Pediatric Ankle

1
Pediatric Ankle Foot Fractures

• Steven Frick, MD
• Original Authors Laura Phieffer, MD and Steven
  Frick, MD March 2004
• New Author Steven Frick, MD Revised August 2006

2
Pediatric Ankle Fractures

• 2nd most common site of physeal fractures in
  children
• Most occur between ages 10 - 15 y.o.
• boys gt girls
• direct and indirect mechanisms

3
Ankle Anatomy

• all ligamentous structures attach distal to the
  physis
• ligaments are stronger than physis
• physeal injury more common

4
Ankle Anatomy

• distal tibial ossification center appears between
  6 - 24 months
• distal fibular ossification center appears
  between 9 - 24 months
• medial malleolar extension begins
  7 y.o. completes 10 y.o.

5
Physeal Closure

• distal tibial physis closes 15 y.o.
  girls 17 y.o. boys
• asymmetric closure over 18 months
• closure distal fibular physis follows distal
  tibial physeal closure by 12-24 months

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Distal Tibial Physeal Closure
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Age / Fracture Pattern

• Spiegel et al JBJS 1978

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Classification - Ankle Fractures

• Anatomic Salter-Harris
• high interobserver correlation
• correlated with outcomes

9
Classification - Ankle Fractures

• Mechanism of injury
• Dias and Tachdjian

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Diagnosis - Ankle Fractures

• direct/indirect mechanisms
• acute/subacute
• subtle exam findings
• Differentiate sprain from nondisplaced fracture
  by location of tenderness

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Diagnosis - Ankle Fractures

• Radiographs - AP, LAT, Mortise
• know normal anatomic variants
• Stress radiographs
• CT scan to assess articular involvement
• MRI role not yet well defined in acute injuries

12
Accessory Ossification Centers Smooth Borders
13
Treatment Considerations

• Location of fracture
• Mechanism of injury
• Degree of displacement
• Age of child (how much growth remains)

14
Salter-Harris Type I fxs

• Typically occurs in younger pts
• seen with all mechanisms
  (SI, SPF, SER, PEER)
• Often missed initially (dx sprain)
• Xrays acute often normal except for soft
  tissue swelling over physis
• Xrays- subacute - reveal widening of physis-
  healing

15
Salter-Harris Type II fxs

• most common distal tibia fx type
• seen with all mechanisms
  (SI, SPF, SER, PEER)
• mechanism deduced by direction of dist tibial
  epiphysis, type assoc fib fx, location of
  metaphyseal spike

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Salter II Distal Tibia Fracture
17
Salter-Harris Type I II fxs

• non-displaced fxs
• LLC x 3-4 wks gt SLWC x 3wks (SH I fxs can be
  treated with SLWC x 3-4wks)
• displaced fxs
• Avoid repeated attempts at CR
• LLC x 3wks gt SLC x 3wks gt SLWC
• Open reduction infrequently indicated
• Follow for growth arrest

18
Healed Distal Tibial Physeal Fracture -2 things
make physes wider - healing fractures and rickets
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Salter-Harris Type I II fxs

• If CR is incomplete, how much residual
  displacement is acceptable?
• Caruthers and Crenshaw AJS 1955
• accurate reposition of the displaced epiphysis
  at the expense of forced or repeated manipulation
  or operative intervention is not indicated

20
Salter-Harris Type I II fxs

• If CR is incomplete, how much residual
  displacement is acceptable?
• Spiegel et al JBJS 1978
• correlated SH classification with risk of
  shortening, angular deformity and joint
  incongruity
• recommend precise anatomical reduction

21
Salter-Harris Type I II fxs

• Differing opinions regarding indication for open
  reduction for interposition of periosteum gt
  widening with minimal angulation
• Kling et al 1984
• Phieffer, Wattenbarger et al 2000- animal model
• Mubarak et al 2005 believe interposed periosteum
  leads to growth disturbance

22
Closed reduction with incomplete reduction
because of interposed soft tissues removed at
ORIF
23
Salter-Harris Type I II fxs

• displaced subacute (gt7-10 days out) fxs
• Residual displacement probably best accepted
• If growth does not sufficiently correct malunion,
  corrective osteotomy performed

24
Salter-Harris Type III IV fxs

• Mechanism of injury similar for both fx patterns
  (typically supination-inversion)
• Usually produced by medial corner of talus being
  driven into the junction of distal tibial
  articular surface and the medial malleolus
• Can see central and lateral fx patterns

