Pediatric and Adolescent Ankle Injuries-Part 2 Rang’s Children’s Fractures Wenger and Pring...
-
Upload
lesley-waters -
Category
Documents
-
view
221 -
download
1
Transcript of Pediatric and Adolescent Ankle Injuries-Part 2 Rang’s Children’s Fractures Wenger and Pring...
Pediatric and Pediatric and Adolescent Ankle Adolescent Ankle
Injuries-Part 2Injuries-Part 2Rang’s Children’s FracturesRang’s Children’s Fractures
Wenger and PringWenger and Pring
20052005
Articular FracturesArticular Fractures
Salter-Harris Type VI Injuries of the Salter-Harris Type VI Injuries of the Distal TibiaDistal Tibia Ablation of the Perichondral RingAblation of the Perichondral Ring
Lawn mower injuriesLawn mower injuries Degloving injuriesDegloving injuries Callus bridge forms between the epiphysis Callus bridge forms between the epiphysis
and metaphysisand metaphysis Varus deformity and failure of growthVarus deformity and failure of growth May be missed on initial x-raysMay be missed on initial x-rays
Articular FracturesArticular Fractures The Tillaux FractureThe Tillaux Fracture
In an adolescent within a year of complete In an adolescent within a year of complete closure of the distal tibial physisclosure of the distal tibial physis
Central and medial aspect of the physis has Central and medial aspect of the physis has closedclosed
Anterolateral aspect of physis Anterolateral aspect of physis Open and vulnerable to avulsion injury by Open and vulnerable to avulsion injury by
external rotation forceexternal rotation force Bound down to fibular by anterior Bound down to fibular by anterior
tibiofibular ligamenttibiofibular ligament Fracture fragment is rectangular or pie Fracture fragment is rectangular or pie
shapedshaped
Articular FracturesArticular Fractures
The Triplane FractureThe Triplane Fracture Complex fracture with sagittal, transverse Complex fracture with sagittal, transverse
and coronal componentsand coronal components Crosses in part along and in part through Crosses in part along and in part through
the physis and enters the ankle jointthe physis and enters the ankle joint Usually external rotation forceUsually external rotation force Type III injury in AP x-ray viewType III injury in AP x-ray view Type II injury in lateral x-ray viewType II injury in lateral x-ray view CT scan defines the fracture configurationCT scan defines the fracture configuration
Articular FracturesArticular Fractures
The Triplane FractureThe Triplane Fracture Lateral triplane more commonLateral triplane more common Medial triplane less commonMedial triplane less common May have associated fibular fractureMay have associated fibular fracture May have associated tibial shaft May have associated tibial shaft
fracturefracture Rare neurovascular compromiseRare neurovascular compromise
Articular FracturesArticular Fractures
The Triplane FractureThe Triplane Fracture Attempt closed reduction under Attempt closed reduction under
sedation or anesthesiasedation or anesthesia Maximum acceptable displacement is Maximum acceptable displacement is
2mm at articular surface2mm at articular surface ORIF ORIF
Anterolateral approach for lateral fractureAnterolateral approach for lateral fracture Posterior medial or lateral incisionsPosterior medial or lateral incisions Interfragmentary screws or plate for fibula Interfragmentary screws or plate for fibula
fracturefracture
Malleolar FracturesMalleolar Fractures
Fracture ManagementFracture Management Attempt closed reduction with Attempt closed reduction with
analgesia or sedationanalgesia or sedation Majority of fractures can be Majority of fractures can be
treated with castingtreated with casting ORIF if closed reduction failsORIF if closed reduction fails
Malleolar FracturesMalleolar Fractures
ORIF indicationsORIF indications Failed closed reductionFailed closed reduction Closed reduction requires forced Closed reduction requires forced
abnormal positioning of the footabnormal positioning of the foot Medial ankle mortise widening 1-2 mmMedial ankle mortise widening 1-2 mm Displaced fractures of articular surfaceDisplaced fractures of articular surface Open fractureOpen fracture
Malleolar FracturesMalleolar Fractures ORIF timingORIF timing
