it has been estimated that fractures of the upper tibial epiphysis account for 0.5 - 3.1% of all epiphyseal injuries . who had no neurovascular deficit , with fixed extension deformity at the left knee we present a case of a 16-year - old boy who while playing cricket on the road was hit by a car . the patient presented in emergency room with extremely swollen knee and soft tissue swelling ( hemarthrosis ) , he was unable to lift his leg actively due to severe pain because of hamstrings spasm , and he had no wound over his left knee and had no other associated injuries . plain radiographs were taken which revealed , separated proximal tibial epiphysis ( salter harris type 1 injury ) the epiphysis was anteriorly displaced fracture line extending beyond growth plate through metaphysis and tibial tuberosity also displaced anteriorly , the proximal fibular epiphysis fragment was displaced anteriorly with no injury to femoral epiphysis and no patellar fracture , radiograph also revealed no intra - articular fracture as joint appears congruent . under spinal anesthesia , under all aseptic precautions traction was applied for few minutes , the fracture was reduced closed as the hamstring spasm gave way , reduction was confirmed under image intensifier in both ap and lateral planes , and joint congruity was examined . post - operative patient was immobilized with nil weight bearing for 4 weeks , check x - rays taken , he was mobilized in wheelchair . after 4 weeks slab was removed , k - wires were removed , and partial weight bearing was started with rehabilitation for full range of motion of the left knee . at 6 weeks , both the knee joints appeared symmetrical with no abnormalities or limb length discrepancy or instability with knee from 0 to 140 , with full weight bearing . although less commonly seen , salter - harris type 1 injuries to proximal tibial physis , if managed early with closed reduction and fixation , excellent long - term results can be achieved . it has been estimated that fractures of the upper tibial epiphysis account for 0.5 - 3.1% of all epiphyseal injuries [ 1 , 2 ] . popliteal artery , which runs posterior to epiphysis , may be disrupted during the injury but with closed reduction ischemia is reversible in the most cases ( fig . the juvenile knee is frequently injured but this injury is relatively rare , rarity of this mode of injury is also known due to many anatomical peculiarities , insertion of semitendinosus directly over metaphysis , insertion of patellar tendon as separate center of ossification protecting epiphysis from avulsion strains , fibular and medial collateral ligaments inserting over the metaphysis , most importantly varus - valgus forces around the knee directly transmits from femur to tibial metaphysis through collateral ligaments due to which distal femoral epiphysis injury being quite common as compared to proximal tibia . we present a case of a 16-year - old boy who while playing cricket on a road was hit by a car from behind ; he was standing in knee flexed position approximately 10 , at the time of injury , his leg was fixed to the ground and his knee was pushed anteriorly and leg was fixed at the ground resulting in hyperextension injury at the left knee . the patient presented in emergency room with extremely swollen knee and soft tissue swelling ( hemarthrosis ) , he was unable to lift his leg actively due to severe pain because of hamstrings spasm , and he had no wound over his left knee and had no other associated injuries . on clinical examination , left knee was in hyperextension attitude , patient had edematous swelling and intra - articular effusion over the left knee with generalized tenderness over the knee , palpation revealed no fracture of the patella or disruption of quadriceps or patellar tendon , any movement at the knee level provoked severe pain so were restricted , patient had palpable distal pulses , and had no sensory or motor loss distal to left knee . assessment of collateral ligaments , menisci could not be done as the patient was in extreme pain , but it did not reveal any significant abnormalities . plain radiographs were taken which revealed , separated proximal tibial epiphysis ( salter harris type 1 injury ) the epiphysis was anteriorly displaced fracture line extending beyond growth plate through metaphysis and tibial tuberosity also displaced anteriorly . the proximal fibular epiphysis fragment was displaced anteriorly with no injury to femoral epiphysis and no patellar fracture , radiograph also revealed no intra - articular fracture as joint appears congruent ( fig . 2 and 3 ) . patient s left lower limb was immobilized and he was immediately shifted to the operation theatre ( 4 h interval following trauma ) . under spinal anesthesia , under all aseptic precautions traction was applied for few minutes , the fracture was reduced closed as the hamstring spasm gave way , reduction was confirmed under image intensifier in both anteroposterior and lateral planes , and joint congruity was examined . two cross k - wires were inserted percutaneous from lateral and medial side and though mini - open approach from proximal epiphysis to metaphysis . the reduction was found to be stable enough , and proximal fibular epiphysis was also stable , distal pulses were felt post reduction , above knee posterior and anterior slab was given in 15 knee flexion to avoid popliteal vessel compression ( fig . post - operative patient was immobilized with nil weight bearing for 4 weeks , check x - rays taken , he was mobilized in wheelchair . after 4 weeks slab was removed , k - wires were removed and partial weight bearing was started with rehabilitation for full range of motion of the left knee . at 6 weeks both