Ankle injuries in children

1. Ankle injuries in children د موفق الرفاعي

2. introduction • Second in frequency • 25-38 of physial fractures • Males > females 10-15 years • Physial fractures are more common than ligamentous injuries in children

3. Anatomy • D.T.E appears at 6-12 m & contributes 45% of the tibial growth • Medial malleolous appears at 7y in females – 8y in males • Physial closure begins at 15y in females – 17y in males and lasts at 18 • D.F.E appears at 18-20 m and close at 12 24 m later than the distal tibia

4. Closure of distal tibial physis

5. Mechanism of injury & classification • Anatomic .c Salter Harris • Mechanism of injury .c Lauge Hansen .c • Dias Tachdjian .c

6. Salter Harris anatomic classification

7. Dias – Tachdjiac classification

8. Variations of grade 2 supination - inversion injuries

9. Severe supination – inversion injury

10. Stage 1 supination – external rotation

11. Stage 2 supination – external rotation injury

12. Pronation – dorsiflection injury

13. Axial compression - type injury

14. Diagnostic Features • Twisting injury • Physical examination: lacerations open .f ecchymosis swelling • Pulse evaluation & neurologic examination • Tenderness over the bony anatomy especially over distal fibular physis • Radiographic examination:AP-lateral-mortize views- stress x ray

15. Stress radiograph

16. Secondary ossification center

17. treatment • Closed reduction: gentle- early- conscious sedation or general anesthesia • ORIF : failure of closed reduction displaced physial fractures displaced articular fractures open fractures fractures with significant tissue . Injury • Campbell: most of salter 3-4 triplane- tillaux . require ORIF and surgery is . recommended for 2-3 mm or . more of displacement

18. Salter 1-2 distal fibular .f • The most common .f of the ankle • Often misdiagnosed as an ankle sprain • Inversion of the supinated foot • Salter 1 12 y Salter 2 10 y • Treatment: nondisplaced salter 1 short leg walking cast 4 weeks displaced salter 1 short leg nonweight bearing cast 4-6 weeks salter 2 short leg nonweight bearing cast 4-6 weeks

19. Salter 1 tibial .f • 15% - 10 .y • All four mechanisms result in this injury • Fibular fracture in 25% • Gentle reduction & long leg cast 4 weeks then short leg cast 2 weeks

20. Salter 2 tibial .f • The most common 40% - 12.5 y • Supination – external rotation Supination – planter flextion • Fibular f. in 20% • Reduction requires a reversal of the mechanism • Thurston holland fragment is helpful in determining the mechanism of injury posterior fragment supination – planter flexion lateral fragment pronation – external rotation posteromedial fragment supination – external rotation

21. treatment • Nondisplaced: long leg cast 4 w short leg cast 3 w • Displaced: gentle closed reduction knee flexion 90 + planter flexion of foot axial rotation [ with the deformity then opposite] long leg cast 4 w then short leg cast 3 w • Supination – external r: the foot in internal rotation • Supination – planterflexion : the foot in dorsiflexion • the patient should be relaxed during reduction • Balance between repeat closed reductions & acceptance of the reduction

23. Salter 3 distal tibial f. • 20% 11-12 • Supination – inversion injury • the epiphyseal f. is always medial to the medline • Fibular f. in 25% • Nondisplaced long leg cast 4 weeks then short leg cast for 4 weeks with the foot in 5-10 degrees of inversion • Displaced > 2 mm closed reduction O.R.I.F [ SCREW ] & SHORT LEG CAST 6 WEEKS • Results are good ,15% premature physial closure

25. Salter 4 distal tibial f. • Rare injuries [1%] • Supination – inversion injury • The most are displaced O.R.I.F • The approach is curvilinear • Fixation with screw parallel to the physis • Long leg cast 4 weeks – short leg cast 3 weeks • Radiographic monitoring every 6 monthes • Bioabsorbable pins

27. Salter 5 distal tibial f. • Extremely rare • Axial compression force • Noted after physial arrest • Compression of the germinal layer or vascular or both

28. complications • Premature closure of the physis [the most common 7,7 % ] • Delayed or nonunion • Valgus deformity secondary to malunion

29. Premature closure of the physis • Injury to the germinal layer asymmetric or symmetric growth arrest • Displaced salter 3 &salter 4 16 12 17m 20m 1,6cm 1,1cm with varus deformity 15 degree • Most of them treated with closed reduction [ importance of ORIF • Follow these patients during first 2 years until near skeletal maturity • Osseous bar within the physis • Park harris growth arrest lines

31. Treatment depends on location – size – amount of growth remaining • Growth remaining >2 years + physial arrest < 50% width of the physis resect the osseous bar &replace with cranioplast or adipose tissue • Metal markers • If the patient is closer to skeletal maturity [ female> 11 y - male> 13 y ] epiphysiodysis of the lateral aspect of the tibial physis [ with contralateral epiphysiodysis ] • Varus deformity opening wedge osteotomy of the tibia with osteotomy of the fibula

32. Varus deformity

33. Valgus deformity secondary to malunion • Inadequate reduction of pronation – eversion –external rotation injury • Valgus tilt > 15-20 degree will not correct by remodeling distal medial epiphysiodesis [screw across the medial physis]

34. Valgus deformity

35. Nonunion & delayed union

37. The Tillaux fracture • Fracture of the lateral portion of the distal tibial end • 2,9% - asymmetric closure of the physis [ centrally medially laterally ] • External rotation stretches the inferior tibiofibular ligament salter 3 fracture • Treatment closed reduction or ORIF • ORIF : displacement> 2mm following closed reduction or the fracture is seen more than 2 -3 days following injury with > 2mm displacement • Fixation with 4mm screw anterolateral to potseromedial

41. The Triplane fracture • 6-8% 10-16 y [13,5 ] • Supination – external rotatoin • Fibular fracture 50% • Coronal – sagittal – transverse

42. Three parts t.f.

43. Two parts t.f.

44. Four parts t.f.

45. Extra articular triplane f. Intramalleolar intraarticular f. within the weight bearing zone Intramalleolar intraarticular f.outside weightbearing zone Extraarticular fracture .

46. Treatment of triplane f. • The goal is anatomic reduction of articular surface • Nondisplaced or minimal displacement axial traction + casting with internal rotation of the foot if the fracture is lateral or eversion if it is medial [ 4 weeks then short leg cast 3 weeks ] • Fibular fracture should be reduced first • ORIF indications: failure to achieve adequate reduction [ within 2mm ] displaced f. > 3mm at time of initial evaluation • Campbell : two parts fracture –closed reduction [ salter 4 ] & 3 part fracture needs ORIF [ salter3 first then salter2 ]

49. MoKazem.com • هذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل الأطباء المقيمين في شعبة الجراحة العظمية في مشفى دمشق, تحت إشراف د. بشار ميرعلي. • الموقع غير مسؤول عن الأخطاء الواردة في هذه المحاضرة. • This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali. • This site is not responsible of any mistake may exist in this lecture. Dr. Muayad Kadhim د. مؤيد كاظم