Working Diagnosis:
Nondisplaced distal tibia metaphyseal fracture

Treatment:
The athlete was placed in a long leg cast and made non weight bearing on crutches for one month. At one month, he transitioned to 50 percent weight bearing in an Aircast and formal physical therapy was started twice a week. At seven weeks from injury, he was transitioned to full weight bearing and at 10.5 weeks he was advanced to sporting activity as tolerated with use of a stirrup brace and taping.

Outcome:
At 10.5 weeks from initial injury the athlete was able to return to sports activity as tolerated with use of a stirrup brace, and taping.
Follow up x-rays showed healing. Case Photo #2 As the initial injury occured in mid June he was able to play in the first regular season game in September.

Author's Comments:
Distal tibia fracture injuries present with tenderness & swelling. Bony tenderness of the tibia should be evaluated with x-rays. For those with no signs of neurovascular compromise, initial therapy consists of measures to reduce swelling, pain management, and restriction of ambulation. Manage the fracture with immobilization.

Editor's Comments:
In young patients, it is important to distinguish between fractures that involve the physis and those that only involve the metaphysis such as with this patient. Physeal fractures have risk of growth arrest and need to be recognized and managed properly. They are classified based on the Salter-Harris (SH) Classification. A SH I fracture involved only the physis and is usually not visible on x-ray. Diagnosis is made based on tenderness at the physis on clinical exam. SH II fractures extend into the metaphysis, SH III into the epiphysis, and SH IV into both the metaphysis and epiphysis. SH V fractures are crush injuries to the physis.

References:
1. Shea KG, Frick SL. Distal tibial and fibular fractures. In: Rockwood & Wilkins' Fractures in Children, 8th, Rockwood CA, Wilkins KE, Beaty JH (Eds), Lippincott Williams & Wilkins, Philadelphia 2015. p.1173.

2.Damore DT, Metzl JD, Ramundo M, et al. Patterns in childhood sports injury. Pediatr Emerg Care 2003; 19:65.

3. Boutis K, Willan AR, Babyn P, et al. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics 2007; 119:e1256.

4. Marsh JS, Daigneault JP. Ankle injuries in the pediatric population. Curr Opin Pediatr 2000; 12:52.

5. Kay RM, Matthys GA. Pediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg 2001; 9:268.

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