Ankle injuries in children

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Ankle injuries in children

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introduction

• Second in frequency
• 25-38 of physial fractures
• Males gt females 10-15 years
• Physial fractures are more common than
  ligamentous injuries in children

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Anatomy

• 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

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Closure of distal tibial physis
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Mechanism of injury classification

• Anatomic .c Salter Harris
• Mechanism of injury .c Lauge Hansen .c
• Dias Tachdjian .c

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Salter Harris anatomic classification
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Dias Tachdjiac classification
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Variations of grade 2 supination - inversion
injuries
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Severe supination inversion injury
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Stage 1 supination external rotation
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Stage 2 supination external rotation injury
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Pronation dorsiflection injury
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Axial compression - type injury
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Diagnostic Features

• Twisting injury
• Physical examination lacerations
• open .f
• ecchymosis
• swelling
• Pulse evaluation neurologic examination
• Tenderness over the bony anatomy especially over
  distal fibular physis
• Radiographic examinationAP-lateral-mortize
  views- stress x ray

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Stress radiograph
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Secondary ossification center
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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
  
  
• . Injury
• Campbell most of salter 3-4 triplane-
  tillaux . require ORIF and
  surgery is .
  recommended for 2-3 mm or .
  more of displacement

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Salter 1-2 distal fibular .f

• 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 4-6 weeks

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Salter 1 tibial .f

• 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

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Salter 2 tibial .f

• 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

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treatment

• 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

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Salter 3 distal tibial f.

• 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 gt 2 mm closed reduction
• O.R.I.F
  SCREW
• SHORT
  LEG CAST 6
• WEEKS
• Results are good ,15 premature physial closure
  

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Salter 4 distal tibial f.

• 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

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Salter 5 distal tibial f.

• Extremely rare
• Axial compression force
• Noted after physial arrest
• Compression of the germinal layer or vascular or
  both

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complications

• Premature closure of the physis the most common
  7,7
• Delayed or nonunion
• Valgus deformity secondary to malunion

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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 gt2 years physial arrest lt 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
  femalegt 11 y - malegt 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

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Varus deformity
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Valgus deformity secondary to malunion

• Inadequate reduction of pronation eversion
  external rotation injury
• Valgus tilt gt 15-20 degree will not correct by
  remodeling distal medial epiphysiodesis
  screw across the medial physis

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Valgus deformity
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Nonunion delayed union
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The Tillaux fracture

• 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 displacementgt 2mm following closed
  reduction or the fracture is seen more than 2 -3
  days following injury with gt 2mm displacement
• Fixation with 4mm screw anterolateral to
  potseromedial

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The Triplane fracture

• 6-8 10-16 y 13,5
• Supination external rotatoin
• Fibular fracture 50
• Coronal sagittal transverse

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Three parts t.f.
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Two parts t.f.
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Four parts t.f.
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Extra articular triplane f.

• Intramalleolar intraarticular f. within the
  weight bearing zone
• Intramalleolar intraarticular f.outside
  weightbearing zone
• Extraarticular fracture .
• 
  

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Treatment of triplane f.

• 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. gt 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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  department of orthopedics in Damascus hospital,
  under the supervision of Dr. Bashar Mirali.
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  exist in this lecture.

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Dr. Muayad Kadhim