were treated by one of six pediatric
orthopaedic surgeons. We recorded gender, age, and mecha-
nism of injury. Initial injury radiographs were categorized ac-
cording to a modification of the SH classification (Fig. 1). Ini-
tial fracture displacement was recorded in millimeters, mea-
suring the largest displacement between the epiphysis and
metaphysis on the AP or lateral radiograph. The categories of
treatment were closed reduction and casting, closed reduction
and percutaneous pinning (CRPP), and open reduction internal
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FIGURE 1. Modified SH fracture classification. A: SH II (AP/lateral views). B: Medial malleolar fractures: SH III (left) and SH IV (right).
C: Triplane (SH IV). D: Tillaux (SH III).
fixation (ORIF). Closed treatment was commonly performed
under conscious sedation in the emergency department. Pa-
tients were instructed to be non-weight-bearing and were
placed in a long-leg cast for 4 weeks, followed by short-leg
casting and weight-bearing as tolerated for another 2 to 3
weeks. If open reduction was performed, any interposed peri-
osteum was noted. Fixation was obtained with percutaneous
pins across the physis or screws parallel to the physis. Pins
were typically smooth 0.062 Kirschner wires that were re-
moved after 4 weeks. The number of reduction attempts was
recorded.
Postreduction radiographs were measured for residual
displacement in millimeters using the method described
above. Residual physeal gap was recorded for SH I and II frac-
tures. Gap was identified as positive if the physis was widened
more than 3 mm on a standard AP or lateral radiograph (Fig. 2).
Patients were followed for 1 year or until physiologic closure
of the physis. Ankle radiographs, including contralateral films,
were evaluated for physeal closure and CT scans were ob-
tained in most cases to further delineate size and location of
any physeal bar. Any evidence of shortening or angular defor-
mity was recorded. Subsequent operations performed second-
ary to PPC, usually bar excision or epiphysiodesis, were docu-
mented.
Statistical analysis was performed by dividing patients
into PPC or non-physeal closure groups. ␹2 analysis and
ANOVA were used for each variable as appropriate.
RESULTS
Ninety-two fractures were included (61 boys, 31 girls).
Forty-six of the fractures were left-sided and 46 were right-
sided. The most common cause of injury was nonspecific fall
(25%), followed by skateboard accidents (16.3%), motor ve-
hicle accidents (12%), football (12%), soccer (7.6%), biking
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(5.4%), baseball (4.3%), and indeterminate cause (17.3%).
Follow-up averaged 12 months (range 1–66 months). The
overall PPC rate across all fracture types was 27.2% (including
Tillaux fractures). PPC was diagnosed at a mean of 7 months
after injury (range 2–12 months). Sixteen of the 25 patients
(64%) with PPC underwent a subsequent operation for short-
ening, angular deformity, or a high potential for either because
of remaining growth. Two of the four triplane injuries in which
PPC developed underwent tibia and fibula epiphysiodesis on
the injured side only.
Fracture Types
We identified eight (8.5%) medial malleolar (SH III and
IV) injuries, with an average age of 12.6 years. Six of the in-
juries underwent ORIF. PPC occurred in three (38%). This in-
crease in PPC rate was significant (P = 0.04) compared with
other fracture types. Nineteen triplane fractures (21%) were
identified, 15 of which were treated with ORIF. Average age
was 14.0 years. PPC occurred in four (21%). Fourteen Tillaux
fractures were identified, 11 of which were treated with ORIF.
Average age was 14.8 years. PPC was not evident in any case.
Associated fibula fractures were present in 44 (47.8%) cases.
Fixation of the fibula, with Kirschner wires or screw, was per-
formed in 11% of these cases. One case of fibula PPC was
documented (2.3% PPC rate).
The 45 SH II fractures accounted for the majority of in-
juries (48.9%). Six (6.5%) SH I injuries were identified, with
four resulting in PPC. Since the fracture type, patient age, and
mechanism of these injuries were similar, these two fracture
types were combined. Radiographs were available for 44 of the
51 SH I and II fractures. Treatment consisted of ORIF for 9,
CRPP for 9, and closed treatment for 26. Average age in this
group was 12.1 years. PPC occurred in 36% (Fig. 3).
© 2003 Lippincott Williams & Wilkins
J Pediatr Orthop • Volume 23, Number 6, November/December 2003
FIGURE 2. Radiographs of SH II distal tibia fracture before (A) and after (B) closed reduction. Note the residual physeal gap after
reduction.
SH I/II Injuries
Fractures that were positive for PPC had an average ini-
tial displacement of 7.5 mm versus 7.9 mm for the group with-
out PPC (P = 0.86). The incidence of PPC with initial displace-
ment of at least 5 mm (31%) was not significantly different
from the incidence of PPC with initial displacement less than 5
mm (42%) (P = 0.51) The number of reduction attempts
ranged from zero to four. There was no difference in incidence
of PPC based on the number of reduction attempts (P = 0.54).
Of the 16 cases complicated by PPC, 69% were treated by
closed methods, 19% were treated by CRPP, and 12% were
treated by ORIF. This difference did not reach significance (P
= 0.55). The average residual displacement after treatment of
the positive PPC group was significantly greater (3.1 mm) than
the group without PPC (1.4 mm) (P < 0.001). The incidence of
PPC in patients with a residual displacement of at least 2 mm
was 73% (11/15 patients), whereas the incidence of PPC in
patients with a residual displacement of less than 2 mm was
18% (5/28 patients) (P = 0.001).
Twenty of the fractures were positive for gap. All gaps
were found anteriorly or medially. The presence of a gap was
associated with a 60% PPC rate; if no gap was found, the PPC
rate was 17% (P = 0.003). This represents a 3.5-fold increased
risk. Nine patients were treated with open reduction after failed
closed reduction. The reason was inadequate reduction in six
patients and evidence of extensor retinaculum syndrome (as
described by Mubarak14) in three patients. Five of the nine
© 2003 Lippincott Williams & Wilkins
Premature Physeal Closure After Tibial Fracture
were retrospectively found to have a residual gap prior to sur-
gery. All five had interposed periosteum removed from the
physis at the time of surgery (Fig. 4). None of these five pa-
tients went on to develop PPC.
DISCUSSION
Previous reports have found low complication rates with
SH I and II fractures. Pacicca et al showed one “physeal dis-
turbance” in 38 SH I and II fractures.15 Their overall incidence
of physeal disturbance was 5%, much lower than ours. This
could be due to shorter follow-up, as fractures were “followed
to union.” In our series fractures were followed for 1 year on
average, as many have recommended.1,8,21 Pacicca et al found
that the quality of reduction did not appear to correlate with
physeal disturbance, contrary to our findings.
Spiegel et al grouped 184 fractures into low-risk, high-
risk, and unpredictable categories based on the rate of compli-
cations, which included PPC, shortening, joint incongruity,
and angular deformity.21 The overall complication rate was
14.1%. It is difficult to know whether shortening or angular
deformity was a result of PPC in most of their cases. Low-risk
injuries included all fibula fractures, SH I distal tibia fractures,
and SH III and IV fractures with less than 2 mm of displace-
ment. High-risk injuries included SH III and IV fractures with
2 mm or more of displacement and triplane and Tillaux frac-
tures. The unpredictable group included only SH II fractures.
They concluded that prognosis was related to the quality of
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FIGURE 3. Flow chart for SH I and II fractures. Gap is defined as a physis widened ⱖ3 mm on postreduction AP or lateral
radiographs. *The operative report for this patient made no mention of entrapped periosteum or other tissue. †This patient was
treated for compartment syndrome and later developed osteomyelitis.

