O1082: Variations in the Management of Closed Salter-harris II Distal Tibia Fractures

Background: There are no established indications for the surgical management of closed, Salter-Harris (SH) II distal tibia fractures. Earlier studies suggested a lower rate of premature physeal closure (PPC) after surgical reduction of the physeal gap associated with this injury; however, more recent studies have shown that surgical management may improve joint alignment, but does not decrease the risk of PPC. The purpose of this study was to survey the indications for operative and nonoperative management of this injury across pediatric tertiary care centers.

Methods: We surveyed pediatric orthopaedic surgeons at 20 tertiary care level-1 pediatric trauma centers. Surgeons were provided with 16 clinical scenarios that varied based on patient age and sex, and highlighted the following surgical indications: translation < 3mm, translation ≥3mm, anterior distal tibial angle (ADTA) >80°, and coronal plane angulation >5°. Each cases scenario and radiographs after closed reduction were presented in a randomized manner. Surgeons also provided demographic information as well as details relating to their surgical practice and experience. Consensus was defined as 75% agreement, and descriptive statistics were used to summarize the results.

Results: In total, 33/37 surgeons completed the survey (89% response rate). Approximately 70% of surgeons were male and 85% of surgeons were white. All surgeons took trauma call at a level-1 pediatric trauma center and had an average of 8.8 years (SD: 6.5years) of experience in clinical practice. Consensus was reached in 5/16 scenarios (Table 1). Specifically, nonoperative management was recommended for all scenarios showing < 3mm of translation after closed reduction. The majority of surgeons recommended operative management in scenarios showing >5° of coronal plane angulation after closed reduction, but only one of these scenarios reached consensus. There was a near equal split in operative and nonoperative management in 8/16 scenarios. These scenarios showed ≥ 3mm translation after closed reduction and ADTA > 80° after closed reduction.

Conclusion: There is considerable variation in the indications for operative and nonoperative management of closed, SH II distal tibia fractures. Consensus was reached for nonoperative management in patients with < 3mm of translation after closed reduction; however, with greater deformity consensus regarding optimal treatment was unable to be reached. The variation in the management of distal tibia SHII fractures is significant, suggesting that perhaps clinical equipoise exists between operative and nonoperative management. Future prospective study in this area is needed.