[MacFarland fractures. A series of 24 cases]

MacFarland fracture is a joint fracture of the ankle in children. The fracture line passes through the medial part of the lower epiphyseal disk of the tibia. Prognosis is dominated by later risk of malalignment and osteoarthritis. MacFarland fracture usually occurs subsequent to adduction trauma. The aim of this study was to analyze prognosis in a retrospective series of children with MacFarland fractures.

The series included 24 cases (14 boys and 10 girls, mean age at the time of trauma 12.7 years, age range 10-15 years). The fractures were classed into two groups according to the Salter and Harris classification for epiphyseal detachment: Salter 3 (n=4) and Salter 4 (n=20). Surgical treatment was given in 17 cases (11 screw fixations, 4 pin fixations and 2 other ostheosynthesis combinations). Orthopedic care was given in 7 cases (mean immobilization=40 days). All 24 children were followed for a mean 3 years 2 months (3 months=12 years). Three outcome categories were used: good (no pain, stiffness or malalignment), fair (pain and/or stiffness, no malalignment), and poor (malalignment).

Overall results were good in 15 cases, fair in 2 and poor in 7 (29 p. 100). Ankle malalignments (7 cases) required surgical correction: epiphysiodesis for varus<5, supramalleolar tibial valgization osteotomy for varus > 5 degrees. After these procedures, outcome was good with a normally aligned painless ankle at 13 months follow-up. Among factors predictive of malalignment (poor outcome), power of the initial trauma (traffic or sports accident in 5 of the 7 poor outcomes), crush injury (medial metaphyseal comminution in two cases which led to varus ankle despite well conducted treatment), fracture type (7 malalignments among the Salter 4 fractures versus none among the Salter 3 fractures), initially defective reduction or osteosynthesis material passing through the epiphyseal disk leading to epiphysiodesis.

Careful radiologic and clinical surveillance is needed and should be continued to the end of growth (fusion of the tibial cartilage) in children with high risk fractures in order to detect epiphysiodesis early and avoid secondary malalignment. Surgical correction does remain possible and gives good results.