reduction, consistent with our findings. According to our data, Historically, triplane and Tillaux fractures have been
the presence of a residual physeal gap in these injuries may treated based on displacement at the articular surface. Due to
predict a higher rate of PPC (Fig. 5). We did not find SH I limited growth remaining, PPC has not been considered a sig-
fractures to be low-risk injuries, although our number of cases nificant problem. We found a PPC rate of 21% in triplane in-
in this category was small (n = 6). This low incidence could be
related to the difficulty in diagnosing minimally or nondis-
placed SH I injuries.
Kling et al reviewed 65 distal tibia physeal fractures.9
The incidence of PPC could not be determined because half of
these fractures were referred for growth plate closures. They
concluded that medial malleolar (SH III and IV) fractures, and
“perhaps type II” fractures, commonly result in growth distur-
bances. They suggested that anatomic reduction of the physis
by open or closed methods decreases the incidence of these
growth disturbances. We agree, and also found SH III and IV
medial malleolar fractures to result in the highest incidence of
growth problems.
Cass et al found that 9 of 18 medial malleolar (SH IV)
fractures resulted in partial growth arrest.1 They stressed the
importance of distinguishing SH IV injuries from SH III inju-
ries by obtaining oblique radiographs. They noted the diffi-
culty of identifying the small metaphyseal fragment in many
SH IV medial malleolar injuries. SH III and IV medial malleo-
lar fractures were categorized in the same group because of FIGURE 4. Periosteum interposed in the physis with subse-
their similarity and are treated similarly at our institution. quent residual gap.

