Pediatric and Adolescent Ankle Injuries-Part 2 Rang’s Children’s Fractures Wenger and Pring 2005

Pediatric and Pediatric and Adolescent Ankle Adolescent Ankle

Injuries-Part 2Injuries-Part 2Rang’s Children’s FracturesRang’s Children’s Fractures

Wenger and PringWenger and Pring

20052005

Articular FracturesArticular Fractures

Salter-Harris Type VI Injuries of the Salter-Harris Type VI Injuries of the Distal TibiaDistal Tibia Ablation of the Perichondral RingAblation of the Perichondral Ring

Lawn mower injuriesLawn mower injuries Degloving injuriesDegloving injuries Callus bridge forms between the epiphysis Callus bridge forms between the epiphysis

and metaphysisand metaphysis Varus deformity and failure of growthVarus deformity and failure of growth May be missed on initial x-raysMay be missed on initial x-rays

Articular FracturesArticular Fractures The Tillaux FractureThe Tillaux Fracture

In an adolescent within a year of complete In an adolescent within a year of complete closure of the distal tibial physisclosure of the distal tibial physis

Central and medial aspect of the physis has Central and medial aspect of the physis has closedclosed

Anterolateral aspect of physis Anterolateral aspect of physis Open and vulnerable to avulsion injury by Open and vulnerable to avulsion injury by

external rotation forceexternal rotation force Bound down to fibular by anterior Bound down to fibular by anterior

tibiofibular ligamenttibiofibular ligament Fracture fragment is rectangular or pie Fracture fragment is rectangular or pie

shapedshaped


The Triplane FractureThe Triplane Fracture Complex fracture with sagittal, transverse Complex fracture with sagittal, transverse

and coronal componentsand coronal components Crosses in part along and in part through Crosses in part along and in part through

the physis and enters the ankle jointthe physis and enters the ankle joint Usually external rotation forceUsually external rotation force Type III injury in AP x-ray viewType III injury in AP x-ray view Type II injury in lateral x-ray viewType II injury in lateral x-ray view CT scan defines the fracture configurationCT scan defines the fracture configuration


The Triplane FractureThe Triplane Fracture Lateral triplane more commonLateral triplane more common Medial triplane less commonMedial triplane less common May have associated fibular fractureMay have associated fibular fracture May have associated tibial shaft May have associated tibial shaft

fracturefracture Rare neurovascular compromiseRare neurovascular compromise


The Triplane FractureThe Triplane Fracture Attempt closed reduction under Attempt closed reduction under

sedation or anesthesiasedation or anesthesia Maximum acceptable displacement is Maximum acceptable displacement is

2mm at articular surface2mm at articular surface ORIF ORIF

Anterolateral approach for lateral fractureAnterolateral approach for lateral fracture Posterior medial or lateral incisionsPosterior medial or lateral incisions Interfragmentary screws or plate for fibula Interfragmentary screws or plate for fibula

fracturefracture

Malleolar FracturesMalleolar Fractures

Fracture ManagementFracture Management Attempt closed reduction with Attempt closed reduction with

analgesia or sedationanalgesia or sedation Majority of fractures can be Majority of fractures can be

treated with castingtreated with casting ORIF if closed reduction failsORIF if closed reduction fails


ORIF indicationsORIF indications Failed closed reductionFailed closed reduction Closed reduction requires forced Closed reduction requires forced

abnormal positioning of the footabnormal positioning of the foot Medial ankle mortise widening 1-2 mmMedial ankle mortise widening 1-2 mm Displaced fractures of articular surfaceDisplaced fractures of articular surface Open fractureOpen fracture

Malleolar FracturesMalleolar Fractures ORIF timingORIF timing

Perform immediately before swelling on day Perform immediately before swelling on day of injury or wait 7-10 days until swelling of injury or wait 7-10 days until swelling resolvesresolves

Splint while awaiting swelling to resolveSplint while awaiting swelling to resolve Perform immediately before swelling on day Perform immediately before swelling on day

of injury or wait 7-10 days until swelling of injury or wait 7-10 days until swelling resolvesresolves

Splint while awaiting swelling to resolveSplint while awaiting swelling to resolve Wrinkle test to determine if swelling is likely Wrinkle test to determine if swelling is likely

to prevent skin closureto prevent skin closure


Lateral MalleolusLateral Malleolus Ligament avulsion injuryLigament avulsion injury

