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Ankle injuries in children
‫د موفق الرفاعي‬
introduction
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Second in frequency
25-38 of physial fractures
Males > females
10-15 years
Physial fractures are more common than
ligamentous injuries in children
Anatomy
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D.T.E appears at 6-12 m & contributes
45% of the tibial growth
Medial malleolous appears at 7y in
females – 8y in males
Physial closure begins at 15y in females –
17y in males and lasts at 18
D.F.E appears at 18-20 m and close at 12
24 m later than the distal tibia
Closure of distal tibial physis
Mechanism of injury & classification
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Anatomic .c
Salter Harris
Mechanism of injury .c
Lauge
Hansen .c
Dias Tachdjian .c
Salter Harris anatomic classification
Dias – Tachdjiac classification
Variations of grade 2 supination - inversion injuries
Severe supination – inversion injury
Stage 1 supination – external rotation
Stage 2 supination – external rotation injury
Pronation – dorsiflection injury
Axial compression - type injury
Diagnostic Features
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Twisting injury
Physical examination: lacerations
open .f
ecchymosis
swelling
Pulse evaluation & neurologic examination
Tenderness over the bony anatomy
especially over distal fibular physis
Radiographic examination:AP-lateralmortize views- stress x ray
Stress radiograph
Secondary ossification center
treatment
Closed reduction: gentle- early- conscious
sedation or general anesthesia
 ORIF : failure of closed reduction
displaced physial fractures
displaced articular fractures
open fractures
fractures with significant tissue
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Injury
 Campbell:
most of salter 3-4 triplane- tillaux
.
require ORIF and surgery is
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recommended for 2-3 mm or
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more of displacement
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Salter 1-2 distal fibular .f
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The most common .f of the ankle
Often misdiagnosed as an ankle sprain
Inversion of the supinated foot
Salter 1 12 y
Salter 2 10 y
Treatment:
nondisplaced salter 1
short leg walking cast
4 weeks
displaced salter 1
short leg nonweight
bearing cast 4-6 weeks
salter 2
short leg nonweight bearing cast 46 weeks
Salter 1 tibial .f
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15% - 10 .y
All four mechanisms result in this injury
Fibular fracture in 25%
Gentle reduction & long leg cast 4 weeks
then short leg cast 2 weeks
Salter 2 tibial .f
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The most common 40% - 12.5 y
Supination – external rotation
Supination – planter flextion
Fibular f. in 20%
Reduction requires a reversal of the mechanism
Thurston holland fragment is helpful in
determining the mechanism of injury
posterior fragment
supination – planter
flexion
lateral fragment
pronation – external
rotation
posteromedial fragment
supination –
external rotation
treatment
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Nondisplaced:
long leg cast 4 w
short leg cast 3 w
Displaced:
gentle closed reduction knee flexion 90 + planter flexion
of foot
axial rotation [ with the deformity then opposite] long leg
cast 4 w then short leg cast 3 w
Supination – external r:
the foot in internal rotation
Supination – planterflexion :
the foot in dorsiflexion
the patient should be relaxed during reduction
Balance between repeat closed reductions & acceptance
of the reduction
Salter 3 distal tibial f.
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20%
11-12
Supination – inversion injury
the epiphyseal f. is always medial to the medline
Fibular f. in 25%
Nondisplaced
long leg cast 4 weeks then
short leg cast for 4 weeks with the foot in 5-10
degrees of inversion
Displaced > 2 mm
closed reduction
O.R.I.F [ SCREW ] &
SHORT LEG CAST 6
WEEKS
Results are good ,15% premature physial
closure
Salter 4 distal tibial f.
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Rare injuries [1%]
Supination – inversion injury
The most are displaced
O.R.I.F
The approach is curvilinear
Fixation with screw parallel to the physis
Long leg cast 4 weeks – short leg cast 3 weeks
Radiographic monitoring every 6 monthes
Bioabsorbable pins
Salter 5 distal tibial f.
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Extremely rare
Axial compression
force
Noted after physial
arrest
Compression of the
germinal layer or
vascular or both
complications
1.
2.
3.
Premature closure of the physis [the
most common 7,7 % ]
Delayed or nonunion
Valgus deformity secondary to malunion
Premature closure of the physis
Injury to the germinal layer
asymmetric
or symmetric growth arrest
 Displaced salter 3 &salter 4
16
12
17m
20m
1,6cm
1,1cm
with varus deformity 15 degree
 Most of them treated with closed reduction [
importance of ORIF
 Follow these patients during first 2 years until
near skeletal maturity
 Osseous bar within the physis
 Park harris growth arrest lines
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Treatment depends on location – size – amount
of growth remaining
Growth remaining >2 years + physial arrest <
50% width of the physis
resect the
osseous bar &replace with cranioplast or adipose
tissue
Metal markers
If the patient is closer to skeletal maturity [
female> 11 y - male> 13 y ]
epiphysiodysis of the lateral aspect of the tibial
physis [ with contralateral epiphysiodysis ]
Varus deformity
opening wedge osteotomy
of the tibia with osteotomy of the fibula
Varus deformity
Valgus deformity secondary to malunion
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Inadequate reduction of pronation –
eversion –external rotation injury
Valgus tilt > 15-20 degree will not correct
by remodeling
distal medial
epiphysiodesis [screw across the medial
physis]
Valgus deformity
Nonunion & delayed union
The Tillaux fracture
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Fracture of the lateral portion of the distal tibial
end
2,9% - asymmetric closure of the physis [
centrally
medially
laterally ]
External rotation stretches the inferior
tibiofibular ligament
salter 3 fracture
Treatment
closed reduction or ORIF
ORIF : displacement> 2mm following closed
reduction or the fracture is seen more than 2 -3
days following injury with > 2mm displacement
Fixation with 4mm screw anterolateral to
potseromedial
The Triplane fracture
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6-8%
10-16 y [13,5 ]
Supination – external rotatoin
Fibular fracture 50%
Coronal – sagittal – transverse
Three parts t.f.
Two parts t.f.
Four parts t.f.
Extra articular triplane f.
1.
2.
Intramalleolar intraarticular
f. within the weight bearing
zone
Intramalleolar intraarticular
f.outside weightbearing zone
3. Extraarticular fracture .
Treatment of triplane f.
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The goal is anatomic reduction of articular
surface
Nondisplaced or minimal displacement
axial
traction + casting with internal rotation of the
foot if the fracture is lateral or eversion if it is
medial [ 4 weeks then short leg cast 3 weeks ]
Fibular fracture should be reduced first
ORIF indications: failure to achieve adequate
reduction [ within 2mm ]
displaced f. > 3mm at time of initial evaluation
Campbell : two parts fracture –closed reduction
[ salter 4 ] & 3 part fracture needs ORIF [
salter3 first then salter2 ]
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.‫• الموقع غير مسؤول عن األخطاء الواردة في هذه المحاضرة‬
• This lecture is one of a series of lectures were prepared and
presented by residents in the department of orthopedics in
Damascus hospital, under the supervision of Dr. Bashar Mirali.
• This site is not responsible of any mistake may exist in this
lecture.
Dr. Muayad Kadhim
‫ مؤيد كاظم‬.‫د‬