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

Articular Fractures Salter-Harris Type VI Injuries of the Distal Tibia Salter-Harris Type VI Injuries of the Distal Tibia Ablation of the Perichondral Ring Ablation of the Perichondral Ring Lawn mower injuries Lawn mower injuries Degloving injuries Degloving injuries Callus bridge forms between the epiphysis and metaphysis Callus bridge forms between the epiphysis and metaphysis Varus deformity and failure of growth Varus deformity and failure of growth May be missed on initial x-rays May be missed on initial x-rays

Articular Fractures The Tillaux Fracture The Tillaux Fracture In an adolescent within a year of complete closure of the distal tibial physis In an adolescent within a year of complete closure of the distal tibial physis Central and medial aspect of the physis has closed Central and medial aspect of the physis has closed Anterolateral aspect of physis Anterolateral aspect of physis Open and vulnerable to avulsion injury by external rotation force Open and vulnerable to avulsion injury by external rotation force Bound down to fibular by anterior tibiofibular ligament Bound down to fibular by anterior tibiofibular ligament Fracture fragment is rectangular or pie shaped Fracture fragment is rectangular or pie shaped

Articular Fractures The Triplane Fracture The Triplane Fracture Complex fracture with sagittal, transverse and coronal components Complex fracture with sagittal, transverse and coronal components Crosses in part along and in part through the physis and enters the ankle joint Crosses in part along and in part through the physis and enters the ankle joint Usually external rotation force Usually external rotation force Type III injury in AP x-ray view Type III injury in AP x-ray view Type II injury in lateral x-ray view Type II injury in lateral x-ray view CT scan defines the fracture configuration CT scan defines the fracture configuration

Articular Fractures The Triplane Fracture The Triplane Fracture Lateral triplane more common Lateral triplane more common Medial triplane less common Medial triplane less common May have associated fibular fracture May have associated fibular fracture May have associated tibial shaft fracture May have associated tibial shaft fracture Rare neurovascular compromise Rare neurovascular compromise

Articular Fractures The Triplane Fracture The Triplane Fracture Attempt closed reduction under sedation or anesthesia Attempt closed reduction under sedation or anesthesia Maximum acceptable displacement is 2mm at articular surface Maximum acceptable displacement is 2mm at articular surface ORIF ORIF Anterolateral approach for lateral fracture Anterolateral approach for lateral fracture Posterior medial or lateral incisions Posterior medial or lateral incisions Interfragmentary screws or plate for fibula fracture Interfragmentary screws or plate for fibula fracture

Malleolar Fractures Fracture Management Fracture Management Attempt closed reduction with analgesia or sedation Attempt closed reduction with analgesia or sedation Majority of fractures can be treated with casting Majority of fractures can be treated with casting ORIF if closed reduction fails ORIF if closed reduction fails

Malleolar Fractures ORIF indications ORIF indications Failed closed reduction Failed closed reduction Closed reduction requires forced abnormal positioning of the foot Closed reduction requires forced abnormal positioning of the foot Medial ankle mortise widening 1-2 mm Medial ankle mortise widening 1-2 mm Displaced fractures of articular surface Displaced fractures of articular surface Open fracture Open fracture

Malleolar Fractures ORIF timing ORIF timing Perform immediately before swelling on day of injury or wait 7-10 days until swelling resolves Perform immediately before swelling on day of injury or wait 7-10 days until swelling resolves Splint while awaiting swelling to resolve Splint while awaiting swelling to resolve Perform immediately before swelling on day of injury or wait 7-10 days until swelling resolves Perform immediately before swelling on day of injury or wait 7-10 days until swelling resolves Splint while awaiting swelling to resolve Splint while awaiting swelling to resolve Wrinkle test to determine if swelling is likely to prevent skin closure Wrinkle test to determine if swelling is likely to prevent skin closure

