OrthoFracs Logo

Paediatric Foot & Ankle Fractures

Paediatric Ankle Fractures

Anatomy

  • Talar dome is more broad anteriorly than posteriorly, therefore more translation + rotation is permitted in plantarflexion
  • Anterior Inferior TaloFibular (AITF)ligament attaches to distal tibial epiphysis & is important in the pathomechanics of transitional fractures (Tillaux + Triplane)
  • TibioFibular syndesmosis allows fibular motion during dorsiflexion + plantarflexion
  • Distal tibial physis provides 3-4mm growth per year (35-40% tibial length or 15-20% lower limb length)
  • In general terms, distal tibial closure is completed by age 14 years in girls + 16 years in boys
  • Closure of distal tibial physis progresses from central → medial → lateral over 18 months
  • Secondary ossific nucleus
    • Distal tibial epiphysis appears 6-24 months
    • Medial malleolus 7-8 years (separate ossification centre = os subtibiale in 20% population)
    • Distal fibula 18-20 months (separate ossification = os fibulare in 1% population)

Classification

Diagnosis

  • Multitrauma patient assessment according to EMST guidelines
  • Examination
    • pulses (Doppler study)
    • capillary refill
    • sensation
    • motor assessment
  • Xrays
    • AP + lateral + mortise
  • CT
    • transitional fracturess
  • MRI
    • osteochondral fragments

Treatment

Salter-Harris 1+2

  • Type 1 = 15% + type 2 = 40% distal tibial fractures
  • Type 2 fracture
    • extends through zone of hypertrophy then exits through metaphysis to produce Thurston-Holland fragment
  • Attempt reduction only once or twice to minimise physeal injury
  • 10˚ angulation produces ↓tibiotalar contact area + ↑tibiotalar contact pressure
  • Growth disturbance lines on Xray
    • are common post fracture & should be parallel to the physis
    • Absent or angled lines = growth arrest
  • Partial arrest = angular deformity + leg length discrepancy
  • Complete arrest does not produce angular deformity but relative fibula overgrowth may proceed

Salter-Harris 3

  • Type 3 = 25% distal tibial fractures
  • Risks are joint incongruity + growth arrest
  • Tillaux fractures
    • are more commonly seen near skeletal maturity
    • anterolateral pattern is a function of the order of distal tibial physeal closure
    • May require ORIF via anterolateral approach

Salter-Harris 4

  • Type 4 = 25% distal tibial fractures
  • are seen with triplane & shearing medial malleolar fractures
  • Triplane fractures
    • generally occur at age 13 years
    • Posterior metaphyseal fragment + lateral epiphyseal fragment
    • CT for comminuted fractures
    • ORIF
      • to restore articular congruity.
      • Avoid elevating perichondral ring

Salter-Harris 5

  • Type = 1% distal tibial fractures
  • Compressive force across germinal layer of physis. Physeal arrest can produce angular + leg length discrepancy

Complications of Ankle Fractures

  • Growth Arrest
    • Most common after Salter-Harris 3+4
    • ORIF is associated with less articular incongruity, physeal arrest, late arthritis compared with closed reduction
    • Near skeletal maturity perform epiphyseodesis of remaining physis provided no angular deformity present as distal tibia grows only 3-4mm per year + distal fibula epiphyseodesis to prevent lateral impingement
    • In younger children physeal bar resection as delineated on MRI
    • Osteotomy for angular deformity
  • Osteoarthritis
  • Ankle Stiffness
  • RSD
Bookmark and Share