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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?
Admit for observation
Cast immobilization and outpatient follow up in 4-6 weeks
Closed reduction under general anesthesia followed by cast immobilization
Open reduction and internal fixation
Repeat closed reduction under general anesthesia & internal fixation followed by cast immobilization
Select Answer to see Preferred Response
Based on the clinical history and radiographs shown, this patient has sustained a supination-inversion type ankle fracture. An inability to reduce the fracture in a closed manner warrants an open approach to remove interposed structures and to confirm anatomic reduction. Stable injuries can be casted but often warrant internal fixation. The failure of closed reduction is likely due to the presence of interposed periosteum.
Ankle fractures are common in patients aged 11-13 years. Plain radiographs are typically used to diagnose these injuries. They may be treated non-operatively with closed reduction and cast immobilization; irreducible fractures suggest the interposition of periosteum, tendon or other neurovascular structures between fragments. Treatment should include an open reduction to remove the incarcerated structure(s) followed by an evaluation of the the stability of the fracture. If the fracture is stable, the patient can be placed into a cast. If not stable, proceed with internal fixation.
Dias et al. studied 71 cases of pediatric ankle fractures. They proposed a mechanistically based classification scheme that accounts for the position of the foot and the deforming force of the ankle. They found that the supination-inversion mechanism accounted for close to 50% of all cases. They recommend using this classification scheme to guide closed reduction methods.
Rohmiller et al. studied distal tibial physeal injuries in 137 patients. They found premature physeal closure in 35% of patients sustaining a supination-external rotation type injury and 54% of patients sustaining a pronation-abduction type injury. Premature physeal closure was found to be most dependent on fracture displacement after reduction. They recommend anatomic reduction to decrease the risk of premature physeal closure.
Figure A shows the radiograph of a skeletally immature patient who has sustained a supination-inversion injury. Illustration A shows the Diaz-Tachdijan classification scheme for pediatric ankle injuries: a. Supination-inversion b. Supination-plantar flexion. c. Supination-external rotation d. Pronation-eversion
Answer 1: Admitting for observation alone is not indicated
Answer 2: Cast immobilization should be completed after an open reduction is performed
Answer 3, 5: Considering that appropriate sedation was administered, repeat manipulations may cause injury to the physis.
Dias LS, Tachdjian MO.
Clin Orthop Relat Res. 1978 Oct;(136):230-3. PMID: 103673 (Link to Abstract)
Dias, CORR 1978
Rohmiller MT, Gaynor TP, Pawelek J, Mubarak SJ
J Pediatr Orthop. 2006 May-Jun;26(3):322-8. PMID: 16670543 (Link to Abstract)
Rohmiller, JPO 2006
Please rate question.
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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?
Increased external foot progression angle
Increased internal foot progression angle
Leg compartment syndrome
The images for this child show a distal tibial physeal fracture which may be associated with malrotation of the foot.
Distal tibial physeal injuries commonly occur in the setting of a twisting injury. Although the foot may appear grossly normal and the radiographs show only mild physeal widening, rotational deformity may exist. Healing in this rotated position can lead to changes in foot progression angle, more often resulting in increased external rotation of the foot. The recommended treatment is to evaluate the child for rotational deformity at the time of injury and then perform a closed reduction followed by bent-knee long leg casting.
Phan et al. review the cases of 23 children with either a Salter-Harris (SH) 1 or SH 2 fracture of the distal tibia. 14 of 23 children had increased external foot progression angle in both feet with significantly more external rotation on the injured side. No patient developed an internal rotation deformity.
Broock et al. present a case report of a 7-year-old child who sustained an external rotation injury that showed only physeal widening on radiographs. Interestingly, this was associated with a 45-degree external rotation deformity of the foot/ankle that reduced following closed reduction.
Figure A demonstrates anterior widening of the distal tibial physis while Figure B shows widening of the medial aspect of the distal tibial physis. Although clinical malrotation may occur in the setting of distal tibial physeal injuries, it may only show mild physeal widening on plain radiographs.
Answer 2: According to the article by Phan et al. (see above), an external foot progression angle is far more common than an internal foot progression angle.
Answer 3: An equinus contracture is unlikely given the rotational nature of the injury.
Answer 4: Avascular necrosis is a very rare complication of distal tibia physeal fractures.
Answer 5: Leg compartment syndrome is rare in the distal tibia, but a compartment syndrome of the foot secondary to a tight extensor retinaculum has been described after pediatric ankle fractures.
Phan VC, Wroten E, Yngve DA
J Pediatr Orthop. 2002 Jan-Feb;22(1):31-5. PMID: 11744850 (Link to Abstract)
Phan, JPO 2002
Broock GJ, Greer RB.
J Bone Joint Surg Am. 1970 Dec;52(8):1666-8. PMID: 4394891 (Link to Abstract)
Broock, JBJS 1970
Average 1.0 of 39 Ratings
HPI - Fall and injury to left ankle
Is the closed reduction acceptable?
HPI - Twisting injury of left ankle while playing football
What is the best management option?
HPI - Twisting injury 4 hours ago
No prior pain or history of trauma
HPI - Twisting injury of ankle. Massive swelling of the ankle. Unable to weight bear
What is the treatment? Fix the fibula or not?