Perform immediately before swelling on day Perform immediately before swelling on day of injury or wait 7-10 days until swelling of injury or wait 7-10 days until swelling resolvesresolves
Splint while awaiting swelling to resolveSplint while awaiting swelling to resolve Perform immediately before swelling on day Perform immediately before swelling on day
of injury or wait 7-10 days until swelling of injury or wait 7-10 days until swelling resolvesresolves
Splint while awaiting swelling to resolveSplint while awaiting swelling to resolve Wrinkle test to determine if swelling is likely Wrinkle test to determine if swelling is likely
to prevent skin closureto prevent skin closure
Malleolar FracturesMalleolar Fractures
Lateral MalleolusLateral Malleolus Ligament avulsion injuryLigament avulsion injury
Patients 4-10 years oldPatients 4-10 years old Ligament avulsion with a fragment of Ligament avulsion with a fragment of
cartilage of epiphysiscartilage of epiphysis ATF and CF ligamentsATF and CF ligaments Treat with short leg cast 4-6 weeksTreat with short leg cast 4-6 weeks Forms bone ossicle when healedForms bone ossicle when healed May require excision if painfulMay require excision if painful
Malleolar FracturesMalleolar Fractures
Lateral MalleolusLateral Malleolus Displaced fracturesDisplaced fractures
Attempt closed reduction and castingAttempt closed reduction and casting ORIF ORIF
Severe injuriesSevere injuries Inadequate reductionInadequate reduction K-wires, screws, 1/3 tubular plateK-wires, screws, 1/3 tubular plate Syndesmotic screw when indicatedSyndesmotic screw when indicated
Malleolar FracturesMalleolar Fractures
Medial MalleolusMedial Malleolus Uncommon injuryUncommon injury Evaluate for Maisonneuve proximal Evaluate for Maisonneuve proximal
fibula fracturefibula fracture Closed treatment if: Closed treatment if:
UndisplacedUndisplaced Distal portion medial malleolusDistal portion medial malleolus Anatomical reduction by manipulationAnatomical reduction by manipulation Obtain CT scan to prove joint surface not Obtain CT scan to prove joint surface not
disrupted disrupted
Malleolar FracturesMalleolar Fractures
Medial MalleolusMedial Malleolus Displaced fractures require ORIFDisplaced fractures require ORIF K-wires should not cross physis if K-wires should not cross physis if
possiblepossible 2 transepiphyseal cannulated or 2 transepiphyseal cannulated or
cancellous screwscancellous screws May need transmetaphyseal screw if May need transmetaphyseal screw if
metaphyseal portion of fracture is large metaphyseal portion of fracture is large
Malleolar FracturesMalleolar Fractures
Medial MalleolusMedial Malleolus If transepiphyseal fixation not possible If transepiphyseal fixation not possible
use smooth K-wires or tension banduse smooth K-wires or tension band Reduction may be hindered by trapped Reduction may be hindered by trapped
loose fragments loose fragments In skeletally mature patients may be In skeletally mature patients may be
stabilized by 2 transepiphyseal stabilized by 2 transepiphyseal cannulated or cancellous screws cannulated or cancellous screws perpendicular to the fracture similar to perpendicular to the fracture similar to adultsadults
PitfallsPitfalls
Physeal fractures of the distal tibiaPhyseal fractures of the distal tibia Premature physeal arrestPremature physeal arrest More common if involvement of medial More common if involvement of medial
malleolusmalleolus Leg length inequalityLeg length inequality Angular deformity of ankleAngular deformity of ankle Follow patients with x-rays at 6 months Follow patients with x-rays at 6 months
and 1 year post-injuryand 1 year post-injury Compare to x-rays of uninvolved ankleCompare to x-rays of uninvolved ankle
Henry HarrisHenry HarrisWelsh AnatomistWelsh Anatomist
Harris growth arrest lines are dense Harris growth arrest lines are dense trabecular transversely oriented trabecular transversely oriented lines with the metaphysis, commonly lines with the metaphysis, commonly seen in children of all ages. These seen in children of all ages. These lines, also called recovery lines, lines, also called recovery lines, follow a period of illness or follow a period of illness or immobilization. These lines relate to immobilization. These lines relate to a temporary slowdown of a a temporary slowdown of a longitudinal growth. longitudinal growth.
