MacFarland fractures in children: a series of 24 cases

Purpose of the study MacFarland fracture is a joint fracture of the ankle in children. The fract ure line passes through the medial part of the lower epiphyseal disk of the tibia. Prognosis is dominated by later risk of malalignment and osteoarthr itis. MacFarland fracture usually occurs subsequent to adduction trauma. Th e aim of this study was to analyze prognosis in a retrospective series of c hildren with MacFarland fractures. Material and method 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 epiphysea l detachment: Salter 3 (n = 4) and Salter 4 (n = 20). Surgical treatment wa s given. in 17 cases (11 screw fixations, 4 pin fixations and 2 other osthe osynthesis combinations). Orthopedic care was given In 7 cases (mean immobi lization = 40 days). All 24 children were followed for a mean 3 years 2 mon ths (3 months = 12 years). Three outcome categories were used: good (no pai n, stiffness or malalignment), fair (pain and/or stiffness, no malalignment ), and poor (malalignment). Results 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 d egrees. After these procedures, outcome was good with a normally aligned pa inless ankle at 13 months follow-up. Among factors predictive of malalignme nt (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), fr acture type (7 malalignments among the Salter 4 fractures versus none among the Salter 3 fractures), initially defective reduction or osteosynthesis m aterial passing through the epiphyseal disk leading to epiphysiodesis. Discussion Careful radiologic and clinical surveillance is needed and should be contin ued to the end of growth (fusion of the tibial cartilage) in children with high risk fractures in order to detect epiphysiodesis early and avoid secon dary malalignment. Surgical correction does remain possible and gives good results.