25
Kling et.al., JBJS 84

• 33 fractures of the distal tibial physis
• Most SH types III and IV
• 19 tx with ORIF
• 9 treated with closed methods
• 0 bone bridges in ORIF group
• 5 of 9 closed tx formed physeal bars
• Recommended anatomic reduction of physis

26
Salter-Harris Type III IV fxs

• Treatment and prognosis are similar
• Medial pattern appears to be at higher risk for
  developing partial growth arrest gt varus
  deformity
• Spiegel et al JBJS 1978
• Kling et al JBJS 1984
• Caterini et al Foot Ankle 1991

27
Salter-Harris Type III IV fxs

• non-displaced fxs (lt1 mm)
• LLC x 3-4 wks gt SLWC x 3wks
• CT after cast placement to assess displacement
• Weekly xrays in cast for first 3 weeks to assure
  no displacement
• Percutaneous fixation also option
• Follow for growth arrest

28
Salter III Injury- CRIF
29
Salter-Harris Type III IV fxs

• displaced fxs (gt2 mm)
• Anatomical reduction
• CR under GA if continued gt 2 mm displacement gt
  open reduction
• Open reduction, epiphyseal fixation parallel to
  growth plate if much growth remaining
• Postop LLC x 3-4 wks gt SLWC x 3wks

30
Salter IV Distal Tibia Fracture
Fixation avoids physis
31
Salter-Harris Type III IV fxs

• subacute displaced fxs
• Accept up to 2 mm displacement
• gt2mm displacement gt recommend reduction
  regardless of time from injury with debridement
  and interposition graft if necessary (goal to
  restore joint congruity)

32
Delayed diagnosis Salter IV medial malleolus
fracture in 6 yo multitrauma patient

• initial radiographs 15 days out from injury

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Anterior Approach

• ORIF 16 days after injury

34
Note growth slowdown line parallels physis and
increased distance between markers normal growth

• nine months post-operative

35
Salter-Harris Type V fxs

• Crush injury to physis
• No associated displacement
• Diagnosis made with follow-up xrays revealing
  premature physeal closure
• treatment directed primarily at sequelae of
  growth arrest

36
High Energy Injuries to Distal Tibia

• Uncommon
• Severe injury to distal tibial articular surface
  poor prognosis
• Restore articular surface if possible
• Length and alignment bridging external fixation
  can be helpful

37
High energy distal tibia fracture/subluxation in
11 year old female in MVC
38
C T scan demonstrates significantly comminuted
articular surface and anterior subluxation of
talus
39
Intraop views bridging external fixation and
ORIF with pin fixation
40
One Year Follow Up
41
12 Year Old High Velocity GSW loss of tibial
epiphysis/anterior soft tissues/tendons -
bridging ex fix-latissimus free flap ankle
fusion
42
Transitional Fractures

• fxs occurring during asymmetric closure of distal
  tibial physis
• Triplane fx
• 2,3 or 4-part fxs
• lateral more common
• Juvenile Tillaux fx

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Transitional Fractures

• Triplane fx
• tend to be seen in younger pts than pts with
  Juvenile Tillaux fx
• more displacement/swelling more severe
• Treatment decisions usually based on articular
  displacement

44
Transitional Fractures

• Triplane fx - results
• overall results are good following adequate
  reduction
• VonLaer JBJS 1985
• Clement and Warlock JBJS 1987
• good early results
• Erlt et al JBJS 1988
• decline in results over time

45
Transitional Fractures

• non-displaced Triplane fxs
• LLC, knee flexed 30?, foot IR x3wks gt SLWC
  x3-4wks
• CT after cast placement to assure no displacement
• Weekly xrays in cast for first 3 weeks to assure
  no displacement in cast
• FU xrays obtained every 6 months for 2 to 3 yrs

46
Transitional Fractures

• displaced fxs Triplane (gt2 mm)
• Anatomical reduction
• CR achieved gt LLC, 30?KF, foot IR
• CR unsuccessful gt OR
• Reduction/internal fixation done in step-wise
  fashion with small frag or 4.0 cannulated screws
• Postop - SLC x 3-4wks gt SLWC x 3wks

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Transitional Fractures

• Juvenile Tillaux fxs
• tend to be older than pts with triplane fx
• Fibula prevents marked displacement/swelling may
  be subtle
• Local tenderness at ant-lat joint line
• Mortise view essential
• Although literature based on small pt series,
  excellent results with anatomic reduction noted

