Ankle fracture (peds): Difference between revisions

Latest revision as of 20:03, 22 March 2023

This page is for pediatric patients. For adult patients, see: ankle fracture

Background

More fractures and fewer sprains since physis is weaker than surrounding ligaments
Usually Salter-Harris I or II
- If assumed Salter-Harris Type I, see radiograph-negative ankle injury (peds)

Clinical Features

Tenderness to palpation of ankle (possibly over growth plate)
- Soft tissue swelling
Distinguish from lateral ligamentous sprain by presence of point tenderness over physis

Differential Diagnosis

Other Ankle Injuries

Distal Leg Fracture Types

Evaluation

Imaging
- May only show soft tissue swelling at lateral fibula

Types

Salter-Harris I
- See radiograph-negative ankle injury (peds)
Salter-Harris II
- Removable ankle brace^[1]
Salter-Harris III (25%)
- Require open reduction of any displacement
Tillaux fracture
- Salter-Harris type III of the anterolateral portion of the distal tibia
  - ATFL avulses off the distal tibia
- May need oblique view to distinguish from triplane fracture
- Usually requires surgical reduction
Triplane fracture
- Medial portion of distal tibia growth plate closes before lateral aspect
- While normal, this causes 18-month period of vulnerability until lateral aspect closes
- Planes
  - Plane 1: Lateral side of tibia through growth plate to fused medial aspect of physis
  - Plane 2: Sagittal through epiphysis
  - Plane 3: Coronal through distial tibial metaphysis
- Imaging
  - Appears as Salter III on AP, Salter II on lateral
- Management
  - CT to delineate injury
  - Ortho consult; closed reduction sufficient in most cases

Management

General Fracture Management

Acute pain management
Open fractures require immediate IV antibiotics and urgent surgical washout
Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
Consider risk for compartment syndrome

Immobilization

If nondisplaced immobilize, ortho follow up optional
Short-leg posterior splint

Disposition

Outpatient

References

↑ . Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6): e1256-e1263.

Authors:

[1] . Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6): e1256-e1263.

[1]

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+{{peds top}} [[ankle fracture]]
 ==Background==
+*More fractures and fewer sprains since physis is weaker than surrounding ligaments
+*Usually [[Salter Harris|Salter-Harris]] I or II
+**If assumed Salter-Harris Type I, see [[radiograph-negative ankle injury (peds)]]
+==Clinical Features==
+*Tenderness to palpation of ankle (possibly over growth plate)
+**Soft tissue swelling
+*Distinguish from lateral ligamentous sprain by presence of point tenderness over physis
--more Fx and fewer sprains since immature bone is more fragile than the surrounding ligaments.
+==Differential Diagnosis==
+{{Other ankle injuries DDX}}
--just always get an x-ray.
+{{Distal leg fractures DDX}}
+==Evaluation==
+*Imaging
+**May only show soft tissue swelling at lateral fibula
-==Tillaux Fx==
+===Types===
+*Salter-Harris I
+**See [[radiograph-negative ankle injury (peds)]]
+*Salter-Harris II
+**Removable ankle brace<ref>. Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6): e1256-e1263.</ref>
+*Salter-Harris III (25%)
+**Require open reduction of any displacement
+*[[Tillaux fracture]]
+**Salter-Harris type III of the anterolateral portion of the distal tibia
+***ATFL avulses off the distal tibia
+**May need oblique view to distinguish from triplane fracture
+**Usually requires surgical reduction
+*[[Triplane fracture]]
+**Medial portion of distal tibia growth plate closes before lateral aspect
+**While normal, this causes 18-month period of vulnerability until lateral aspect closes
+**Planes
+***Plane 1: Lateral side of tibia through growth plate to fused medial aspect of physis
+***Plane 2: Sagittal through epiphysis
+***Plane 3: Coronal through distial tibial metaphysis
+**Imaging
+***Appears as Salter III on AP, Salter II on lateral
+**Management
+***CT to delineate injury
+***Ortho consult; closed reduction sufficient in most cases
+==Management==
+{{General Fracture Management}}
--ave age 11-15 yrs.
+===Immobilization===
+*If nondisplaced [[Splinting#Lower Extremity|immobilize]], ortho follow up optional
+*[[Short-leg posterior splint]]
--more common in girls
+==Disposition==
+*Outpatient
-salter-harris type 3 Fx that avulses the anterolateral tibial epiphysis (distal to the growth plate).
--caused by ext rotation of the leg with the foot fixed, the ATFL avulses off the distal tibia.
--oblique films are often necessary to distinguish a tillaux from the more common triplane fx.
--more than 2mm of displacement after reduction requires surgical intervention.
--since most of the growth plate has closed at this age, leg length discrepancies and rotational deformities are rare.
-==Triplane Fx==
--more common and serious than tillaux Fx.
--10% of all pediatric ankle Fx.
--mechanism is a combination of external rotation and axial loading in a foot in plantarflexion.
--occur about one year prior to growth plate closure usually.
--more common in boys.
--can be 2 part, 3 part, or 4 part fractures-if the distal tibula is also fractured do not count it as part of the triplane Fx.
-- 2 part Fx is a salter-Harris 4 Fx. One Fx line is transverse through the tibial epiphysis (growth plate). The medial portion of the plate is already closed, so the fracture doesn't extend through the plate. second fracture plane extends up the tibia (coronal plane-up the metaphysis). the third fracture line (sagittal) extends distally into the joint.
--the three and four part fractures are similar in that there are fractures in all three planes, but the distal tibia is in two or three parts respectively.
--can be treated with closed reduction if less than 2mm of displacement can be achieved.
--unfortunately, this Fx has a lot of swelling and if the cast accommodates the swelling then there is enough room for the reduction to slip off when the swelling subsides.
--most three or four part Fxs are treated with ORIF.
--growth arrest is uncommon since the growth plate is near closure at the time of injury.
 ==See Also==
+*[[Fractures (Main)]]
+*[[Ankle diagnoses]]
+*[[Ankle fracture]]
+*[[Radiograph-negative ankle injury (peds)]]
+==References==
-Ortho:  Ankle (Fracture)
+<references/>
+[[Category:Pediatrics]]
+[[Category:Orthopedics]]
-[[Category:Peds]]