Pediatric and Adolescent Ankle Injuries-Part 2

Report
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

Ablation of the Perichondral Ring
Lawn mower injuries
 Degloving injuries
 Callus bridge forms between the epiphysis and metaphysis
 Varus deformity and failure of growth
 May be missed on initial x-rays

Articular Fractures

The Tillaux Fracture
In an adolescent within a year of complete closure
of the distal tibial physis
 Central and medial aspect of the physis has closed
 Anterolateral aspect of physis
 Open and vulnerable to avulsion injury by
external rotation force
 Bound down to fibular by anterior tibiofibular
ligament
 Fracture fragment is rectangular or pie shaped

Articular Fractures

The Triplane Fracture
Complex fracture with sagittal, transverse and
coronal components
 Crosses in part along and in part through the physis
and enters the ankle joint
 Usually external rotation force
 Type III injury in AP x-ray view
 Type II injury in lateral x-ray view
 CT scan defines the fracture configuration

Articular Fractures

The Triplane Fracture
Lateral triplane more common
 Medial triplane less common
 May have associated fibular fracture
 May have associated tibial shaft fracture
 Rare neurovascular compromise

Articular Fractures

The Triplane Fracture
Attempt closed reduction under sedation or
anesthesia
 Maximum acceptable displacement is 2mm at
articular surface
 ORIF

Anterolateral approach for lateral fracture
 Posterior medial or lateral incisions
 Interfragmentary screws or plate for fibula fracture

Malleolar Fractures

Fracture Management
 Attempt
closed reduction with analgesia or
sedation
 Majority of fractures can be treated with
casting
 ORIF if closed reduction fails
Malleolar Fractures

ORIF indications
Failed closed reduction
 Closed reduction requires forced abnormal
positioning of the foot
 Medial ankle mortise widening 1-2 mm
 Displaced fractures of articular surface
 Open fracture

Malleolar Fractures

ORIF timing
 Perform immediately before swelling on day of
injury or wait 7-10 days until swelling resolves
 Splint while awaiting swelling to resolve
 Perform immediately before swelling on day of
injury or wait 7-10 days until swelling resolves
 Splint while awaiting swelling to resolve
 Wrinkle test to determine if swelling is likely to
prevent skin closure
Malleolar Fractures

Lateral Malleolus

Ligament avulsion injury
Patients 4-10 years old
 Ligament avulsion with a fragment of cartilage of
epiphysis
 ATF and CF ligaments
 Treat with short leg cast 4-6 weeks
 Forms bone ossicle when healed
 May require excision if painful

Malleolar Fractures

Lateral Malleolus

Displaced fractures
Attempt closed reduction and casting
 ORIF
 Severe injuries
 Inadequate reduction
 K-wires, screws, 1/3 tubular plate
 Syndesmotic screw when indicated

Malleolar Fractures

Medial Malleolus
Uncommon injury
 Evaluate for Maisonneuve proximal fibula fracture
 Closed treatment if:

Undisplaced
 Distal portion medial malleolus
 Anatomical reduction by manipulation
 Obtain CT scan to prove joint surface not disrupted

Malleolar Fractures

Medial Malleolus
Displaced fractures require ORIF
 K-wires should not cross physis if possible
 2 transepiphyseal cannulated or cancellous screws
 May need transmetaphyseal screw if metaphyseal
portion of fracture is large

Malleolar Fractures

Medial Malleolus
If transepiphyseal fixation not possible use smooth
K-wires or tension band
 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

Pitfalls

Physeal fractures of the distal tibia
Premature physeal arrest
 More common if involvement of medial malleolus
 Leg length inequality
 Angular deformity of ankle
 Follow patients with x-rays at 6 months and 1 year
post-injury
 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.
Pitfalls

Physeal fractures of the distal tibia
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
 Obtain hand x-ray for bone age
 MRI or CT for the extent and location of physeal
arrest

Pitfalls

Physeal arrest of the distal tibia
Close observation with serial x-rays
 Excision of physeal bar with interposition material
 Epiphysiodesis of the remaining open tibial physis,
ipsilateral distal physis
 Epiphysiodesis of contralateral open distal tibial
physis & ipsilateral distal physis
 Corrective osteotomy

Syndesmosis Injuries

Syndesmotic disruption
Usually pronation-abduction/ external rotation
 Usually unstable
 Require intraoperative assessment of stability
 Use bone hook around fibula at syndesmosis to
apply lateral stress
 Usually require operative stabilization

Syndesmosis Injuries

Indications for syndesmotic fixation
Medial ligamentous injury, syndesmotic disruption &
talar shift without fracture of fibula-tibiofibular
diastasis
 Maisonneuve fracture
 Syndesmotic instability after fixation of fibula and
avulsion of fractures of the tubercles or medial
malleolus

Syndesmosis Injuries

Fixation techniques
1or 2 3.5-4.5 cortical screws
 Hold but do not compress syndesmosis
 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

Syndesmosis Injuries

Fixation techniques
Both cortices of the fibula and tibia are drilled,
tapped and engaged by each screw
 Keep non-weight bearing for 6-8 weeks
 Remove syndesmotic screws prior to weight bearing

Ankle Sprains



Very common injuries
Usually inversion stress to ankle
Most commonly injured
Anterior talofibular ligament
 Calcaneo-fibular ligament



Anterolateral swelling, tenderness, ecchymosis
Differentiate from Salter-Harris I & II injury of
distal fibula by location of tenderness
Ankle Sprains

Grades according to severity
Grade I ligaments in continuity
 Grade II partial tear of ligaments
 Grade III complete tear of ligaments with gross
instability-5 locations

Midsubstance rupture
 Rupture at bone attachment
 Avulsion of bone at ligament attachment

Ankle Sprains

Treatment
“Ace, Ice and Adios”
 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
 Obtain stress x-ray views

Ankle Sprains

Recurrent ankle sprains
Residual ankle loss of motion, strength and balance
sense
 Ligamentous instability
 Tarsal coalition
 Talar dome injury
 Obtain CT or MRI to better evaluate
 Treat with physical therapy, external support,
prolotherapy and surgery

Questions?

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