PitfallsPitfalls
Physeal fractures of the distal tibiaPhyseal fractures of the distal tibia Asymmetry of Harris growth line of is an Asymmetry of Harris growth line of is an
indicator of early premature physeal closureindicator of early premature physeal closure A Harris growth arrest line pertains to A Harris growth arrest line pertains to
children/teens in whom the bone lines show children/teens in whom the bone lines show retarded growth, usually due to trauma to a retarded growth, usually due to trauma to a bonebone
Obtain hand x-ray for bone ageObtain hand x-ray for bone age MRI or CT for the extent and location of MRI or CT for the extent and location of
physeal arrestphyseal arrest
PitfallsPitfalls
Physeal arrest of the distal tibiaPhyseal arrest of the distal tibia Close observation with serial x-raysClose observation with serial x-rays Excision of physeal bar with interposition Excision of physeal bar with interposition
materialmaterial Epiphysiodesis of the remaining open Epiphysiodesis of the remaining open
tibial physis, ipsilateral distal physistibial physis, ipsilateral distal physis Epiphysiodesis of contralateral open Epiphysiodesis of contralateral open
distal tibial physis & ipsilateral distal distal tibial physis & ipsilateral distal physisphysis
Corrective osteotomy Corrective osteotomy
Syndesmosis InjuriesSyndesmosis Injuries
Syndesmotic disruptionSyndesmotic disruption Usually pronation-abduction/ external Usually pronation-abduction/ external
rotationrotation Usually unstableUsually unstable Require intraoperative assessment of Require intraoperative assessment of
stabilitystability Use bone hook around fibula at Use bone hook around fibula at
syndesmosis to apply lateral stresssyndesmosis to apply lateral stress Usually require operative stabilizationUsually require operative stabilization
Syndesmosis InjuriesSyndesmosis Injuries
Indications for syndesmotic fixationIndications for syndesmotic fixation Medial ligamentous injury, syndesmotic Medial ligamentous injury, syndesmotic
disruption & talar shift without fracture disruption & talar shift without fracture of fibula-tibiofibular diastasisof fibula-tibiofibular diastasis
Maisonneuve fractureMaisonneuve fracture Syndesmotic instability after fixation of Syndesmotic instability after fixation of
fibula and avulsion of fractures of the fibula and avulsion of fractures of the tubercles or medial malleolustubercles or medial malleolus
Syndesmosis InjuriesSyndesmosis Injuries
Fixation techniquesFixation techniques 1or 2 3.5-4.5 cortical screws1or 2 3.5-4.5 cortical screws Hold but do not compress syndesmosisHold but do not compress syndesmosis Insert screws just above the level of the Insert screws just above the level of the
tibiofibular ligamentstibiofibular ligaments Place ankle in dorsiflexion to bring Place ankle in dorsiflexion to bring
widest portion of the talus in the widest portion of the talus in the mortise when you tighten screwsmortise when you tighten screws
Syndesmosis InjuriesSyndesmosis Injuries
Fixation techniquesFixation techniques Both cortices of the fibula and tibia are Both cortices of the fibula and tibia are
drilled, tapped and engaged by each drilled, tapped and engaged by each screwscrew
Keep non-weight bearing for 6-8 weeksKeep non-weight bearing for 6-8 weeks Remove syndesmotic screws prior to Remove syndesmotic screws prior to
weight bearingweight bearing
Ankle SprainsAnkle Sprains
Very common injuriesVery common injuries Usually inversion stress to ankleUsually inversion stress to ankle Most commonly injuredMost commonly injured
Anterior talofibular ligamentAnterior talofibular ligament Calcaneo-fibular ligamentCalcaneo-fibular ligament
Anterolateral swelling, tenderness, Anterolateral swelling, tenderness, ecchymosisecchymosis
Differentiate from Salter-Harris I & II Differentiate from Salter-Harris I & II injury of distal fibula by location of injury of distal fibula by location of tendernesstenderness
Ankle SprainsAnkle Sprains
Grades according to severityGrades according to severity Grade IGrade I ligaments in continuity ligaments in continuity Grade IIGrade II partial tear of ligaments partial tear of ligaments Grade IIIGrade III complete tear of ligaments complete tear of ligaments
with gross instability-5 locationswith gross instability-5 locations Midsubstance ruptureMidsubstance rupture Rupture at bone attachmentRupture at bone attachment Avulsion of bone at ligament attachmentAvulsion of bone at ligament attachment
Ankle SprainsAnkle Sprains
Treatment Treatment ““Ace, Ice and Adios”Ace, Ice and Adios” Elastic support, ankle brace, posterior Elastic support, ankle brace, posterior
mold, short leg castmold, short leg cast Grade I-II sprainGrade I-II sprain allow weight bearing allow weight bearing
as tolerated with or without crutches as tolerated with or without crutches depending on immobilizationdepending on immobilization
Obtain stress x-ray viewsObtain stress x-ray views
Ankle SprainsAnkle Sprains
Recurrent ankle sprainsRecurrent ankle sprains Residual ankle loss of motion, strength Residual ankle loss of motion, strength
and balance senseand balance sense Ligamentous instabilityLigamentous instability Tarsal coalitionTarsal coalition Talar dome injuryTalar dome injury Obtain CT or MRI to better evaluateObtain CT or MRI to better evaluate Treat with physical therapy, external Treat with physical therapy, external
support, prolotherapy and surgerysupport, prolotherapy and surgery
Questions?Questions?