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Pediatric Ankle & Foot Fractures

Pediatric Ankle & Foot Fractures. Steven Frick, MD Original Authors: Laura Phieffer, MD and Steven Frick, MD; March 2004 New Author: Steven Frick, MD; Revised August 2006. Pediatric Ankle Fractures. 2nd most common site of physeal fractures in children Most occur between ages 10 - 15 y.o.

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Pediatric Ankle & Foot Fractures

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  1. Pediatric Ankle & Foot Fractures Steven Frick, MD Original Authors: Laura Phieffer, MD and Steven Frick, MD; March 2004 New Author: Steven Frick, MD; Revised August 2006

  2. Pediatric Ankle Fractures • 2nd most common site of physeal fractures in children • Most occur between ages 10 - 15 y.o. • boys > girls • direct and indirect mechanisms

  3. Ankle Anatomy • all ligamentous structures attach distal to the physis • ligaments are stronger than physis • physeal injury more common

  4. Ankle Anatomy • distal tibial ossification center appears between 6 - 24 months • distal fibular ossification center appears between 9 - 24 months • medial malleolar extension begins ~ 7 y.o. completes ~ 10 y.o.

  5. Physeal Closure • distal tibial physis closes ~15 y.o. girls ~17 y.o. boys • asymmetric closure over ~18 months • closure distal fibular physis follows distal tibial physeal closure by ~12-24 months

  6. Distal Tibial Physeal Closure

  7. Age / Fracture Pattern • Spiegel et al JBJS 1978

  8. Classification - Ankle Fractures • Anatomic: Salter-Harris • high interobserver correlation • correlated with outcomes

  9. Classification - Ankle Fractures • Mechanism of injury: Dias and Tachdjian

  10. Diagnosis - Ankle Fractures • direct/indirect mechanisms • acute/subacute • subtle exam findings • Differentiate sprain from nondisplaced fracture by location of tenderness

  11. Diagnosis - Ankle Fractures • Radiographs - AP, LAT, Mortise • know normal anatomic variants • Stress radiographs • CT scan – to assess articular involvement • MRI – role not yet well defined in acute injuries

  12. Accessory Ossification Centers – Smooth Borders

  13. Treatment Considerations • Location of fracture • Mechanism of injury • Degree of displacement • Age of child (how much growth remains)

  14. Salter-Harris Type I fxs • Typically occurs in younger pts • seen with all mechanisms (SI, SPF, SER, PEER) • Often missed initially (dx “sprain”) • Xrays – acute – often normal except for soft tissue swelling over physis • Xrays- subacute - reveal widening of physis- healing

  15. Salter-Harris Type II fxs • most common distal tibia fx type • seen with all mechanisms (SI, SPF, SER, PEER) • mechanism deduced by direction of dist tibial epiphysis, type assoc fib fx, location of metaphyseal spike

  16. Salter II Distal Tibia Fracture

  17. Salter-Harris Type I & II fxs • non-displaced fxs • LLC x 3-4 wks => SLWC x 3wks (SH I fxs can be treated with SLWC x 3-4wks) • displaced fxs • Avoid repeated attempts at CR • LLC x 3wks => SLC x 3wks => SLWC • Open reduction infrequently indicated • Follow for growth arrest

  18. Healed Distal Tibial Physeal Fracture -2 things make physes wider - healing fractures and rickets

  19. Salter-Harris Type I & II fxs • If CR is incomplete, how much residual displacement is acceptable? • Caruthers and Crenshaw AJS 1955 • “accurate reposition of the displaced epiphysis at the expense of forced or repeated manipulation or operative intervention is not indicated”

  20. Salter-Harris Type I & II fxs • If CR is incomplete, how much residual displacement is acceptable? • Spiegel et al JBJS 1978 • correlated SH classification with risk of shortening, angular deformity and joint incongruity • recommend “precise anatomical reduction”

  21. Salter-Harris Type I & II fxs • Differing opinions regarding indication for open reduction for interposition of periosteum => widening with minimal angulation • Kling et al 1984 • Phieffer, Wattenbarger et al 2000- animal model • Mubarak et al 2005 believe interposed periosteum leads to growth disturbance

  22. Closed reduction with incomplete reduction because of interposed soft tissues – removed at ORIF

  23. Salter-Harris Type I & II fxs • displaced subacute (>7-10 days out) fxs • Residual displacement probably best accepted • If growth does not sufficiently correct malunion, corrective osteotomy performed

  24. Salter-Harris Type III & IV fxs • Mechanism of injury similar for both fx patterns (typically supination-inversion) • Usually produced by medial corner of talus being driven into the junction of distal tibial articular surface and the medial malleolus • Can see central and lateral fx patterns

