Salter Harris II Fracture of the Distal Tibial Growth Plate and Spiral Fibular Fracture Accompanying an Anterior Distal Tibial Growth Plate Dislocation in an Adolescent Gymnast: A Case Study

Kristen Fosness, Nicole German PhD, ATC

North Dakota State University

Department of Health, Nutrition and Exercise Sciences, Fargo ND, USA

Abstract

Background

Uniqueness

Treatment

Clinical Significance

• Timely recognition, immediate treatment, an appropriate rehabilitation program, and a proper return to play protocol helped return this athlete to gymnastic participation 12 weeks post-injury without any restrictions.

A 13 year old, female gymnast exhibited extreme pain in her left ankle after landing a back-flip into a foam pit. The athlete was unable to bear weight and there was obvious deformity and immediate swelling. This warranted splinting and immediate referral for emergency care by the athletic trainer. X-ray and a CT scan indicated a dislocation of the distal tibial growth plate which was corrected with a closed reduction, as well as a Salter Harris II Fracture of the distal tibial growth plate and a spiral fracture of the fibula which were casted to allow for healing. A rehabilitation and gradual return to play program were developed to return the athlete to competitive gymnastics. She returned to full participation 12 weeks post-injury. This is a unique case because it involved a combination of three injuries and it is rare to have a dislocation of the growth plate. There is currently no rehabilitation protocol for treating the combination of injuries or discussion of post-injury return to play outcomes. Recognition, management, and rehabilitation are all pertinent when working with growth plate injuries.

• 13 year old, female, gymnast landed a back-flip into a foam pit. While her ankles where stuck in the foam, the backward momentum carried her upper body posteriorly towards the pit. As a result her ankles were placed in extreme plantarflexion. • Athlete was unable to bear weight, there was obvious deformity, and immediate swelling. • The athletic trainer applied a split to protect the area and the athlete was immediately transported for emergency care.

Differential Diagnosis

Conclusions

• It is unique to have a combination of all three injuries. • It is rare to see a dislocation of the growth plate. • All three injuries alone tend to occur more often in young males than females. • There is currently no rehabilitation protocol for treating the combination of injuries or discussion of post-injury return to play outcomes.

1 Pediatric Orthopaedic Society of North America-OrthoInfo. Ankle fractures in children. AAOS. 2012. http://orthoinfo.aaos.org/topic.cfm?topic=A00632 2 University of Bridgeport College of Chiropractic. Salter-Harris Classification. 2002. 3 Gregory A. The growing athlete. Athlet Ther Today. 2005; 10(6): 64-66. 4 Pediatric Orthopaedic Society of North America-OrthoInfo. Growth plate fractures. AAOS. 2012. http://orthoinfo.aaos.org/topic.cfm?topic=A00040 5 Caine D, DiFiori J, Maffulli N. Physeal injuries in children’s and youth sports: reason for concern? Br. J. Sports Med. 2006;40: 749-760. 6 Keany JE, McKeever D. Ankle dislocation in emergency medicine. Medscape. 2012. http://emedicine.medscape.com/article/823087-clinical

Improving Clinical Outcomes • Gained knowledge of immediate care and rehabilitation which can result in a positive outcome. • It is important to closely examine the healing process and rehabilitation conducted to promote the best outcome for the patient. • Due to the underdeveloped bones of youth athletes, fractures are more common than ligamentous damage and therefore, athletic trainers need to be aware of the populations they are working with. • Growth plate fractures are commonly seen in athletes who participate in football, basketball, or gymnastics. • Incidence rates of growth plate fractures increase during pubescence.

• Salter-Harris Fracture(growth plate fracture) • Fracture of the Tibia, Fibula, or Talus • Dislocation of the Tibia, Fibula, or Talus • Severe ankle sprain

References

• The physis, or growth plates at each end of the bone are the last part of a bone to harden and are more susceptible to fractures; especially during periods of rapid growth. • Traumatic injuries or training for prolonged periods of time at a higher intensity can cause growth plate pathologies. • Recognition, management, and rehabilitation are all pertinent when working with growth plate injuries. • Growth plate dislocations and fractures should be treated as medical emergencies and monitored carefully due to their potential for long term negative effects. • Depending on the severity of the dislocation and the fractures, usually a close reduction and casting is all that is needed immediately after injury. • A rehabilitation program should be initiated to help strengthen the muscles around the joint and a monitored, gradual return to play protocol should be set in place by both the physician and the athletic trainer.

Date Exercises/Limitations Goals/ROM 8/23/13 6 weeks 2 days post *Began full weight bearing without CAM boot or crutches *Jumping and hopping were as tolerated and limited by number done per day monitored by the patient’s athletic trainer.

Exercises -4 minute elliptical warm-up -lateral tubing walks -Theraband kicks -calf raises -standing supported fire hydrants -balance beam forward and backward tandem walks -single leg squats -4-way Ankle Theraband exercises -double leg balance board -Ice application

Long Term Goal: Return to gymnastics without any pain or instability ROM Dorsiflexion Plantarflexion Inversion Eversion

9/4/13 8 weeks post

Continued with same exercises except: -decrease reps for calf raises -support removed from fire hydrant exercises -discontinued balance beam exercises Additional exercises: -pool rehab: running, jumping, and hopping in chest deep water, progressing to waist deep Ultrasound was administered for six minutes Began floor tumbling with soft landings only

9/11/13 9 weeks post *Patient reported unusual feeling when landing on the left leg but no pain was reported with activity

Continued previous exercises with increasing resistance and repetitions as appropriate Additional exercises: -jogging and skipping 25 yards X 4 -laterally shuffling and carioca 25 yards X 2 -bounding 36 inches 10x2 -squat jumps 2x5 -five leaps Progression of landings: no more than 100/day; began “round-off flip-flop” on 8 inch pad

9/18/13 10 weeks post

Continued fire hydrants, single leg squats, 4 Way Ankle Theraband exercises , and balance board exercises *Increased resistance or reps Addition of: -time double leg and single leg standing on a wobble board -weighted BAPS board -touches and ball tosses on BOSU -trampoline bounces and sticks on a single leg *Patient was able to perform a 360° spin and was working on a 540° spin Progression of landings: no more than 150/day

Short Term Goals Met: -minimal pain with single limb tasks -ambulate unlimited distances -use stairs independently with reciprocal pattern -squat to pick up items -start return to running program

10/4/13 12 weeks 2 days post

-Last x-ray taken: fractures were healed well and barely visible Limitations -Athlete was allowed to return to activity as tolerated continuing with the progression of jumps, hops, and landings -Progression of vault drills

ROM Dorsiflexion Plantarflexion Inversion Eversion

25° 30° 25° 10°

Limitations -ADLs -transitions -self-care -turning -standing -bending -sleeping -lifting -lying -carrying -sitting -reaching -arising from sitting -prolonged sitting -walking -running -stair negotiation

4/5 4/5 4/5 4/5 4/5 4/5

MMT Dorsiflexion Plantarflexion Anterior Tibial Posterior Tibial Gastrosoleus Peroneal muscle

MMT Dorsiflexion Plantarflexion Anterior Tibial Posterior Tibial Gastrosoleus Peroneal muscle

Long Term Goals Met: -self-management of symptoms -multiplaner movement -pain free ADLs -strength WNL -normal gait on all surfaces -improved functional scores

30° 25° 20° 20°

5/5 5/5 5/5 5/5 5/5 5/5

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Salter-Harris Type II Fracture: occurs when there is a shear or angular avulsion force that causes a division of the epiphysis and metaphysis at the growth plate and a small portion of the metaphyseal bone shaft to break off.

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