Ankle injuries in children Ankle injuries in children

الرفاعي موفق الرفاعي د موفق د

introductionintroduction

Second in frequencySecond in frequency 25-38 of physial fractures25-38 of physial fractures Males > females 10-15 yearsMales > females 10-15 years Physial fractures are more common Physial fractures are more common

than ligamentous injuries in than ligamentous injuries in childrenchildren

AnatomyAnatomy

D.T.E appears at 6-12 m & contributes D.T.E appears at 6-12 m & contributes 45% of the tibial growth45% of the tibial growth

Medial malleolous appears at 7y in Medial malleolous appears at 7y in females – 8y in malesfemales – 8y in males

Physial closure begins at 15y in Physial closure begins at 15y in females – 17y in males and lasts at 18females – 17y in males and lasts at 18

D.F.E appears at 18-20 m and close at D.F.E appears at 18-20 m and close at 12 24 m later than the distal tibia12 24 m later than the distal tibia

Closure of distal tibial physisClosure of distal tibial physis

Mechanism of injury & Mechanism of injury & classificationclassification

Anatomic .c Salter HarrisAnatomic .c Salter Harris Mechanism of injury .c Lauge Mechanism of injury .c Lauge

Hansen .cHansen .c Dias Tachdjian .cDias Tachdjian .c

Salter Harris anatomic Salter Harris anatomic classificationclassification

Dias – Tachdjiac Dias – Tachdjiac classificationclassification

Variations of grade 2 supination - inversion Variations of grade 2 supination - inversion injuriesinjuries

Severe supination – inversion Severe supination – inversion injuryinjury

Stage 1 supination – external Stage 1 supination – external

rotationrotation

Stage 2 supination – external rotation Stage 2 supination – external rotation injuryinjury

Pronation – dorsiflection Pronation – dorsiflection injuryinjury

Axial compression - type Axial compression - type injuryinjury

Diagnostic FeaturesDiagnostic Features

Twisting injuryTwisting injury Physical examination: lacerationsPhysical examination: lacerations open .fopen .f ecchymosisecchymosis swellingswelling Pulse evaluation & neurologic examinationPulse evaluation & neurologic examination Tenderness over the bony anatomy especially Tenderness over the bony anatomy especially

over distal fibular physisover distal fibular physis Radiographic examination:AP-lateral-mortize Radiographic examination:AP-lateral-mortize

views- stress x rayviews- stress x ray

Stress radiographStress radiograph

Secondary ossification Secondary ossification centercenter

treatmenttreatment Closed reduction: gentle- early- conscious sedation or Closed reduction: gentle- early- conscious sedation or

general anesthesiageneral anesthesia ORIF : failure of closed reduction ORIF : failure of closed reduction displaced physial fracturesdisplaced physial fractures displaced articular fracturesdisplaced articular fractures open fractures open fractures fractures with significant tissue fractures with significant tissue

. Injury. Injury Campbell: most of salter 3-4 triplane- tillaux . Campbell: most of salter 3-4 triplane- tillaux .

require ORIF and surgery is . require ORIF and surgery is . recommended for 2-3 mm or . more recommended for 2-3 mm or . more of displacement of displacement

Salter 1-2 distal fibular .fSalter 1-2 distal fibular .f The most common .f of the ankleThe most common .f of the ankle Often misdiagnosed as an ankle sprain Often misdiagnosed as an ankle sprain Inversion of the supinated foot Inversion of the supinated foot Salter 1 12 y Salter 1 12 y Salter 2 10 ySalter 2 10 y Treatment:Treatment: nondisplaced salter 1 short leg walking cast 4 nondisplaced salter 1 short leg walking cast 4

weeksweeks displaced salter 1 short leg nonweight bearing displaced salter 1 short leg nonweight bearing

cast 4-6 weekscast 4-6 weeks salter 2 short leg nonweight bearing cast 4-6 salter 2 short leg nonweight bearing cast 4-6

weeks weeks

Salter 1 tibial .fSalter 1 tibial .f

15% - 10 .y15% - 10 .y All four mechanisms result in this All four mechanisms result in this

injuryinjury Fibular fracture in 25%Fibular fracture in 25% Gentle reduction & long leg cast 4 Gentle reduction & long leg cast 4

