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Introduction
  • Pediatric ankle fractures include
    • SH type I
      • fibular fx
    • SH type II 
      • fibular fx
    • SH type III
      • tillaux fractures 
      • medial malleolus fractures
    • SH type IV
      • triplane fractures 
      • medial malleolus shear fractures
  • Epidemiology
    • incidence
      • 25-40% of all physeal injuries (second most common)
    • demographics
      • typically occur between 8-15 years-old
  • Pathophysiology
    • mechanism of injury
      • direct trauma
      • rotation about a fixed foot and ankle
Anatomy
  • Physeal considerations
    • distal tibial physis closes in predictable pattern 
      • central to medial
      • anterolateral closes last
Classification
  • Anatomic classification
    • Salter-Harris Classification
  • Diaz and Tachdjian classification  (patterned off adult Lauge-Hansen classification)
    • supination-inversion
    • supination-plantar flexion
    • supination-external rotation
    • pronation/eversion-external rotation
Presentation
  • Symptoms
    • ankle pain, inability to bear weight
  • Physical exam
    • inspection
      • swelling, focal tenderness
Imaging
  • Radiographs
    • recommended views
      • AP, mortise, and lateral
    • optional views
      • full-length tibia, or proximal tibia, to rule out Maisonneuve-type fracture
    • findings
      • triplane fractures
        • AP or mortise reveals intraarticular component
        • lateral reveals posterolateral metaphyseal fragment (Thurston-Holland fragment
  • CT scan
    • indications
      • assess fracture displacement
      • assess articular step-off
Treatment
  • Nonoperative
    • cast immobilization
      • indications
        • <2mm articular displacement
  • Operative
    • CRPP vs ORIF
      • indications
        • >2mm displacement
        • intra-articular fractures 
        • irreducible reduction by closed means
          • may have interposed periosteum, tendons, neurovascular structures  
Techniques
  • CRPP vs ORIF
    • reduction
      • percutaneous manipulation with k-wires may aid reduction
      • open reduction may be required if interposed tissue
    • fixation
      • 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 wire fixation typically used
Complications
  • Ankle pain and degeneration
    • high rate associated with articular step-off >2mm
  • Growth arrest  
    • medial malleolus SH IV have highest rate of growth disturbance of any fracture
    • risk factors 
      • degree of initial displacement
      • residual physeal displacement >3mm
        • represents periosteum entrapped in the fracture site
      • high energy injury mechanism 
      • SH III and IV
    • partial arrests can lead to angular deformity
      • distal fibular arrest results in valgus
      • medial distal tibia arrest results in varus
    • complete arrests can result in leg-length discrepancy
      • can be addressed with contralateral epiphysiodesis
  • Extensor retinacular syndrome
    • displaced fracture can lead to foot compartment syndrome
  • Rotational deformity 
 

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(SBQ04PE.6) A 7-year old female injures her foot while rollerblading. She has mild swelling over the ankle with no neurovascular deficit and soft compartments throughout the lower extremity. Her radiographs are shown in Figures A and B. Which of the following sequelae is most commonly associated with this injury? Review Topic

QID: 2191
FIGURES:
1

Increased external foot progression angle

50%

(263/523)

2

Increased internal foot progression angle

31%

(164/523)

3

Equinus contracture

11%

(57/523)

4

Avascular necrosis

4%

(20/523)

5

Leg compartment syndrome

3%

(14/523)

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PREFERRED RESPONSE 1
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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? Review Topic

QID: 4632
FIGURES:
1

Admit for observation

0%

(5/2433)

2

Cast immobilization and outpatient follow up in 4-6 weeks

0%

(9/2433)

3

Closed reduction under general anesthesia followed by cast immobilization

3%

(65/2433)

4

Open reduction and internal fixation

81%

(1969/2433)

5

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

15%

(374/2433)

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PREFERRED RESPONSE 4
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