48
Transitional Fractures

• non-displaced Tillaux fxs
• LLC, knee flexed 30?, foot IR x3wks gt SLWC
  x3-4wks
• CT scan after cast placement to assure no
  displacement
• Weekly radiographs in cast for first 3 weeks to
  assure no displacement in cast
• FU xrays obtained every 6 months for 2 to 3 yrs

49
Transitional Fractures

• displaced (gt2mm) Tillaux fxs
• Anatomical reduction
• CR achieved gt LLC, 30?KF, foot IR
• CR unsuccessful gt OR for CR, unsuccessful gt
  k-wires to joystick Tillaux fragment
  (percutaneously or open)
• Fixation with small frag or 4.0 cannulated screw,
  can cross physis
• Postop - SLC x3-4wks gt SLWC x3wks

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Juvenile Tilleaux Fracture-ORIF
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Other Distal Tibial Fractures

• Injury to accessory ossification centers
• Treatment SLWC 3-4 weeks
• Ogden and Lee JPO 1990
• Good results 26/27 pts with injuries involving
  the medial side
• 5/11 pts with injuries involving the lateral side
  had persistent sxs requiring excision

52
Distal Fibular Fractures

• typically SH I or II fxs (sup-inversion)
• when isolated typically minimally displaced gt
  SLWC 3-4 wks
• significant displacement occurs with SH III and
  IV distal tibial fxs, usually reduces with
  tibial reduction
• if remains unstable after tibial fixation gt fix
  with smooth intramedullary or oblique k-wires

53
Salter I Distal Fibula typical goose egg
swelling over distal fibula with tenderness over
distal fibular physis
54
Pediatric Ankle Sprains

• should be diagnosis of exclusion
• Where is tenderness over bone/physis or ankle
  ligaments?
• often represent missed Salter I ankle fractures,
  non-displaced calcaneal fractures
• follow-up persistent pain

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Prognosis - Ankle Fractures

• mechanism of injury
• distal tibial physis medial lesions
• presence of residual articular step off
• presence fibular fx no prognostic significance

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Complications - Ankle Fractures

• growth arrest
• associated with SH III and IV fxs (medial)
• few series report high rate with SH II fxs
• 6 to 18 months after injury (as late as 2 yrs
  after injury)

57
Complications - Ankle Fractures

• growth arrest
• occur in fx treated operatively and non-op
• radiographic Harris growth lines - allow for
  earlier intervention. Look for in x-rays 6-12
  weeks
• LLD tolerated well, angular deformity less well
  tolerated

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Complications - Ankle Fractures

• arthritis
• malunion
• delayed/nonunion
• AVN distal tibial epiphysis-rare

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10 Year Old - 3 Months after Distal Tibia Fracture
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CT Anterior Central Bar
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Summary - Ankle Fractures

• Heterogenous group of fractures
• Age dependent
• Important to have high index of suspicion to
  avoid missing diagnosis
• Correlate PE and xray findings
• followed until skeletally maturity
• may develop late sequelae

62
Pediatric Foot Fractures

• often missed diagnosis
• reductions of fractures important
• less remodeling potential
• reach 50 of mature length of foot bones by 18
  mo. (compared to femur/tibia - do not reach until
  3 y.o.)

63
Pediatric Foot Fractures

• types of foot injuries1
• metatarsal fractures 90
• phalangeal fractures 18
• navicular fractures 5
• talar fractures 3
• calcaneal fractures 3
• cuboid fractures 2
• 1data from Cleveland Fracture Service, A.Crawford
  (Skeletal Trauma)

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Pediatric Foot Anatomy

• hindfoot talus, calcaneus
• midfoot navicular, cuboid, 3 cuneiforms
• forefoot 5 metatarsals (distal epiphyses except
  for 1st MT - proximal epiphysis), 14 phalanges
  (proximal epiphysis)
• variable number of sesamoids/accessory ossicles
• distal 1st MT pseuodoepiphysis may occur

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Pediatric Accessory Ossicles
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Radiographs

• AP, lateral, oblique XR of foot
• AP, lateral, oblique XR of ankle as well
• co-existent unrecognized fractures of distal
  tibia/fibula occur in up to 8

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Pediatric Talus Fractures

• rare injury
• neck fractures most common with apex plantar
  angulation
• angulation lt 30 acceptable
• gt 30 angulation requires reduction under general
  anesthesia
• displaced (gt2mm)fractures require ORIF
• monitor 1 year for possible AVN (rare)

