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Ankle injuries in children . د موفق الرفاعي. introduction. Second in frequency 25-38 of physial fractures Males > females 10-15 years Physial fractures are more common than ligamentous injuries in children. Anatomy. D.T.E appears at 6-12 m & contributes 45% of the tibial growth

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ankle injuries in children

Ankle injuries in children

د موفق الرفاعي

introduction
introduction
  • Second in frequency
  • 25-38 of physial fractures
  • Males > females 10-15 years
  • Physial fractures are more common than ligamentous injuries in children
anatomy
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
mechanism of injury classification
Mechanism of injury & classification
  • Anatomic .c Salter Harris
  • Mechanism of injury .c Lauge Hansen .c
  • Dias Tachdjian .c
diagnostic features
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
treatment
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
salter 1 2 distal fibular f
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

salter 1 tibial f
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
salter 2 tibial f
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

treatment21
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
salter 3 distal tibial f
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
salter 4 distal tibial f
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
salter 5 distal tibial f
Salter 5 distal tibial f.
  • Extremely rare
  • Axial compression force
  • Noted after physial arrest
  • Compression of the germinal layer or vascular or both
complications
complications
  • Premature closure of the physis [the most common 7,7 % ]
  • Delayed or nonunion
  • Valgus deformity secondary to malunion
premature closure of the physis
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
slide31
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
valgus deformity secondary to malunion
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]
the tillaux fracture
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
the triplane fracture
The Triplane fracture
  • 6-8% 10-16 y [13,5 ]
  • Supination – external rotatoin
  • Fibular fracture 50%
  • Coronal – sagittal – transverse
extra articular triplane f

Extra articular triplane f.

Intramalleolar intraarticular f. within the weight bearing zone

Intramalleolar intraarticular f.outside weightbearing zone

Extraarticular fracture .

treatment of triplane f
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 ]
mokazem com
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