Pediatric Ankle Fractures

When to Cast, When to Cut,

When to Treat Like an Adult

John Deegan, DO

No Disclosures

Children’s Healthcare of Atlanta

Background

• 2nd MC physeal injury in kids (long bone)

– 10-25% of all Physeal Injuries Occur About the Ankle

Background

Goals of Treatment:

• Stable reduction

• Anatomic articular surface (SH III/IV)

• Symmetric mortise

• Preserve physeal growth (+/-)

Background

• Classification

– Salter Harris

– Lauge-Hansen (Dias-Tachdjian)

• Subtypes

– Transitional fractures

Classification

• Salter-Harris

– Helpful, prognostic

Copyright Cleveland Clinic

Foundation, 2011, Cleveland, OH.)

Classification

• Lauge Hansen

Foundation, 2011, Cleveland, OH

Classification

• Lauge Hansen

Foundation, 2011, Cleveland, OH

• And the Dias Modification of the Lauge Hansen

Common Subtype - Transitional Fractures

• Occur near skeletal maturity due to asymmetric closure of the physis

– CML

Anthony Riccio TSRH

• Occur near skeletal maturity due to asymmetric closure of the physis

– CML

Common Subtype - Transitional Fractures

Anthony Riccio TSRH

Transitional Fractures

• Triplane

– Complex SH IV

– SER type mechanism• Medial triplane is 2/2 adduction

– Occur ~13 yo (10-17)

• Tillaux

– SH III distal tibia (AITFL)

– ER twisting force

– Slightly older

• Triplane fractures

• Tillaux fractures

Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.

Don’t get fooled

Normal anatomic variants

Kump’s Bump

Fracture

Post-op

• Harris lines parallel to physis = symmetric growth

Goals of Treatment

• Stable reduction

• Anatomic articular surface (SH III/IV)

• Symmetric mortise

• (+/-) Preserve physeal growth

• REMOVE PERIOSTEUM

– Gap >3 mm in SH I/II → growth arrest → ORIF

Barmada A, et al.

Children’s Healthcare of Atlanta 21

Anatomic Reduction – get the

periosteum out

• Barmada et al23

Anatomic Reduction – get the

periosteum out

Articular/Physeal Ankle Fractures

• Should I get advanced imaging?

– 25 triplane fractures • XR alone vs CT

• Changed definition of the fracture pattern in 46% of cases, degree of displacement in 39%, treatment plan in 27%, and either the number or orientation of screws in 41% of cases after

Treatment - Triplanes

Treatment - Triplane Fractures

• Non-displaced Triplane fxs

• Less than 2 mm displacement on all views

– LLC, knee flexed 30, foot IR x3wks → SLWC x3-4wks

– CT after cast placement to assure no displacement• (Weekly xrays in cast for first 3 weeks to assure no displacement in

– FU xrays obtained every 6 months for 2 to 3 yrs

• Closed reduction

– Knee flexion, ankle PF and IR• Or ER for AM fragment

– Check reduction with CT

• Residual displacement after attempted CR→ ORIF

• Ertl (JBJS 1988)

– No successful closed reductions if displaced > 3mm at presentation

– This has not been verified with follow-up studies

– Many recommend attempted reduction despite amt. of initial displacement

• SH III Component Reduction

– Mobilize Fragment

– Reduce Articular Surface Anatomically

– Reduction Clamps or Dental Pick to Hold Reduction

• SH II Component Reduction

– Usually Amenable to Manipulative Reduction

– Posterolateral Approach and Clamp Reduction if fail Closed

– 3.5 mm or 4.0 mm Partially Threaded Cannulated Screw +/- Washer

– Direction of Screw Based on fx orientation (CT) - Percutaneous Incision

– Do Not Cross Physis in Younger Children • OK in slightly older kids

Stepwise fixation

Treatment - Tillaux Fractures

• Slightly older

• Less obvious

– Fibula prevents marked displacement and/or swelling

• Mortise view critical

• Non-displaced

– <3 mm displacement

– LLC, knee flexed 30, foot IR x3wks → 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

• Closed Reduction

– Internal rotation (think about the mechanism)

– LLC → same protocol

– CT scan to assess reduction

• ORIF

– displaced (>2mm) after reduction attempt

Lemburg et al Arch Orthop Trauma Surg 2010

Tillaux Fracture: ORIF

• Anterior Approach

Tillaux Fracture: ORIF

• Anterior Approach

• Reduction– Mobilize Fragment

– Reduce Articular Surface Anatomically

– Reduction Clamps or Dental Pick to Hold Reduction

• Fixation – 3.5 mm or 4.0 mm Partially Threaded Cannulated Screw +/-

Washer

– Screw Trajectory Lateral to Medial - Separate Perc Incision

– OK to cross the physis

• Surgical Post-op

– Postop - SLC x3-4wks → SLWC x 3 wks

• 60% of patients were treated with closed reduction percutaneous fixation, 33% with closed reduction and 5% with ORIF