weeks then short leg cast 2 weeksweeks then short leg cast 2 weeks

Salter 2 tibial .fSalter 2 tibial .f The most common 40% - 12.5 yThe most common 40% - 12.5 y Supination – external rotation Supination – external rotation Supination – planter flextion Supination – planter flextion Fibular f. in 20%Fibular f. in 20% Reduction requires a reversal of the mechanism Reduction requires a reversal of the mechanism Thurston holland fragment is helpful in determining Thurston holland fragment is helpful in determining

the mechanism of injury the mechanism of injury posterior fragment supination – planter flexion posterior fragment supination – planter flexion lateral fragment pronation – external rotation lateral fragment pronation – external rotation posteromedial fragment supination – external posteromedial fragment supination – external

rotation rotation

treatmenttreatment Nondisplaced:Nondisplaced: long leg cast 4 wlong leg cast 4 w short leg cast 3 wshort leg cast 3 w Displaced:Displaced: gentle closed reduction knee flexion 90 + planter flexion of gentle closed reduction knee flexion 90 + planter flexion of

footfoot axial rotation [ with the deformity then opposite] long leg axial rotation [ with the deformity then opposite] long leg

cast 4 w then short leg cast 3 w cast 4 w then short leg cast 3 w Supination – external r:Supination – external r: the foot in internal rotationthe foot in internal rotation Supination – planterflexion :Supination – planterflexion : the foot in dorsiflexionthe foot in dorsiflexion the patient should be relaxed during reductionthe patient should be relaxed during reduction Balance between repeat closed reductions & acceptance of Balance between repeat closed reductions & acceptance of

the reduction the reduction

Salter 3 distal tibial fSalter 3 distal tibial f.. 20% 11-1220% 11-12 Supination – inversion injurySupination – inversion injury the epiphyseal f. is always medial to the the epiphyseal f. is always medial to the

medline medline Fibular f. in 25% Fibular f. in 25% Nondisplaced long leg cast 4 weeks Nondisplaced long leg cast 4 weeks

then short leg cast for 4 weeks with the foot then short leg cast for 4 weeks with the foot in 5-10 degrees of inversion in 5-10 degrees of inversion

Displaced > 2 mm closed reduction Displaced > 2 mm closed reduction O.R.I.F [ SCREW ] & O.R.I.F [ SCREW ] & SHORT LEG CAST 6 SHORT LEG CAST 6 WEEKSWEEKS Results are good ,15% premature physial Results are good ,15% premature physial

closure closure

Salter 4 distal tibial fSalter 4 distal tibial f..

Rare injuries [1%]Rare injuries [1%] Supination – inversion injurySupination – inversion injury The most are displaced O.R.I.FThe most are displaced O.R.I.F The approach is curvilinear The approach is curvilinear Fixation with screw parallel to the physisFixation with screw parallel to the physis Long leg cast 4 weeks – short leg cast 3 Long leg cast 4 weeks – short leg cast 3

weeksweeks Radiographic monitoring every 6 monthesRadiographic monitoring every 6 monthes Bioabsorbable pinsBioabsorbable pins

Salter 5 distal tibial fSalter 5 distal tibial f..

Extremely rareExtremely rare Axial compression Axial compression

forceforce Noted after physial Noted after physial

arrestarrest Compression of the Compression of the

germinal layer or germinal layer or vascular or bothvascular or both

complicationscomplications

1.1. Premature closure of the physis Premature closure of the physis [the most common 7,7 % ][the most common 7,7 % ]

2.2. Delayed or nonunionDelayed or nonunion

3.3. Valgus deformity secondary to Valgus deformity secondary to malunionmalunion

Premature closure of the physisPremature closure of the physis Injury to the germinal layer Injury to the germinal layer

asymmetric or symmetric growth arrestasymmetric or symmetric growth arrest Displaced salter 3 &salter 4 Displaced salter 3 &salter 4 16 1216 12 17m 20m17m 20m 1,6cm 1,1cm 1,6cm 1,1cm with varus deformity 15 degreewith varus deformity 15 degree Most of them treated with closed reduction [ Most of them treated with closed reduction [

importance of ORIF importance of ORIF Follow these patients during first 2 years Follow these patients during first 2 years

until near skeletal maturityuntil near skeletal maturity Osseous bar within the physisOsseous bar within the physis Park harris growth arrest lines Park harris growth arrest lines

Treatment depends on location – size – Treatment depends on location – size – amount of growth remainingamount of growth remaining