  25. Kling et.al., JBJS ‘84 • 33 fractures of the distal tibial physis • Most SH types III and IV • 19 tx with ORIF • 9 treated with closed methods • 0 bone bridges in ORIF group • 5 of 9 closed tx formed physeal bars • Recommended anatomic reduction of physis

  26. Salter-Harris Type III & IV fxs • Treatment and prognosis are similar • Medial pattern appears to be at higher risk for developing partial growth arrest => varus deformity • Spiegel et al JBJS 1978 • Kling et al JBJS 1984 • Caterini et al Foot & Ankle 1991

  27. Salter-Harris Type III & IV fxs • non-displaced fxs (<1 mm) • LLC x 3-4 wks => SLWC x 3wks • CT after cast placement to assess displacement • Weekly xrays in cast for first 3 weeks to assure no displacement • Percutaneous fixation also option • Follow for growth arrest

  28. Salter III Injury- CRIF

  29. Salter-Harris Type III & IV fxs • displaced fxs (>2 mm) • Anatomical reduction • CR under GA if continued > 2 mm displacement => open reduction • Open reduction, epiphyseal fixation parallel to growth plate if much growth remaining • Postop LLC x 3-4 wks => SLWC x 3wks

  30. Salter IV Distal Tibia Fracture Fixation avoids physis

  31. Salter-Harris Type III & IV fxs • subacute displaced fxs • Accept up to 2 mm displacement • >2mm displacement => recommend reduction regardless of time from injury with debridement and interposition graft if necessary (goal to restore joint congruity)

  32. Delayed diagnosis Salter IV medial malleolus fracture in 6 yo multitrauma patient • initial radiographs 15 days out from injury

  33. Anterior Approach • ORIF 16 days after injury

  34. Note growth slowdown line parallels physis and increased distance between markers – normal growth • nine months post-operative

  35. Salter-Harris Type V fxs • Crush injury to physis • No associated displacement • Diagnosis made with follow-up xrays revealing premature physeal closure • treatment directed primarily at sequelae of growth arrest

  36. High Energy Injuries to Distal Tibia • Uncommon • Severe injury to distal tibial articular surface – poor prognosis • Restore articular surface if possible • Length and alignment – bridging external fixation can be helpful

  37. High energy distal tibia fracture/subluxation in 11 year old female in MVC

  38. C T scan demonstrates significantly comminuted articular surface and anterior subluxation of talus

  39. Intraop views – bridging external fixation and ORIF with pin fixation

  40. One Year Follow Up

  41. 12 Year Old – High Velocity GSW – loss of tibial epiphysis/anterior soft tissues/tendons - bridging ex fix-latissimus free flap – ankle fusion

  42. “Transitional” Fractures • fxs occurring during asymmetric closure of distal tibial physis • Triplane fx • 2,3 or 4-part fxs • lateral more common • Juvenile Tillaux fx

  43. “Transitional” Fractures • Triplane fx • tend to be seen in younger pts than pts with Juvenile Tillaux fx • more displacement/swelling more severe • Treatment decisions usually based on articular displacement

  44. “Transitional” Fractures • Triplane fx - results • overall results are good following adequate reduction • VonLaer JBJS 1985 • Clement and Warlock JBJS 1987 • good early results • Erlt et al JBJS 1988 • decline in results over time

  45. “Transitional” Fractures • non-displaced Triplane fxs • 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 cast • FU xrays obtained every 6 months for 2 to 3 yrs

  46. “Transitional” Fractures • displaced fxs Triplane (>2 mm) • Anatomical reduction • CR achieved => LLC, 30KF, foot IR • CR unsuccessful => OR • Reduction/internal fixation done in step-wise fashion with small frag or 4.0 cannulated screws • Postop - SLC x 3-4wks => SLWC x 3wks

  47. “Transitional” Fractures • Juvenile Tillaux fxs • tend to be older than pts with triplane fx • Fibula prevents marked displacement/swelling may be subtle • Local tenderness at ant-lat joint line • Mortise view essential • Although literature based on small pt series, excellent results with anatomic reduction noted

  48. “Transitional” Fractures • non-displaced Tillaux fxs • 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

  49. “Transitional” Fractures • displaced (>2mm) Tillaux fxs • Anatomical reduction • CR achieved => LLC, 30KF, foot IR • CR unsuccessful => OR for CR, unsuccessful => k-wires to joystick Tillaux fragment (percutaneously or open) • Fixation with small frag or 4.0 cannulated screw, can cross physis • Postop - SLC x3-4wks => SLWC x3wks

  50. Juvenile Tilleaux Fracture-ORIF

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