Patients 4-10 years oldPatients 4-10 years old Ligament avulsion with a fragment of Ligament avulsion with a fragment of

cartilage of epiphysiscartilage of epiphysis ATF and CF ligamentsATF and CF ligaments Treat with short leg cast 4-6 weeksTreat with short leg cast 4-6 weeks Forms bone ossicle when healedForms bone ossicle when healed May require excision if painfulMay require excision if painful


Lateral MalleolusLateral Malleolus Displaced fracturesDisplaced fractures

Attempt closed reduction and castingAttempt closed reduction and casting ORIF ORIF

Severe injuriesSevere injuries Inadequate reductionInadequate reduction K-wires, screws, 1/3 tubular plateK-wires, screws, 1/3 tubular plate Syndesmotic screw when indicatedSyndesmotic screw when indicated


Medial MalleolusMedial Malleolus Uncommon injuryUncommon injury Evaluate for Maisonneuve proximal Evaluate for Maisonneuve proximal

fibula fracturefibula fracture Closed treatment if: Closed treatment if:

UndisplacedUndisplaced Distal portion medial malleolusDistal portion medial malleolus Anatomical reduction by manipulationAnatomical reduction by manipulation Obtain CT scan to prove joint surface not Obtain CT scan to prove joint surface not

disrupted disrupted


Medial MalleolusMedial Malleolus Displaced fractures require ORIFDisplaced fractures require ORIF K-wires should not cross physis if K-wires should not cross physis if

possiblepossible 2 transepiphyseal cannulated or 2 transepiphyseal cannulated or

cancellous screwscancellous screws May need transmetaphyseal screw if May need transmetaphyseal screw if

metaphyseal portion of fracture is large metaphyseal portion of fracture is large


Medial MalleolusMedial Malleolus If transepiphyseal fixation not possible If transepiphyseal fixation not possible

use smooth K-wires or tension banduse smooth K-wires or tension band Reduction may be hindered by trapped Reduction may be hindered by trapped

loose fragments loose fragments In skeletally mature patients may be In skeletally mature patients may be

stabilized by 2 transepiphyseal stabilized by 2 transepiphyseal cannulated or cancellous screws cannulated or cancellous screws perpendicular to the fracture similar to perpendicular to the fracture similar to adultsadults

PitfallsPitfalls

Physeal fractures of the distal tibiaPhyseal fractures of the distal tibia Premature physeal arrestPremature physeal arrest More common if involvement of medial More common if involvement of medial

malleolusmalleolus Leg length inequalityLeg length inequality Angular deformity of ankleAngular deformity of ankle Follow patients with x-rays at 6 months Follow patients with x-rays at 6 months

and 1 year post-injuryand 1 year post-injury Compare to x-rays of uninvolved ankleCompare to x-rays of uninvolved ankle

Henry HarrisHenry HarrisWelsh AnatomistWelsh Anatomist

Harris growth arrest lines are dense Harris growth arrest lines are dense trabecular transversely oriented trabecular transversely oriented lines with the metaphysis, commonly lines with the metaphysis, commonly seen in children of all ages. These seen in children of all ages. These lines, also called recovery lines, lines, also called recovery lines, follow a period of illness or follow a period of illness or immobilization. These lines relate to immobilization. These lines relate to a temporary slowdown of a a temporary slowdown of a longitudinal growth. longitudinal growth.

PitfallsPitfalls

Physeal fractures of the distal tibiaPhyseal fractures of the distal tibia Asymmetry of Harris growth line of is an Asymmetry of Harris growth line of is an

indicator of early premature physeal closureindicator of early premature physeal closure A Harris growth arrest line pertains to A Harris growth arrest line pertains to

children/teens in whom the bone lines show children/teens in whom the bone lines show retarded growth, usually due to trauma to a retarded growth, usually due to trauma to a bonebone

Obtain hand x-ray for bone ageObtain hand x-ray for bone age MRI or CT for the extent and location of MRI or CT for the extent and location of

physeal arrestphyseal arrest

PitfallsPitfalls

Physeal arrest of the distal tibiaPhyseal arrest of the distal tibia Close observation with serial x-raysClose observation with serial x-rays Excision of physeal bar with interposition Excision of physeal bar with interposition

materialmaterial Epiphysiodesis of the remaining open Epiphysiodesis of the remaining open

tibial physis, ipsilateral distal physistibial physis, ipsilateral distal physis Epiphysiodesis of contralateral open Epiphysiodesis of contralateral open

distal tibial physis & ipsilateral distal distal tibial physis & ipsilateral distal physisphysis