Malleolar Fractures Lateral Malleolus Lateral Malleolus Ligament avulsion injury Ligament avulsion injury Patients 4-10 years old Patients 4-10 years old Ligament avulsion with a fragment of cartilage of epiphysis Ligament avulsion with a fragment of cartilage of epiphysis ATF and CF ligaments ATF and CF ligaments Treat with short leg cast 4-6 weeks Treat with short leg cast 4-6 weeks Forms bone ossicle when healed Forms bone ossicle when healed May require excision if painful May require excision if painful

Malleolar Fractures Lateral Malleolus Lateral Malleolus Displaced fractures Displaced fractures Attempt closed reduction and casting Attempt closed reduction and casting ORIF ORIF Severe injuries Severe injuries Inadequate reduction Inadequate reduction K-wires, screws, 1/3 tubular plate K-wires, screws, 1/3 tubular plate Syndesmotic screw when indicated Syndesmotic screw when indicated

Malleolar Fractures Medial Malleolus Medial Malleolus Uncommon injury Uncommon injury Evaluate for Maisonneuve proximal fibula fracture Evaluate for Maisonneuve proximal fibula fracture Closed treatment if: Closed treatment if: Undisplaced Undisplaced Distal portion medial malleolus Distal portion medial malleolus Anatomical reduction by manipulation Anatomical reduction by manipulation Obtain CT scan to prove joint surface not disrupted Obtain CT scan to prove joint surface not disrupted

Malleolar Fractures Medial Malleolus Medial Malleolus Displaced fractures require ORIF Displaced fractures require ORIF K-wires should not cross physis if possible K-wires should not cross physis if possible 2 transepiphyseal cannulated or cancellous screws 2 transepiphyseal cannulated or cancellous screws May need transmetaphyseal screw if metaphyseal portion of fracture is large May need transmetaphyseal screw if metaphyseal portion of fracture is large

Malleolar Fractures Medial Malleolus Medial Malleolus If transepiphyseal fixation not possible use smooth K-wires or tension band If transepiphyseal fixation not possible use smooth K-wires or tension band Reduction may be hindered by trapped loose fragments Reduction may be hindered by trapped loose fragments In skeletally mature patients may be stabilized by 2 transepiphyseal cannulated or cancellous screws perpendicular to the fracture similar to adults In skeletally mature patients may be stabilized by 2 transepiphyseal cannulated or cancellous screws perpendicular to the fracture similar to adults

Pitfalls Physeal fractures of the distal tibia Physeal fractures of the distal tibia Premature physeal arrest Premature physeal arrest More common if involvement of medial malleolus More common if involvement of medial malleolus Leg length inequality Leg length inequality Angular deformity of ankle Angular deformity of ankle Follow patients with x-rays at 6 months and 1 year post-injury Follow patients with x-rays at 6 months and 1 year post-injury Compare to x-rays of uninvolved ankle Compare to x-rays of uninvolved ankle

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

Pitfalls Physeal fractures of the distal tibia Physeal fractures of the distal tibia Asymmetry of Harris growth line of is an indicator of early premature physeal closure Asymmetry of Harris growth line of is an indicator of early premature physeal closure A Harris growth arrest line pertains to children/teens in whom the bone lines show retarded growth, usually due to trauma to a bone A Harris growth arrest line pertains to children/teens in whom the bone lines show retarded growth, usually due to trauma to a bone Obtain hand x-ray for bone age Obtain hand x-ray for bone age MRI or CT for the extent and location of physeal arrest MRI or CT for the extent and location of physeal arrest

Pitfalls Physeal arrest of the distal tibia Physeal arrest of the distal tibia Close observation with serial x-rays Close observation with serial x-rays Excision of physeal bar with interposition material Excision of physeal bar with interposition material Epiphysiodesis of the remaining open tibial physis, ipsilateral distal physis Epiphysiodesis of the remaining open tibial physis, ipsilateral distal physis Epiphysiodesis of contralateral open distal tibial physis & ipsilateral distal physis Epiphysiodesis of contralateral open distal tibial physis & ipsilateral distal physis Corrective osteotomy Corrective osteotomy

