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Stage II Supination Inversion Injury

- Discussion:
    - involves injury to distal tibial ephiphysis, & are due to plantar hyperflexion or external rotation force;
    - presents as SH II, SH III, or SH IV type injury of distal tibia which may disrupt articular surface as well as physis;
    - Salter Harris III:
           - involves medial side of distal physis;
           - less common frx involving lateral half of distal tibial epiphysis is in children near end of adolescence;
    - Salter Harris IV:
           - cross union between epiphysis & metaphysis is main problem because of resulting in cessation of growth on medial side of plate, & because this is rarely achieved w/ closed reduction;

- Treatment:
    - if these frx are not reduced and stabilized anatomically, growth deformity will result;
    - closed reduction & insertion of percutaneously inserted transepiphyseal screw;
           - may decrease incidence of local growth arrest;
           - active motion can be initiated early;

- Complications:
    - commonly associated w/ growth arrest leading to varus deformity;
    - due to asymmetric arrest of distal medial tibial growth plate:
    - osseous bridge in medial part of physeal plate may develop after a Salter Harris III or IV injury;
    - if the growth plate is damaged at the time of injury, even an undisplaced frx can develop a varus deformity;
    - radiographs:
           - Harris growth arrest lines are seen to converge over the physis at the point of injury;
           - damaged physis may appear radiodense;
           - tomograms help define the bone bridge;
    - prevention:
           - anatomical reduction of the fracture may reduce the incidence of varus growth deformity;
           - in late cases, consider physeal bar resection or opening wedge supra-malleolar osteotomy

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