Pediatrics Case #10

CC: Ankle painHPI: 15 yo male presents to

the ED after jumping off a merry-go-round 1 hour ago. Patient states that he “landed funny” on his R foot and experienced onset of achy pain and swelling in his ankle shortly after the fall. He cannot walk on his leg due to pain. He denies weakness or sensory changes. He denies any other active complaints or other injuries.

History and PhysicalVS: T: 98.4 P: 110 R: 18 BP: 114/78 O2: 96%Musculoskeletal: RLE: Dorsal swelling of foot with TTP about dorsal foot. TTP over medial malleolus. No proximal tibia/fibula TTP. 2+DP. 2+ PT. <2 sec cap refill in all 5 digits. Pain with active dorsiflexion/plantar flexion of ankle.

Images

Diagnosis: Triplane Fracture

• Triplane fracture involves the tibial metaphysis, tibial growth plate (physis), and the epiphysis

• Fracture through frontal, lateral, transverse planes. • Doesn’t fit well into Salter Harris Classification (atypical fracture)

Nondisplaced (<2mm) Splint in ER (posterior/stirrup), urgent ortho

referrelDisplaced

Closed Reduction –avoid more than 2 attemptsTypicall Requires ORIF

ED Management

A triplane fracture of the distal tibia is generally sustained during adolescence and occurs before complete closure of the distal tibial physis

Fractures are explained by the fusion of tibial physis, and can be classified into 2 or 3 part fractures

Mechanism: External rotation of the foot and ankle

Associated fibular fracture is common

Pearls

ComplicationsAngular Deformity

Leg Length Discrepancy

Posttraumatic Arthritis

Pearls

Ankle Images

ReferencesKoval, K. et al. Handbook of Fractures. 4th Edition. 2010.

Northwestern University School of Medicine: Emergency Medicine Residency Orthopedic Teaching Files http://www.feinberg.northwestern.edu/emergencymed/residency/ortho-teaching/

Wheeles Ortho online textbook http://www.wheelessonline.com/

http://eorif.com/triplane-ankle-fracture-8248

http://emedicine.medscape.com/article/1269816-overview

http://eorif.com/triplane-ankle-fracture-8248