736 © 2003 Lippincott Williams & Wilkins

J Pediatr Orthop • Volume 23, Number 6, November/December 2003 Premature Physeal Closure After Tibial Fracture

FIGURE 5. Ankle fracture in a 12-year-old boy. A: Initial injury PA radiograph showing SH II fracture of the distal tibia. B: Initial
injury lateral radiograph. C: After closed reduction and casting; note the residual gap seen medially on the AP radiograph. D: The
residual gap is also seen anteriorly on the lateral radiograph. E: Nine months after injury, the AP radiograph shows partial PPC
centrally. F: The closure is also noted centrally on the lateral radiograph. Due to older bone age and limited remaining growth
potential, subsequent surgery was not necessary.

juries, half of which received a subsequent operation. At in- for growth plate disturbances. Tillaux fractures never resulted
jury, the average age of boys was 14.6 years; that of girls was in PPC and can be followed to union. At injury, the average age
12.7 years. We recommend careful follow-up of these injuries of boys was 15.5 years; that of girls was 13.1 years. Our op-

© 2003 Lippincott Williams & Wilkins 737

Barmada et al J Pediatr Orthop • Volume 23, Number 6, November/December 2003

erative indication is consistent with most authors: more than 2
mm of displacement at the articular surface.3,8,19,22
Some have suggested that PPC results from the trauma to
the physis at the time of injury.2 The presence of larger initial
displacement or physeal crush (SH V) injury may lead one to
infer a higher-energy injury, more significant injury to sur-
rounding tissues and blood supply, and therefore a higher PPC
rate. We did not identify any SH V injuries and were not able to
support this hypothesis.
Repeated reduction attempts are contraindicated secondary
to additional physeal damage. We did not find a relationship be-
tween the number of reduction attempts and PPC rates. However,
we recognize the difficulty of defining and documenting each “re-
duction attempt” with a retrospective review. We limit the num-
ber of closed reduction attempts to two prior to open reduction.
Studies in animal models have shown that periosteum
interposed into fractured physes results in physeal bar forma-
tion and significant growth disturbances compared with frac-
tures with intact physes.4,18 We believe that the residual phy-
seal gap seen after reduction attempts in SH I and II fractures
represents interposed periosteum in most cases. Phan et al sug-
gested that physeal widening may indicate the presence of ro-
tational deformity.17 However, they noted a poor correlation
between physeal widening and rotational deformity at follow-
up. Kling et al stated, “any residual gap between the fractured
physeal edges may result in a partial growth arrest.”9 Our re-
sults showed a 3.5-fold increase in the PPC rate if a gap was
present on the postreduction film in SH I and II fractures. Open
reduction and removal of interposed periosteum may decrease
the incidence of PPC (Fig. 6).
The overall incidence of PPC following distal tibia phy-
seal fractures in this series was 32%. This excludes Tillaux
fractures, which never resulted in PPC and should be treated
based on articular incongruity. Over half (64%) of patients

FIGURE 6. Another ankle fracture in a 12-year-old boy. A: Initial injury PA radiograph showing a SH II distal tibia fracture with
associated fibula fracture. B: Initial injury lateral radiograph. C: After closed reduction and casting; note the residual gap seen
medially on the AP radiograph. D: The gap is also noted anteriorly on the lateral radiograph. E: AP radiograph after open
reduction, removal of interposed periosteum, and pin fixation. F: Lateral radiograph after open reduction and fixation; no gap is
seen. G: Twelve months after injury, the physis remains open on the AP radiograph. H: The lateral radiograph also shows a normal
physis.

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J Pediatr Orthop • Volume 23, Number 6, November/December 2003
with PPC received a subsequent operation for shortening, an-
gular deformity, or a high potential for either. The presence of
PPC does not always lead to measurable growth disturbance.
Approximately 3 to 4 mm a year is gained from the distal tibia
physis.7 The importance of maintaining the distal tibia and
fibula relationship for ankle alignment has been acknowl-
edged.6,10,13,20 The decision to intervene surgically includes
these factors and the patient’s remaining growth.
We conclude that PPC after distal tibia physeal fractures
is more common than previously reported. Patients should be
followed for at least 1 year or until physiologic physeal clo-
sure. Anatomic reduction of the physis appears to decrease the
incidence of PPC. The radiographic presence of postreduction
residual displacement and/or a physeal gap in SH I and II frac-
ture types is associated with a greater than three-fold increase
in the incidence of PPC. Open reduction and removal of any
interposed soft tissue in these cases allows for a more anatomic
reduction and may decrease the incidence of PPC.
ACKNOWLEDGMENT
The authors thank J. D. Bomar for his assistance with the
preparation of this manuscript.
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