the knee joints appeared symmetrical with no abnormalities or limb length discrepancy or instability with knee from 0 to 140 , with full weight bearing ( fig . ( a and b ) follow - up radiograph at 1 year . ( a - d ) clinical photograph at 1 year . follow - up at 1 year showed the full range of motion , no joint laxity , and no limb length discrepancy ( fig . in the case presented , the mechanism of injury was twisting force with the foot fixed to the ground . clinical features include the inability to lift the leg because of pain and because of hamstring spasm . hyperextension of the knee should be avoided because of the possibility of popliteal artery injury . rotational force has resulted in a fracture through the growth plate , as opposed to ligamentous injury . this may be because with the patient s body weight acting through the extended knee , the proximal tibial epiphysis becomes the focus through which the rotational force acts . clinically , there was an internal rotation deformity and this is in contrast to the expected appearance of the knee when the mechanism of injury has been the more commonly described shearing , avulsing splitting , or crushing . the treatment consisted of accurate closed reduction and stabilisation with heavy k - wires and slab . had the fracture extended into the joint surface ( salter - harris types iii or iv ) , open reduction to gain articular congruity would have been carried out . analysis of five series of these types of injuries , published by burkhart and peterson , poulsen et al . , rhemrev et al . , wozasek et al . , and gautier et al . gives a total of 84 patients of whom 63 were males and 21 were females . there were 15 salter - harris type i injuries , 19 type ii injuries , 24 type iii injuries , 22 v injuries ( one case was bilateral type iv fractures , four type v injuries and one fracture described as mode of epiphysis separation include , direct violence ( burkhart and peterson , 1979 ) intra - articular shearing stresses ( aitken and ingersoll , 1956 ; burkhart and peterson , 1979 ; salter and harris , 1963 )   avulsion strains transmitted by the patellar tendon ( burkhart and peterson , 1979 ; hutchinson , 1894 ) or by an abnormally large insertion of the medial collateral ligament into the epiphysis ( aitken and ingersoll , 1956 ) . the cruciate ligaments seem to play no part in the causation of these injuries ( aitken and ingersoll , 1956 ; burkhart and peterson , 1979 ) . complications include ligamentous injuries , vascular complications   including compartment syndrome , knee instability , and growth disturbance [ 4 , 6 ] . growth disturbance , as defined by deformities of more than 25 mm in length , or more than 50 of angulation , has been reported to occur in more than 25% of cases of proximal tibial injuries in children , when a meta - analysis of published series was performed . gautier et al . , in a study of six children with proximal tibial injuries reports that the most consistent clinical deformity was recurvatum , with a resultant effect on the range of motion of the knee . although less commonly seen , salter - harris type i injuries to proximal tibial physis , if managed early with closed reduction and fixation , excellent long - term results can be achieved . proximal tibial epiphyseal injuries are rare to be seen but early diagnosis , and neurovascular status evaluation is of utmost importance . immediate management in the form of reduction and re - evaluation of the neurovascular status is crucial and is beneficial for the patient .
introduction : fractures of the proximal tibial epiphysis rare . 
 it has been estimated that fractures of the upper tibial epiphysis account for 0.5 - 3.1% of all epiphyseal injuries . who had no neurovascular deficit , with fixed extension deformity at the left knee 
 was treated early with closed reduction techniques.case report : we present a case of a 16-year - old boy who while playing cricket on the road was hit by a car . 
 the patient presented in emergency room with extremely swollen knee and soft tissue swelling ( hemarthrosis ) , he was unable to lift his leg actively due to severe pain because of hamstrings spasm , and he had no wound over his left knee and had no other associated injuries . 
 plain radiographs were taken which revealed , separated proximal tibial epiphysis ( salter harris type 1 injury ) the epiphysis was anteriorly displaced fracture line extending beyond growth plate through metaphysis and tibial tuberosity also displaced anteriorly , the proximal fibular epiphysis fragment was displaced anteriorly with no injury to femoral epiphysis and no patellar fracture , radiograph also revealed no intra - articular fracture as joint appears congruent . under spinal anesthesia , under all aseptic precautions traction was applied for few minutes , the fracture was reduced closed as the hamstring spasm gave way , reduction was confirmed under image intensifier in both ap and lateral planes , and joint congruity was examined . 
 proximal fibular epiphysis also snapped back in place . 
 post - operative patient was immobilized with nil weight bearing for 4 weeks , check x - rays taken , he was mobilized in wheelchair . after 4 weeks slab was removed , k - wires were removed , and partial weight bearing was started with rehabilitation for full range of motion of the left knee . at 6 weeks , both the knee joints appeared symmetrical with no abnormalities or limb length discrepancy or instability with knee from 0 to 140 , with full weight bearing.conclusion:although less commonly seen , salter - harris type 1 injuries to proximal tibial physis , if managed early with closed reduction and fixation , excellent long - term results can be achieved .