Working Diagnosis:
Salter-Harris II distal tibia physeal fracture with 6 degrees valgus deformity at the ankle

Treatment:
After consulting with our orthopedic colleagues, the athlete was immediately taken to the operating room for closed reduction and casting under anesthesia. Under fluoroscopy, reduction was performed with slight accentuation of the deformity with traction. This resulted in an intended varus reduction Case Photo #2 .

Outcome:
Post-reduction radiographs Case Photo #3 demonstrated appropriate alignment of the subtalar joint and distal tibial epiphysis. A long leg cast was then applied and molded with varus support to avoid valgus displacement. The patient was made non-weight-bearing for four weeks. At 2-month follow-up, he showed evidence of healing and has returned to sport without difficulty.

Author's Comments:
When dealing with joint injuries in the adolescent athlete, physicians need to maintain a high level of clinical suspicion for Salter-Harris fractures. The literature has demonstrated a potential high rate of premature physeal closure in Salter-Harris II fractures of the distal tibia. Physicians who treat adolescent sports medicine injuries should be aware of the guidelines for treatment of Salter-Harris II tibial fractures to ensure favorable outcomes.

Learning Points:
1) The mechanism of injury can add value to the likelihood of premature physeal closure.
2) There is a high rate of premature physeal closure in Salter-Harris II fractures of the distal tibia.
3) Goals are to preserve leg length, alignment, and rotation at the joint.

Editor's Comments:
Although it is well known that higher grade Salter-Harris fractures can lead to abnormal bone growth, Salter-Harris I and II fractures can lead to permanent disability if not addressed properly, especially in the distal tibial and fibular physis. Even with significantly displaced fractures, closed reduction can often be performed. Orthopaedics should also be consulted in case there is a need for open reduction. Whether closed or open reduction is attempted, improving alignment will lead to a decreased risk of premature physeal closure. In this case, the initial treatment of placing a posterior splint without reduction was likely insufficient to allow for proper alignment.

References:
Salter RB, Harris WR: Injuries involving the epophyseal plate, J Bone Joint Surg 45-A:587-622, 1963.

Mubarak SJ, Kim JR, Edmonds EW, Pring ME, Bastrom TP. Classification of proximal tibial fractures in children. J Child Orthop. 2009 Jun;3(3):191-7. Epub 2009 Mar 17.

Rohmiller MT, Gaynor TP, Pawelek J, Mubarak SJ. Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure. J Pediatr Orthop. 2006 May-Jun;26(3):322-8.

Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003 Nov-Dec;23(6):733-9.

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