Updated: 8/24/2021

Ankle Fractures - Pediatric

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  • summray
    • Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury.
    • Diagnosis is made with plain radiographs of the ankle. A CT scan may be required to further characterize the fracture pattern and for surgical planning. 
    • Treatment may be nonoperative or operative depending on patient age, fracture displacement, and fracture morphology. 
  • Epidemiology
    • Incidence
      • accounts for 25-40% of all physeal injuries (second most common)
      • accounts for 5% of all pediatric fractures
    • Demographics
      • more common in males 2:1
      • typically occur between 8-15 years-old
    • Risk factors
      • participation in sports
      • increased BMI
    • Anatomic location
      • pediatric ankle fractures are a common injury that includes
        • SH type I
        • SH type II
        • SH type III
          • Tillaux fractures
          • medial malleolus fractures
        • SH type IV
          • triplane fractures
          • medial malleolus fractures
  • Pathophysiology
    • Mechanism of injury
      • direct trauma
      • twisting injury, i.e. rotation about a planted foot and ankle
  • Anatomy
    • Physeal considerations
      • distal tibial physis
        • accounts for 35-40% of overall tibial growth and 15-20% of overall lower extremity growth
        • rate of growth is 3-4 mm/year
        • growth continues until 14 years in girls and 16 years in boys
        • closure occurs during an 18 month transitional period
          • pattern of closure occurs in a predictable pattern: central > anteromedial > posteromedial > lateral
      • distal fibular physis
        • closure occurs 12-24 months after closure of distal tibial physis
    • Ligaments (origins are distal to the physes)
      • medial ligaments
        • deltoid ligament
          • superficial
            • anterior talotibial ligament
            • posterior talotibial ligament
            • tibionavicular ligament
            • calcaneotibial ligament
          • deep
            • primary restraint to lateral displacement of talus
      • lateral ligaments
        • anterior talofibular ligament (ATFL)
        • calcaneofibular ligament (CFL)
        • posterior talofibular ligament (PTFL)
      • syndesmosis ligaments
        • anterior inferior tibiofibular ligament (AITFL)
          • extends from anterior aspect of lateral distal tibial epiphysis (Chaput tubercle) to the anterior aspect of distal fibula (Wagstaffe tubercle)
          • plays an important role in transitional fractures (Tillaux, Triplane)
        • posterior inferior tibiofibular ligament (PITFL)
          • extends from posterior aspect of lateral distal tibial epiphysis (Volkmanns tubercle) to posterior aspect of distal fibula
        • inferior transverse ligament (ITL)
          • extends from posterior distal fibula across posterior aspect of distal tibial articular surface
          • functions as posterior labrum of the ankle
        • interosseous ligament (IOL)
          • continuous with interosseous membrane
          • located between AITFL and PITFL
  • Classification
    • Anatomic
    • Salter-Harris Classification
      Type I
      15%
      • Fracture extends through the physis
      Type II
      45%
      • Fracture extends through the physis and exits through the metaphysis, forming a Thurston-Holland fragment
      Type III
      25%
      • Fracture extends through the physis and exits through the epiphysis
      • Seen with medial malleolus fractures and Tillaux fractures
      • Increased risk of physeal arrest
      Type IV
      25%
      • Fracture involves the physis, metaphysis and epiphysis
      • Can occur with lateral malleolus fractures, usually SH I or II
      • Seen with medial malleolus shearing injuries and triplane fractures
      • Increased risk of physeal arrest
      Type V
      1%
      • Crush injury to the physis
      • Can be difficult to identify on initial presentation (diagnosis is usually made when growth arrest is seen on follow-up radiographs)
      • Increased risk of physeal arrest
      Type VI
      rare
      • Perichondral ring injury
      • Results from open injury (i.e. lawnmower) or iatrogenic during surgical dissection
    • Mechanism of injury
    • Dias & Tachdjian Classification
      (patterned off adult Lauge-Hansen classification)
      Supination-inversion
      Grade 1
      • Adduction or inversion force avulses the distal fibular epiphysis (SH I or II)
      • Occasionally can be transepiphyseal
      • Rarely occurs with failure of lateral ligaments
      Grade 2
      • Further inversion leads to distal tibial fracture (usually SH III or IV, but can be SH I or II)
      • Occasionally can cause fracture through medial malleolus below the physis
      Supination-plantarflexion
      • Plantarflexion force displaces the tibial epiphysis posteriorly (SH I or II)
      • Thurston-Holland fragment is composed of the posterior tibial metaphysis and displaces posteriorly
      • Occurs without fibular fracture
      • Can be difficult to see on AP radiograph
      Supination-external rotation
      Grade 1
      • External rotation force leads to distal tibial fracture (SH II)
      • Distal fragment displaces posteriorly
      • Thurston-Holland fragment displaces posteromedially
      • Easily visible on AP radiograph (fracture line extends proximally and medially)
      Grade 2
      • Further external rotation leads to low spiral fracture of fibula (anteroinferior to posterosuperior)
      Pronation/eversion-external rotation
      • External rotation force leads to distal tibial fracture (SH I or II) and transverse fibula fracture
      • Occasionally can be transepiphyseal medial malleolus fracture (SH II)
      • Distal tibial fragment displaces laterally
