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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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