A 14-year-old boy presented to the emergency department (ED) after sustaining a twisting injury to his right ankle while playing basketball. Clinical evaluation showed significant swelling and deformity around the ankle. There were no neurovascular deficits. He was unable to bear weight. Radiographs showed a displaced distal tibia SH type II physeal fracture and a transverse fracture of the fibula with valgus angulation (Figure 1).
An initial attempt at closed reduction performed in the ED under conscious sedation was unsuccessful; the fracture could not be moved from its displaced position after sustained traction and manipulation (Figure 2). The patient was taken to the operating room, and a second attempt at closed reduction was performed with the patient under general anesthesia and muscle relaxation. Again, the fracture could not be moved from its displaced position. Tendon interposition was suspected and open reduction of the fracture was performed by making an incision on the anteromedial aspect of the distal tibia centered over the metaphyseal spike. The fracture site was exposed, and the posterior tibial tendon was found interposed within the physeal fracture site. The tendon was bowstringing around the metaphyseal fragment from the proximal-posterior to distal-anterior direction between the metaphysis and epiphysis (Figure 3). Traction on the distal fragment increased the tension and worsened the bowstringing of the tendon. Hence, the traction was released and the interposed tendon was retracted out from the fracture site. This allowed the fracture to be reduced without difficulty. The tendon had mild fraying but did not show any laceration or tear (Figure 4). The fracture reduction was confirmed on fluoroscopic evaluation, and two 4 mm partially threaded cannulated screws were used for fracture compression and fixation across the large Thurston-Holland metaphyseal fragment (Figure 5).
Postoperatively, the leg was immobilized in a boot and nonweight bearing with crutches was used for 4 weeks, followed by weaning of the boot and gradual transition to full weight bearing. The patient was released to full activities at 4 months. Eighteen months postinjury, he had no pain or deformity, had full ankle range of motion, and had no limitations with sports. The radiographs showed complete healing of the fracture with no deformity and closing physis (Figure 6).