• Residual articular displacement <2.5 mm, measured on follow-up x-rays or CT

– Functional outcomes comparable to anatomic reduction

– No decline in function was found with longer-term follow-up (4 to 10 y) for residual displacement <2.5 mm

Treatment - Distal Fibula/Lateral Mal

• Treatment less well defined

• Isolated fractures stable

• Sprain vs SHI distal fibula

– Clinical exam

– Normal XR

– Lateral ankle tenderness

• Xrays – Look for soft tissue swelling over the physis– Late findings- widening of physis

(healing)

Treatment - SH I Fibula

• Sankar et al (JPO 2008)– 37 Children

– All with Open Physes, Lateral Ankle Tenderness + Normal Films

– 18%: Periosteal Bone Formation at 3 Weeks

• Boutis et al (JAMA Pediatr 2016)– 140 Children with Ankle Injuries - Prospectively Enrolled

– All With Normal Films

– 135 Underwent Ankle MRI

– 3%: Salter Harris I Distal Fibula Fractures

– 80%: Isolated Ligamentous Injuries

– All did well with removable ankle brace

Treatment - SH I Fibula

Non-displaced Distal Fibula Fractures

• Boutis et al (Pediatrics 2007):

– Randomized Single Blind Study

– Short Leg Walking Cast versus Removable Brace

– Brace Group:• Quicker Return to Baseline Activities

• More Cost Effective

Displaced SH I and II Distal Fibula

• Rarely seen in isolation

– Treatment determined by tibia fracture and mortise symmetry

• Closed reduction

– Acceptable:• NWB SLC ~ 6 weeks

– Unacceptable:• Open reduction

– Perc Pinning if >2 years remaining

– Internal fixation <2 years remaining

Treatment – Medial Epiphysis

(Medial mal) fractures

• Commonly a supination-inversion mechanism

• Common in younger kids too

– Respect the physis

• Salter Harris III & IV

• Risk for Nonunion Due to Intra-articular Nature of Fracture

• Risk for Delayed Union and Late Displacement

• Abbott et al (POSNA 2015)– 42 Pediatric Medial Malleolus Fractures with > 3 Months Follow-Up

– 52% Developed a Physeal Bar

– SH Classification and Amount of Displacement not Predictive of Bar

– Adequacy of Reduction = Only Predictive Factor of Bar Formation

KEY = Low Threshold to TX Operatively and Careful F/U for Physeal Arrest

• Nondisplaced:

– Short Leg Cast

– Non-Weightbearing

– Close Follow-Up

• Prone to late displacement

• Displaced:

– Open Reduction

– Anatomic Restoration of Physis and Joint Line

– Screw, K-Wire or Hybrid Fixation

– Avoid Screws Across Open Physis Unless Absolutely Necessary

Medial mal fractures

Medial Mal Fractures

• Surgical Post-op

– Postop - SLC x3-4wks => SLWC x3wk

Summary

• Pediatric Ankle Fractures cover a wide spectrum of injuries

• Non-operative management is still a mainstay for many

• Know when to respect the physis

• Always respect the articular surface

– <2 mm important

• Follow injuries through maturity (esp medial mal)

References

• Peterson CA, Peterson HA (1972) Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma 12: 275-281.

• Spiegel PG, Cooperman DR, Laros GS (1978) Epiphyseal fractures of the distal ends of the tibia and bula. A retrospective study of two hundred and thirty-seven cases in children. J Bone Joint Surg Am 60: 1046-1050.

• Dias LS, Tachdjian MO (1978) Physeal injuries of the ankle in children: classi cation. Clin Orthop Relat Res 136: 230-233.

• Goldberg VM, Aadalen R (1978) Distal tibial epiphyseal injuries: the role of athletics in 53 cases. Am J Sports Med 6: 263-268.

• Rohmiller MT, Gaynor TP, Pawelek J, Mubarak SJ (2006) Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure? J Pediatr Orthop 26: 322-328.

• Aslam N, Gwilym S, Apostolou C, Birch N, Natarajan R, et al. (2004) Microscooter injuries in the paediatricpopulation. Eur J Emerg Med 11: 148- 150.

• Ebbeling CB, Pawlak DB, Ludwig DS (2002) Childhood obesity: Public-health crisis, common sense cure. Lancet 360: 473-482.

• McHugh MP (2010) Oversized young athletes: a weighty concern. Br J Sports Med 44: 45-49.

• Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, et al. (2006) Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295: 1549-1555.

• Tyler TF, McHugh MP, Mirabella MR, Mullaney MJ, Nicholas SJ (2005) Risk factors for noncontact ankle sprains in

high school football players: the role of previous ankle sprains and body mass index. Am J Sports Med 34: 471-475.

• Zonfrillo MR, Seiden JA, House EM, Shapiro ED, Dubrow R, et al. (2008) The association of overweight and ankle injuries in children. Ambul Pediatr 8: 66-69.

• Kay RM, Matthys GA (2001) Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg 9: 268-278.

• Ogden JA, Lee J (1990) Accessory ossi cation patterns and injuries of the malleoli. J Pediatr Orthop 10: 306-316

Thank You

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