      • Thurston-Holland fragment is lateral or posterolateral distal tibal metaphysis
      • Can be associated with diastasis of ankle joint
      Axial compression
      • Leads to SH V injury of distal tibial physis
      • Can be difficult to identify on initial presentation (diagnosis typically made when growth arrest is seen on follow-up radiographs)
  • Presentation
    • Symptoms
      • common symptoms
        • pain
        • inability to bear weight
    • Physical exam
      • inspection
        • ecchymosis & swelling
        • deformity (if displaced)
      • focal tenderness
        • distal fibula physeal tenderness may represent non-displaced SHI
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • mortise
        • lateral
      • optional views
        • full-length tibia (or proximal tibia) to rule out Maisonneuve-type fracture
    • CT scan
      • indications
        • assess fracture displacement (best obtained post-reduction)
        • assess articular step-off
        • preop planning
  • Treatment
    • Nonoperative
      • removable walking boot vs. NWB short-leg cast for 4 weeks
        • indications
          • distal fibula
            • non-displaced (< 2mm) isolated distal fibular fracture
      • closed reduction and NWB cast for 6 weeks
        • indications
          • distal fibula
            • displaced (> 2mm) SH I or II fracture with acceptable closed reduction
          • distal tibia
            • displaced SH I or II fracture with acceptable closed reduction (no varus, < 10° valgus, < 10° recurvatum/procurvatum, < 3mm physeal widening)
    • Operative
      • CRPP
        • indications
          • distal fibula
            • displaced (> 2mm) SH I or II fracture with unacceptable closed reduction and > 2 years of growth remaining
          • distal tibia
            • displaced SH I or II fracture with unacceptable closed reduction (varus, > 10° valgus, > 10° recurvatum/procurvatum, > 3mm physeal widening) and > 2 years of growth remaining
            • displaced SH III or IV fracture with < 2mm displacement following closed reduction
      • ORIF
        • indications
          • distal fibula
            • displaced (> 2mm) isolated distal fibula fracture (usually SH I or II) with unacceptable closed reduction and < 2 years of growth remaining
          • distal tibia
            • displaced SH I or II fracture with unacceptable closed reduction (varus, > 10° valgus, > 10° recurvatum/procurvatum, > 3mm physeal widening) and < 2 years of growth remaining
            • displaced SH III or IV fracture with > 2mm displacement following closed reduction
  • Techniques
    • Closed reduction
      • sedation
        • requires adequate sedation and muscle relaxation
      • technique
        • only attempt reduction two times to prevent further physeal injury
        • confirm reduction with mortise view
        • acceptable reduction for tibia is
      • post-op
        • immobilize for 6 weeks
          • NWB short-leg cast if isolated distal fibula fracture
          • NWB long-leg cast if distal tibia fracture
      • complications
        • failed reduction
          • may have interposed periosteum, tendons, or neurovascular structures
    • CRPP vs. ORIF
      • reduction
        • percutaneous manipulation with K wires may aid reduction
        • open reduction may be required if interposed tissue present
      • instrumentation
        • transepiphyseal fixation best if at all possible
          • cannulated screws parallel to physis
            • Tillaux and triplane fractures
          • 2 parallel epiphyseal screws
            • medial malleolus shear fractures
        • transphyseal fixation
          • smooth K wires
  • Complications
    • Ankle pain and degeneration
      • high rate associated with articular step-off > 2mm
    • Growth arrest
      • medial malleolus SH IV fractures have the highest rate of growth disturbance
      • risk factors
        • degree of initial displacement
          • 15% increased risk of physeal injury for every 1mm of displacement
        • residual physeal displacement > 3mm
          • can represent periosteum entrapped in the fracture site
        • high-energy injury mechanism
        • SH III and IV fractures
      • types
        • partial arrests can lead to angular deformity
          • distal fibular arrest results in ankle valgus defomity
          • medial distal tibia arrest results in varus deformity
        • complete arrests can result in leg-length discrepancy
      • treatment
        • angular deformity
          • physeal bar resection
            • if < 20 degrees of angulation with < 50% physeal involvement and > 2 years of growth remaining
          • osteotomy
          • ipsilateral fibular epiphysiodesis
            • bar of >50% physeal involvement in a patient with at least 2 years of growth
            • fibular epiphysiodesis helps prevent varus deformity
        • leg-length discrepancy
          • physeal bar resection
            • if < 50% physeal involvement and > 2 years of growth remaining
          • contralateral epiphysiodesis if near skeletal maturity with significant expected leg-length discrepancy
    • Extensor retinacular syndrome
      • typically seen in posteriorly displaced fractures
    • Malunion
      • rotational deformity
        • can occur after triplane fractures, SH I or II fractures
        • usually leads to an increased external foot rotation angle
        • treatment is derotational osteotomy
      • anterior angulation or plantarflexion deformity
        • occurs after supination-plantarflexion SH II fractures
      • valgus deformity
        • occurs after external rotation SH II fractures
    • Reflex sympathetic dystrophy
      • more common in girls
      • treatment options include physical therapy, psychological counseling, drug therapy, sympathetic blockade

