Chapter 32: Ankle Fractures

Kevin G. Shea, Steven L. Frick

Chapter Outline

Introduction to Distal Tibial and Fibular Fractures

Injuries to the distal tibial and fibular physes are generally reported to account for 25% to 38% of all physeal fractures,88,173 second in frequency only to distal radial physeal fractures157; however, Peterson et al.159 reported that phalangeal physeal fractures were most common, followed by physeal injuries of the radius and ankle. In skeletally immature individuals, physeal ankle fractures are slightly more common than fractures of the tibial or fibular diaphysis,130 and these fractures are a common cause of hospital admission in children.49 
Participation in sports is associated with a significant number of ankle injuries, including sprains and fractures. Up to 58% of physeal ankle fractures occur during sports activities73,215 and account for 10% to 40% of all injuries to skeletally immature athletes.147,152,177,200 Physeal ankle fractures are more common in males than in females in some studies.196 Other studies have demonstrated that ankle injuries may be more likely in young female soccer athletes compared with males.115 Fractures of the ankle are associated with the following sport activities: Trampolines,188 scooters,129 soccer,115 basketball,53 skating,145 and downhill skiing.17 Increased BMI is also a risk factor for ankle injury in the skeletally immature.216 
In addition to sports, higher-energy trauma is associated with a significant number of distal tibia and fibular fractures in children. These fractures occur in approximately 10% to 20% of trauma patients presenting to the emergency room.17 Tibial physeal fractures are most common between the ages of 8 and 15 years, and fibular fractures are most common between 8 and 14 years of age.196 

Assessment of Distal Tibial and Fibular Fractures

Mechanisms of Injury and Classification of Distal Tibial and Fibular Fractures

Fracture classifications are usually based upon anatomy2,149,158,196 or mechanism of injury descriptions.5,13,113 Anatomical classifications distinguish fractures based on the regions of the metaphysis, physis, and epiphysis. Mechanism-of-injury classifications incorporate the forces, which produce the fracture and the anatomic position of the foot and ankle that existed at the time of the injury. Most mechanism-of-injury classifications include the anatomical type of injury produced by a particular mechanism. 
Since its description, the Salter–Harris classification system has been widely used to describe the anatomic features of fractures associated with open physes. This straightforward anatomic classification (Fig. 32-1) is effective for rapid communication. It has five distinct categories, which can be applied to most periarticular regions. 
Figure 32-1
Salter–Harris anatomic classification as applied to injuries of the distal tibial epiphysis.
Flynn-ch032-image001.png
View Original | Slide (.ppt)
X
Injury classifications based upon the mechanism of injury may have some advantages. The description of the injury includes the anatomic deformity and the forces that produced the injury. An understanding of these forces can facilitate reduction of a displaced fracture. Advanced imaging techniques that allow for comprehensive three-dimensional visualization of the fracture anatomy also facilitate surgical planning and reduction techniques. 
Both anatomical and mechanism-of-injury classifications can provide useful information for determining appropriate treatment. The prognoses for growth and deformity have been predicted on the basis of both types of classification.98,99,196 A theoretical advantage of mechanism-of-injury classifications is that identification of the force producing the injury might give even more information about the possible development of growth arrest than anatomical classifications. For example, a Salter–Harris type III or IV fracture of the tibia produced by a shearing or crushing force might be more likely to result in growth arrest than is a similar injury produced by an avulsion force (Fig. 32-2). However, it is difficult to establish that one type of classification is superior to the other in this regard because of the relatively small numbers of patients reported, the varying ages of patients in most series, and questions about the reproducibility of various classifications. 
Figure 32-2
Comminuted Salter–Harris type IV fracture of the distal tibia and displaced Salter–Harris type I fracture of the distal fibula produced by an inversion (shearing) mechanism in a 10-year-old girl.
Flynn-ch032-image002.png
View Original | Slide (.ppt)
X
Ideally, classification systems should have high interobserver and intraobserver agreement. Thomsen et al.204 studied the reproducibility of the Lauge-Hansen (mechanism-of-injury) and Weber (anatomical) classifications in a series of adult ankle fractures. After all investigators in the study had received a tutorial on both systems and their application, they were asked to classify 94 fractures. On the first attempt, only the Weber classification produced an acceptable level of interobserver agreement. On a second attempt, the Weber classification and most of the Lauge-Hansen classification achieved an acceptable level of interobserver agreement. These authors concluded that all fracture classification systems should have demonstrably acceptable interobserver agreement rates before they are adopted, an argument made even more forcefully in an editorial by Burstein.33 Vahvanen and Aalto207 compared their ability to classify 310 ankle fractures in children with the Weber, Lauge-Hansen, and Salter–Harris classifications. They found that they were “largely unsuccessful” using the Weber and Lauge-Hansen classifications, but could easily classify the fractures using the Salter–Harris system. 
The most widely accepted mechanism-of-injury classification of ankle fractures in children is that described by Dias and Tachdjian,57 who modified the Lauge-Hansen classification based on their review of 71 fractures (Fig. 32-3). Their original classification (1978) consisted of four types in which the first word refers to the position of the foot at the time of injury and the second word refers to the force that produces the injury. 
Figure 32-3
Dias–Tachdjian classification of physeal injuries of the distal tibia and fibula.
Flynn-ch032-image003.png
View Original | Slide (.ppt)
X
Other fracture types were subsequently added, including axial compression, juvenile Tillaux, triplane, and other physeal injuries by Tachdjian.201 Syndesmosis injuries have also been recently described.51 “Axial compression injury” describes the mechanism of injury but not the position of the foot. Juvenile Tillaux and triplane fractures are called transitional fractures as they occur when the physis is transitioning from open to closed, and are believed to be caused by external rotation.175 The final category, “other physeal injuries,” includes diverse injuries, many of which have no specific mechanism of injury. 

