Updated: 11/21/2018

Ankle Fractures - Pediatric

Topic
Review Topic
0
0
Questions
7
0
0
Evidence
11
0
0
Cases
4
https://upload.orthobullets.com/topic/4027/images/ankle fx 333.jpg
https://upload.orthobullets.com/topic/4027/images/graphic014010010.jpg
Introduction
  • Overview
    • 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
    • treatment is typically immobilization if nondisplaced or ORIF if displaced
  • 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
  • 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
    • closed reduction and casting
      • indications
        • < 2mm displacement
      • modalities
        • only attempt reduction two times to prevent further physeal injury
        • requires adequate sedation and muscle relaxation
        • place in long leg cast for 4-6 weeks
          • short leg can be used if fracture is nondisplaced
  • Operative
    • CRPP vs. ORIF
      • indications
        • > 2mm displacement
        • intra-articular fractures with >2mm of articular displacement
        • irreducible fractures
          • may have interposed periosteum, tendons, or neurovascular structures  
Techniques
  • 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
      • 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
      • consider distal fibular epiphysiodesis to prevent fibular overgrowth and lateral impingement
  • 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 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
 

Please rate topic.

Average 3.2 of 31 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (7)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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

49%

(309/630)

2

Increased internal foot progression angle

33%

(211/630)

3

Equinus contracture

11%

(69/630)

4

Avascular necrosis

3%

(21/630)

5

Leg compartment syndrome

2%

(15/630)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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%

(5/2446)

2

Cast immobilization and outpatient follow up in 4-6 weeks

0%

(9/2446)

3

Closed reduction under general anesthesia followed by cast immobilization

3%

(65/2446)

4

Open reduction and internal fixation

81%

(1980/2446)

5

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

15%

(376/2446)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
ARTICLES (17)
CASES (4)
Topic COMMENTS (7)
Private Note