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(OBQ17.88) A fibular epiphysiodesis would be indicated in which of the following scenarios?

QID: 210175
1

A 10-year-old boy with a SH IV distal tibia fracture with > 3mm of residual displacement

4%

(61/1599)

2

A 10-year-old girl with a < 50% physeal bar in the distal tibia 4 months after an ankle fracture

9%

(151/1599)

3

A 13-year-old girl with a < 50% central physeal bar in the distal tibia 6 months after an ankle fracture

6%

(101/1599)

4

A 15-year-old girl with a 25° varus angular deformity of the distal tibia 2 years after an ankle fracture

6%

(88/1599)

5

A 13-year-old boy with a > 50% physeal bar in the distal tibia 5 months after an ankle fracture

74%

(1178/1599)

L 2 A

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(OBQ13.13) A 12-year-old male patient sustained a Salter-Harris IV fracture of the distal tibia. He presents 2 years later with the MRI scan images seen in Figures A through C. The distal tibia is in 30 degrees of varus (Figure A). The physeal map is shown in Figure C. What is the best treatment plan?

QID: 4648
FIGURES:
1

Physeal bridge resection and fat interposition through a metaphyseal window

19%

(1066/5718)

2

Corrective osteotomy, with physeal bridge resection and fat interposition through the osteotomy site

74%

(4240/5718)

3

Transarticular arthroscopically-assisted physeal bridge resection and fat interposition through the ankle joint

2%

(125/5718)

4

Completion of epiphysiodesis

3%

(152/5718)

5

Non-operative treatment

2%

(95/5718)

L 3 B

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(OBQ12.272) A 12-year-old sustains an ankle injury while running on wet grass. Radiographs are shown in Figures A and B. A reduction maneuver is attempted under conscious sedation but fluoroscopic images are unchanged. What is the next best step in management?

QID: 4632
FIGURES:
1

Admit for observation

0%

(8/3402)

2

Cast immobilization and outpatient follow up in 4-6 weeks

0%

(15/3402)

3

Closed reduction under general anesthesia followed by cast immobilization

3%

(92/3402)

4

Open reduction and internal fixation

81%

(2742/3402)

5

Repeat closed reduction under general anesthesia & internal fixation followed by cast immobilization

15%

(526/3402)

L 2 B

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(SAE07PE.66) A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment should now consist of

QID: 6126
FIGURES:
1

at least two more attempts at closed reduction in the emergency department before the patient’s sedation wears off.

1%

(3/425)

2

at least two attempts at closed reduction in the operating room under general anesthesia with muscle relaxation.

5%

(20/425)

3

acceptance of the reduction because the alignment is satisfactory and growth problems are rare with Salter-Harris type I fractures.

4%

(18/425)

4

open reduction, extraction of any interposed periosteum, and smooth wire fixation to prevent nonunion.

8%

(33/425)

5

open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

82%

(347/425)

L 2 D

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