A 14 year old girl presented to emergency department with pain in left ankle following trauma.
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.
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.
Cleft Tibial Epiphysis
Based on the patient’s left ankle X-ray, the following can be observed:
Considering the clinical history and imaging findings, possible diagnoses include:
This is a normal variant commonly seen before or during adolescence, where a cleft-like radiolucent line appears in the medial malleolus of the distal tibia or other epiphyses. Typically, there is no obvious displacement and no surgical intervention is required.
If the growth plate is subjected to significant trauma, the fracture line may involve the articular surface and extend into the metaphysis, usually accompanied by severe soft tissue swelling, marked local tenderness, and a visible fracture line or displacement.
Based on the patient’s age, symptoms (mild pain without significant swelling or functional impairment), imaging features (radiolucent line in the physis region but no clear fracture line or displacement), and clinical examination (especially if local tenderness is not pronounced), the most likely diagnosis is: Cleft Epiphysis. This is a common normal variation of the growth plate in adolescents, often mistaken for a Salter-Harris fracture, and over-treatment should be avoided.
Since this type of cleft epiphysis is generally not a true fracture and does not result in serious structural damage, surgical intervention is typically unnecessary. If mild soft tissue injury or ankle pain is present, consider the following:
Special Note: If pain escalates, or if there is apparent redness or significant functional impairment during rehabilitation, seek medical attention promptly to exclude other potential injuries. If a fracture or soft tissue tear is confirmed, more aggressive treatment such as surgery or external fixation may be necessary.
Disclaimer:
This report is a reference-based medical analysis derived from current available information. It should not serve as a substitute for a face-to-face consultation or the opinion of a professional physician. If you have any questions or if symptoms worsen, please consult a qualified healthcare professional in a timely manner.
Cleft Tibial Epiphysis