Cleft Tibial Epiphysis

Clinical Cases 16.05.2007
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Section: Musculoskeletal system
Case Type: Clinical Cases
Patient: 14 years, female
Authors: Dr Zergham Zia, Dr Shahid Hussain
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Details
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AI Report

Clinical History

A 14 year old girl presented to emergency department with pain in left ankle following trauma.

Imaging Findings

A 14 year old girl presented to emergency department with painful right ankle following an inversion injury. On examination there was tenderness over the lateral collateral ligament with no swelling. Joint movement at the ankle and subtalar joint was minimally restricted due to pain. The X-ray of the ankle joint revealed a well defined lucent line at the lateral aspect of the tibia extending intraarticularly. She was put in a back slab and referred to fracture clinic.

Discussion

Cleft epiphyses are a normal variant and it requires distinction from epiphyseal fractures. Cleft epiphyses may be unilateral or bilateral, and typically manifest just prior to puberty. They typically occur at the basal epiphysis of the proximal phalanx of great toe, although they can occur at any epiphyses. Radiographically, they are lucent defect traversing the length of epiphysis, and may have sharp or irregular borders. There may be slight spreading of either half of the epiphysis away from the cleft. In distal tibia the cleft tends to prefer the medial plafond at its connection with the medial malleolus. Cleft tends to remain till the growth plate fuses. Cleft of distal tibial epiphyses most closely resemble Salter-Harris III or IV fractures. In the absence of trauma or significant ankle symptomatology, distinguishing a cleft of distal tibial epiphysis from Salter-Harris III or IV fractures is not difficult. However it may be difficult to differentiate between these two conditions in the presence of trauma. Clinical correlation with site of maximal tenderness and are area of lucent defect is essential. If a suspected site of trauma is non tender, there is little likelihood of fracture. Secondary signs such as soft tissue swelling can also be useful in differentiation. Radiologically, there are direct findings that distinguish fracture from clefts. Satler-Harris type III fractures tend to demonstrate some degree of fragment displacement, with widening of defect in the epiphysis as well as the physis. The visualization of a metaphyseal fragment (type IV fracture) virtually rules out the possibility of a cleft, but this fragment is occasionally too small to visualize. Fractures should demonstrate some radiographic evidence of healing within 3-6 weeks time. The recognition of cleft epiphyses is essential to avoid over treatment and expose the patient to unneccesary treatment/surgery.

Differential Diagnosis List

Cleft Tibial Epiphysis

Final Diagnosis

Cleft Tibial Epiphysis

Liscense

Figures

There is an oblique lucent line extending from lateral aspect of distal tibia intraarticularly. This was identified and treated as a fracture.

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There is an oblique lucent line extending from lateral aspect of distal tibia intraarticularly. This was identified and treated as a fracture.

No change in the appearance of the lucent line following 8 weeks in ankle cast.

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No change in the appearance of the lucent line following 8 weeks in ankle cast.