Syndesmosis Injuries Syndesmotic disruption Syndesmotic disruption Usually pronation-abduction/ external rotation Usually pronation-abduction/ external rotation Usually unstable Usually unstable Require intraoperative assessment of stability Require intraoperative assessment of stability Use bone hook around fibula at syndesmosis to apply lateral stress Use bone hook around fibula at syndesmosis to apply lateral stress Usually require operative stabilization Usually require operative stabilization

Syndesmosis Injuries Indications for syndesmotic fixation Indications for syndesmotic fixation Medial ligamentous injury, syndesmotic disruption & talar shift without fracture of fibula-tibiofibular diastasis Medial ligamentous injury, syndesmotic disruption & talar shift without fracture of fibula-tibiofibular diastasis Maisonneuve fracture Maisonneuve fracture Syndesmotic instability after fixation of fibula and avulsion of fractures of the tubercles or medial malleolus Syndesmotic instability after fixation of fibula and avulsion of fractures of the tubercles or medial malleolus

Syndesmosis Injuries Fixation techniques Fixation techniques 1or cortical screws 1or cortical screws Hold but do not compress syndesmosis Hold but do not compress syndesmosis Insert screws just above the level of the tibiofibular ligaments Insert screws just above the level of the tibiofibular ligaments Place ankle in dorsiflexion to bring widest portion of the talus in the mortise when you tighten screws Place ankle in dorsiflexion to bring widest portion of the talus in the mortise when you tighten screws

Syndesmosis Injuries Fixation techniques Fixation techniques Both cortices of the fibula and tibia are drilled, tapped and engaged by each screw Both cortices of the fibula and tibia are drilled, tapped and engaged by each screw Keep non-weight bearing for 6-8 weeks Keep non-weight bearing for 6-8 weeks Remove syndesmotic screws prior to weight bearing Remove syndesmotic screws prior to weight bearing

Ankle Sprains Very common injuries Very common injuries Usually inversion stress to ankle Usually inversion stress to ankle Most commonly injured Most commonly injured Anterior talofibular ligament Anterior talofibular ligament Calcaneo-fibular ligament Calcaneo-fibular ligament Anterolateral swelling, tenderness, ecchymosis Anterolateral swelling, tenderness, ecchymosis Differentiate from Salter-Harris I & II injury of distal fibula by location of tenderness Differentiate from Salter-Harris I & II injury of distal fibula by location of tenderness

Ankle Sprains Grades according to severity Grades according to severity Grade I  ligaments in continuity Grade I  ligaments in continuity Grade II  partial tear of ligaments Grade II  partial tear of ligaments Grade III  complete tear of ligaments with gross instability-5 locations Grade III  complete tear of ligaments with gross instability-5 locations Midsubstance rupture Midsubstance rupture Rupture at bone attachment Rupture at bone attachment Avulsion of bone at ligament attachment Avulsion of bone at ligament attachment

Ankle Sprains Treatment Treatment “Ace, Ice and Adios” “Ace, Ice and Adios” Elastic support, ankle brace, posterior mold, short leg cast Elastic support, ankle brace, posterior mold, short leg cast Grade I-II sprain  allow weight bearing as tolerated with or without crutches depending on immobilization Grade I-II sprain  allow weight bearing as tolerated with or without crutches depending on immobilization Obtain stress x-ray views Obtain stress x-ray views

Ankle Sprains Recurrent ankle sprains Recurrent ankle sprains Residual ankle loss of motion, strength and balance sense Residual ankle loss of motion, strength and balance sense Ligamentous instability Ligamentous instability Tarsal coalition Tarsal coalition Talar dome injury Talar dome injury Obtain CT or MRI to better evaluate Obtain CT or MRI to better evaluate Treat with physical therapy, external support, prolotherapy and surgery Treat with physical therapy, external support, prolotherapy and surgery

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