Growth remaining >2 years + physial arrest Growth remaining >2 years + physial arrest < 50% width of the physis resect the < 50% width of the physis resect the osseous bar &replace with cranioplast or osseous bar &replace with cranioplast or adipose tissueadipose tissue

Metal markers Metal markers If the patient is closer to skeletal maturity If the patient is closer to skeletal maturity

[ female> 11 y - male> 13 y ] [ female> 11 y - male> 13 y ] epiphysiodysis of the lateral aspect of the epiphysiodysis of the lateral aspect of the tibial physis [ with contralateral tibial physis [ with contralateral epiphysiodysis ]epiphysiodysis ]

Varus deformity opening wedge Varus deformity opening wedge osteotomy of the tibia with osteotomy of the osteotomy of the tibia with osteotomy of the fibulafibula

Varus deformityVarus deformity

Valgus deformity secondary to malunionValgus deformity secondary to malunion

Inadequate reduction of pronation – Inadequate reduction of pronation – eversion –external rotation injuryeversion –external rotation injury

Valgus tilt > 15-20 degree will not Valgus tilt > 15-20 degree will not correct by remodeling distal correct by remodeling distal medial epiphysiodesis [screw across medial epiphysiodesis [screw across the medial physis] the medial physis]

Valgus deformityValgus deformity

Nonunion & delayed unionNonunion & delayed union

The Tillaux fractureThe Tillaux fracture Fracture of the lateral portion of the distal tibial Fracture of the lateral portion of the distal tibial

end end 2,9% - asymmetric closure of the physis 2,9% - asymmetric closure of the physis

[ centrally medially laterally ][ centrally medially laterally ] External rotation stretches the inferior tibiofibular External rotation stretches the inferior tibiofibular

ligamentligament salter 3 fracture salter 3 fracture Treatment closed reduction or ORIFTreatment closed reduction or ORIF ORIF : displacement> 2mm following closed ORIF : displacement> 2mm following closed

reduction or the fracture is seen more than 2 -3 reduction or the fracture is seen more than 2 -3 days following injury with > 2mm displacementdays following injury with > 2mm displacement

Fixation with 4mm screw anterolateral to Fixation with 4mm screw anterolateral to potseromedialpotseromedial

The Triplane fractureThe Triplane fracture

6-8% 10-16 y [13,5 ]6-8% 10-16 y [13,5 ] Supination – external rotatoinSupination – external rotatoin Fibular fracture 50% Fibular fracture 50% Coronal – sagittal – transverse Coronal – sagittal – transverse

Three parts t.fThree parts t.f..

Two parts t.fTwo parts t.f..

Four parts t.fFour parts t.f..

Extra articular triplane f.Extra articular triplane f.

1.1. Intramalleolar Intramalleolar intraarticular f. within the intraarticular f. within the

weight bearing zoneweight bearing zone2.2. Intramalleolar Intramalleolar

intraarticular f.outside intraarticular f.outside weightbearing zoneweightbearing zone

3.3. Extraarticular fracture . Extraarticular fracture .

Treatment of triplane fTreatment of triplane f.. The goal is anatomic reduction of articular The goal is anatomic reduction of articular

surfacesurface Nondisplaced or minimal displacement Nondisplaced or minimal displacement

axial traction + casting with internal rotation axial traction + casting with internal rotation of the foot if the fracture is lateral or eversion of the foot if the fracture is lateral or eversion if it is medial [ 4 weeks then short leg cast 3 if it is medial [ 4 weeks then short leg cast 3 weeks ]weeks ]

Fibular fracture should be reduced firstFibular fracture should be reduced first ORIF indications: failure to achieve adequate ORIF indications: failure to achieve adequate

reduction [ within 2mm ] reduction [ within 2mm ] displaced f. > 3mm at time of initial evaluation displaced f. > 3mm at time of initial evaluation Campbell : two parts fracture –closed Campbell : two parts fracture –closed

reduction [ salter 4 ] & 3 part fracture needs reduction [ salter 4 ] & 3 part fracture needs ORIF [ salter3 first then salter2 ] ORIF [ salter3 first then salter2 ]

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من • تقديمها و إعدادها تم محاضرات سلسلة من هي المحاضرة هذه , دمشق مشفى في العظمية الجراحة شعبة في المقيمين األطباء قبل

. . ميرعلي بشار د إشراف تحت• . المحاضرة هذه في الواردة األخطاء عن مسؤول غير الموقع

•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.

كاظم. مؤيد Dr. Muayad Kadhimد