Entrapped periosteum in distal tibial physeal fracture: Is open reduction always necessary? - A case report

Distal tibial physeal fractures are common in pediatric trauma and are typically managed with closed reduction. However, in some cases, reduction failure is due to soft tissue interposition, particularly periosteum, which may necessitate open reduction. This case examines whether open reduction is indicated when confirming periosteal interposition.

We report the case of a 14-year-old male with a displaced Salter-Harris type II distal tibial fracture and concurrent fibular fracture sustained during sports activity. Closed reduction attempts failed, and MRI revealed periosteal interposition. Open reduction via anteromedial approach confirmed periosteal entrapment, which was removed, followed by internal fixation with smooth pins. Postoperative recovery was uneventful, and at 12-month follow-up, full union was observed with no evidence of physeal arrest. The patient had regained complete ankle range of motion, was pain-free in daily activities.

Comparison with previously published reports reveals that while not all cases of periosteal interposition lead to growth arrest, the presence of entrapped periosteum, particularly in the setting of failed closed reduction, poses a non-negligible risk. Preoperative MRI facilitates early diagnosis and surgical planning. Open reduction, when selectively applied, may prevent complications such as angular deformity or physeal bar formation.

Periosteal entrapment should be considered in irreducible distal tibial physeal fractures. MRI evaluation and timely open reduction in selected cases allow for effective treatment and favorable outcomes. Surgical decisions should be individualized, guided by imaging and intraoperative findings.