Closed reduction; K-wire fixation for Epiphysiolysis (Salter-Harris I and II) of the distal fibula

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Diagnosis
Indications
Treatment

Introduction

Reduction and stabilization of a tibial fracture will frequently reduce the fibula such that fixation is not required.

Unstable fibular fractures may require temporary internal fixation across the physis to produce adequate stability.

Open reduction is necessary if it is not possible to obtain or maintain adequate reduction by closed manipulation.

The following should be considered to minimize secondary damage to the physis:

Manipulation of the fracture must be gentle
Multiple passes across the physis with a K-wire should be avoided
Select smooth, appropriately sized K-wires

A retrograde K-wire may be inserted from the epiphysis into the medullary canal.

$Closed reduction and K-wire fixation of a Salter-Harris I and II fracture of the distal fibula$

Treatment goals

The main treatment goals are:

Stabilize the fracture
Minimize further physeal injury

The following equipment is used:

K-wires of appropriate sizes
Drill or a T-handle for manual insertion
Wire cutting instruments
Standard orthopedic instrument set

Place the patient in a supine position on a radiolucent table with a block under the heel.

$Patient and leg position for treatment of distal fibular fractures$

Apply longitudinal traction through the foot.

Correct translation and angulation of the fracture and confirm reduction clinically and with an image intensifier if available.

$Closed reduction of distal fibular fracture by longitudinal traction$

Insert the K-wire from the tip of the fibula retrograde across the physis into the medullary canal.

$Insertion of a K-wire for closed reduction and K-wire fixation of a Salter-Harris I fracture of the distal fibula$

K-wire cutting and dressing

Bend the K-wire approximately 1 cm from the skin to allow for swelling.

Cut the K-wire and apply a dressing to protect the skin.

A K-wire inserted through the tip of the fibula can be buried if there is adequate soft-tissue coverage.

$Closed reduction and K-wire fixation of a Salter-Harris I fracture of the distal fibula$

Release tethered skin around the K-wire by extending the incision.

Release of tethered skin around the K-wire by extending the incision

Alternatively, the K-wire may be placed under the skin with the bent end on the surface of the bone.

Recheck the fracture alignment and implant position clinically and with an image intensifier before anesthesia is reversed.

Confirm stability of the fixation by moving the ankle through a range of dorsi/plantar flexion.

A molded below-knee cast or fixed ankle boot is recommended for a period of 2–6 weeks as the strength of fixation may not provide sufficient stability for unrestricted weight-bearing.

Pediatric patient walking with crutches and a short leg cast for immobilization of the ankle

Immediate postoperative care

Weight-bearing is encouraged.

Older children may be able to use crutches or a walker.

Pain control

Patients tend to be more comfortable if the limb is splinted.

Routine pain medication is prescribed for 3–5 days after surgery.

Neurovascular examination

The patient should be examined frequently to exclude neurovascular compromise or evolving compartment syndrome.

Discharge care

Discharge follows local practice and is usually possible within 48 hours.

Follow-up

The first clinical and radiological follow-up is usually undertaken 5–7 days after surgery to check the wound and confirm that reduction has been maintained.

Cast and K-wire removal

Distal tibial and fibular fractures heal rapidly. Cast and K-wires are typically removed 3–6 weeks after injury, depending on the age and weight of the patient.