68
Hawkins 2 talar neck fx, distal fibular avulsion
fxORIF both
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Pediatric Talus Fractures

• lateral/medial process fractures
• rarely displace
• symptomatic treatment only
• non-unions rare, asymptomatic if they occur

70
Displaced talar neck /medial malleolar
fracturesAVN at follow-up
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Pediatric Talus Fractures

• osteochondral fractures
• inversion/plantar flexion injury gt posteromedial
  lesion (more common)
• eversion/dorsiflexion injury gtanterolateral
  lesion
• often requires MRI for diagnosis
• undisplaced lesion gt NWB in cast
• displaced lesion gt excision/currettage

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Ankle sprain that didnt heal-anterolateral
talar OCD
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Peritalar Dislocations in Children

• extremely rare injury (case reports only)
• represents dislocation of subtalar and
  talonavicular joint
• four types (medial - most common, lateral,
  anterior, posterior) based on direction of foot
• adults - associated with displaced talar neck fx
  versus in children - isolated dislocations more
  common

74
Peritalar Dislocations in Children

• often see associated foot fracture
• attempt closed reduction
• open reductions associated with ultimate
  decreased ROM
• associated intra-articular fracture of
  talonavicular joint adversely affects outcome
• no reported cases of associated AVN

75
Pediatric Calcaneal Fractures

• rare
• result of significant falls
• 5 associated with lumbar spine injuries
• often missed diagnosis
• XR difficult to diagnosis if non-displaced
• bone scan can confirm diagnosis

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Pediatric Calcaneal Fractures

• non-displaced injuries - elevate, NWB cast when
  soft tissue swelling subsides
• displaced injuries
• treat soft tissues first with elevation
• ORIF when soft tissues amenable

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Tarsal-metatarsal Injuries

• direct/indirect mechanisms of injury
• represent significant force
• if see fx of base of 2nd MT - implies more severe
  injury
• if see associated cuboid fx - implies dislocation
• treatment - requires anatomic reduction
• treat soft tissues first with elevation
• closed reduction/pinning vs. ORIF

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Pediatric Metatarsal Fractures

• most common childrens foot fracture
• usually result of direct trauma
• metatarsal shaft fractures most common
• lateral displacement - acceptable
• dorsal/plantar angulation not acceptable,
  requires closed reduction/pinning

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Pediatric Metatarsal Fractures

• metatarsal base fractures
• require significant force
• consider early fasciotomy if significant
  swelling/venous congestion in toes (no reported
  compartment pressures to guide, clinical judgment)

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Pediatric Metatarsal Fractures

• metatarsal neck fractures (growth plate injury)
• growth inhibition unusual, overgrowth more common
• treatment SLWC
• if significant displacement - skeletal traction
  until swelling subsides then percutaneous pinning
• avoid open reductions

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Pediatric Metatarsal Fractures

• 1st metatarsal fractures
• can see buckle fracture just distal to proximal
  physis (treatment - SLWC)
• do not confuse pseudoepiphysis at distal end with
  fracture

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Pediatric Metatarsal Fractures

• 5th metatarsal fractures
• proximal metaphyseal transverse fractures most
  common
• treatment SLWC
• distinguish from Jones fractures
• occurs in proximal diaphysis
• older children (15 - 20 y.o.)
• do not confuse os vesalianum (os peronei) with
  fracture (oblique orientation proximally)

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Pediatric Phalangeal Fractures

• 18 childrens foot fractures
• 2/3 involve proximal phalanges
• 1/3 middle phalanges
• rare distal phalages
• treatment - traction, closed reduction, buddy
  taping, hard sole shoe
• open injures require ID/IV abx coverage
• osteomyelitis can occur

84
Pediatric Phalangeal Fractures

• great toe distal phalangeal fractures
• beware of crush injuries
• may represent open fractures
• if suspect open injury, treat with ID/Abx to
  avoid complication of osteomyelitis

85
Lawnmower Injuries

• probably most common cause of open fractures in
  children
• most children are a rider or bystander (70)
• high complication rate - infection, growth
  arrest,amputation
• gt 50 unsatisfactory results (Loder)

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Lawnmower Foot Injury
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Lawnmower Injuries

• Education/ Prevention key
• Children lt 14 - shouldnt operate keep out
  of yard
• No riders other than mower operator

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