Pediatric and Adolescent Ankle Injuries-Part 2

1. Pediatric and Adolescent Ankle Injuries-Part 2 Rang’s Children’s Fractures Wenger and Pring 2005

2. 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

3. 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

9. 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

10. 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

11. 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

14. Malleolar Fractures • Fracture Management • Attempt closed reduction with analgesia or sedation • Majority of fractures can be treated with casting • ORIF if closed reduction fails

15. 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

16. 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

17. 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

19. 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

22. 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

23. 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

24. 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

26. 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

27. Henry HarrisWelsh 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.

28. 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

29. 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

31. 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

32. 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

33. 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

34. 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

36. 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

37. 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

38. 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

40. 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

42. Questions?