Corrective osteotomy Corrective osteotomy

Syndesmosis InjuriesSyndesmosis Injuries

Syndesmotic disruptionSyndesmotic disruption Usually pronation-abduction/ external Usually pronation-abduction/ external

rotationrotation Usually unstableUsually unstable Require intraoperative assessment of Require intraoperative assessment of

stabilitystability Use bone hook around fibula at Use bone hook around fibula at

syndesmosis to apply lateral stresssyndesmosis to apply lateral stress Usually require operative stabilizationUsually require operative stabilization


Indications for syndesmotic fixationIndications for syndesmotic fixation Medial ligamentous injury, syndesmotic Medial ligamentous injury, syndesmotic

disruption & talar shift without fracture disruption & talar shift without fracture of fibula-tibiofibular diastasisof fibula-tibiofibular diastasis

Maisonneuve fractureMaisonneuve fracture Syndesmotic instability after fixation of Syndesmotic instability after fixation of

fibula and avulsion of fractures of the fibula and avulsion of fractures of the tubercles or medial malleolustubercles or medial malleolus


Fixation techniquesFixation techniques 1or 2 3.5-4.5 cortical screws1or 2 3.5-4.5 cortical screws Hold but do not compress syndesmosisHold but do not compress syndesmosis Insert screws just above the level of the Insert screws just above the level of the

tibiofibular ligamentstibiofibular ligaments Place ankle in dorsiflexion to bring Place ankle in dorsiflexion to bring

widest portion of the talus in the widest portion of the talus in the mortise when you tighten screwsmortise when you tighten screws


Fixation techniquesFixation techniques Both cortices of the fibula and tibia are Both cortices of the fibula and tibia are

drilled, tapped and engaged by each drilled, tapped and engaged by each screwscrew

Keep non-weight bearing for 6-8 weeksKeep non-weight bearing for 6-8 weeks Remove syndesmotic screws prior to Remove syndesmotic screws prior to

weight bearingweight bearing

Ankle SprainsAnkle Sprains

Very common injuriesVery common injuries Usually inversion stress to ankleUsually inversion stress to ankle Most commonly injuredMost commonly injured

Anterior talofibular ligamentAnterior talofibular ligament Calcaneo-fibular ligamentCalcaneo-fibular ligament

Anterolateral swelling, tenderness, Anterolateral swelling, tenderness, ecchymosisecchymosis

Differentiate from Salter-Harris I & II Differentiate from Salter-Harris I & II injury of distal fibula by location of injury of distal fibula by location of tendernesstenderness


Grades according to severityGrades according to severity Grade IGrade I ligaments in continuity ligaments in continuity Grade IIGrade II partial tear of ligaments partial tear of ligaments Grade IIIGrade III complete tear of ligaments complete tear of ligaments

with gross instability-5 locationswith gross instability-5 locations Midsubstance ruptureMidsubstance rupture Rupture at bone attachmentRupture at bone attachment Avulsion of bone at ligament attachmentAvulsion of bone at ligament attachment


Treatment Treatment ““Ace, Ice and Adios”Ace, Ice and Adios” Elastic support, ankle brace, posterior Elastic support, ankle brace, posterior

mold, short leg castmold, short leg cast Grade I-II sprainGrade I-II sprain allow weight bearing allow weight bearing

as tolerated with or without crutches as tolerated with or without crutches depending on immobilizationdepending on immobilization

Obtain stress x-ray viewsObtain stress x-ray views


Recurrent ankle sprainsRecurrent ankle sprains Residual ankle loss of motion, strength Residual ankle loss of motion, strength

and balance senseand balance sense Ligamentous instabilityLigamentous instability Tarsal coalitionTarsal coalition Talar dome injuryTalar dome injury Obtain CT or MRI to better evaluateObtain CT or MRI to better evaluate Treat with physical therapy, external Treat with physical therapy, external

support, prolotherapy and surgerysupport, prolotherapy and surgery

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Pediatric and Adolescent Ankle Injuries-Part 2 Rang’s Children’s Fractures Wenger and Pring 2005