Classification of Ankle Fracture in Children (Dias–Tachdjian) (Fig. 32-3)

Supination–Inversion

  •  
    Grade I: The adduction or inversion force avulses the distal fibular epiphysis (Salter–Harris type I or II fracture). Occasionally, the fracture is transepiphyseal; rarely, the lateral ligaments fail.
  •  
    Grade II (Fig. 32-4): Further inversion produces a tibial fracture, usually a Salter–Harris type III or IV and rarely a Salter–Harris type I or II injury, or the fracture passes through the medial malleolus below the physis (Fig. 32-5).
Figure 32-4
Variants of grade II supination–inversion injuries (Dias–Tachdjian classification).
 
A: Salter–Harris type I fracture of the distal tibia and fibula. B: Salter–Harris type I fracture of the fibula, Salter–Harris type II tibial fracture. C: Salter–Harris type I fibular fracture, Salter–Harris type III tibial fracture. D: Salter–Harris type I fibular fracture, Salter–Harris type IV tibial fracture.
A: Salter–Harris type I fracture of the distal tibia and fibula. B: Salter–Harris type I fracture of the fibula, Salter–Harris type II tibial fracture. C: Salter–Harris type I fibular fracture, Salter–Harris type III tibial fracture. D: Salter–Harris type I fibular fracture, Salter–Harris type IV tibial fracture.
View Original | Slide (.ppt)
Figure 32-4
Variants of grade II supination–inversion injuries (Dias–Tachdjian classification).
A: Salter–Harris type I fracture of the distal tibia and fibula. B: Salter–Harris type I fracture of the fibula, Salter–Harris type II tibial fracture. C: Salter–Harris type I fibular fracture, Salter–Harris type III tibial fracture. D: Salter–Harris type I fibular fracture, Salter–Harris type IV tibial fracture.
A: Salter–Harris type I fracture of the distal tibia and fibula. B: Salter–Harris type I fracture of the fibula, Salter–Harris type II tibial fracture. C: Salter–Harris type I fibular fracture, Salter–Harris type III tibial fracture. D: Salter–Harris type I fibular fracture, Salter–Harris type IV tibial fracture.
View Original | Slide (.ppt)
X
Figure 32-5
Severe supination–inversion injury with displaced fracture of the medial malleolus distal to the physis of the tibia.
Flynn-ch032-image005.png
View Original | Slide (.ppt)
X

Supination–Plantarflexion

The plantarflexion force displaces the epiphysis directly posteriorly, resulting in a Salter–Harris type I or II fracture. Fibular fractures were not reported with this mechanism. The tibial fracture may be difficult to see on anteroposterior radiographs (Fig. 32-6). 
Figure 32-6
Lateral view of a supination–plantarflexion injury.
Flynn-ch032-image006.png
View Original | Slide (.ppt)
X

Supination–External Rotation

  •  
    Grade I: The external rotation force results in a Salter–Harris type II fracture of the distal tibia (Fig. 32-7). The distal fragment is displaced posteriorly, as in a supination–plantarflexion injury, but the Thurston–Holland fragment is visible on the anteroposterior radiographs, with the fracture line extending proximally and medially. Occasionally, the distal tibial epiphysis is rotated but not displaced.
  •  
    Grade II: With further external rotation, a spiral fracture of the fibula is produced, running from anteroinferior to posterosuperior (Fig. 32.8).
Figure 32-7
Stage I supination–external rotation injury in a 10-year-old child; the Salter–Harris type II fracture begins laterally.
Flynn-ch032-image007.png
View Original | Slide (.ppt)
X
Figure 32-8
Stage II supination–external rotation injury.
 
A: Oblique fibular fracture also is visible on anteroposterior view. B: Lateral view shows the posterior metaphyseal fragment and posterior displacement.
A: Oblique fibular fracture also is visible on anteroposterior view. B: Lateral view shows the posterior metaphyseal fragment and posterior displacement.
View Original | Slide (.ppt)
Figure 32-8
Stage II supination–external rotation injury.
A: Oblique fibular fracture also is visible on anteroposterior view. B: Lateral view shows the posterior metaphyseal fragment and posterior displacement.
A: Oblique fibular fracture also is visible on anteroposterior view. B: Lateral view shows the posterior metaphyseal fragment and posterior displacement.
View Original | Slide (.ppt)
X

Pronation–Eversion–External Rotation

A Salter–Harris type I or II fracture of the distal tibia occurs simultaneously with a transverse fibular fracture. The distal tibial fragment is displaced laterally and the Thurston–Holland fragment, when present, is lateral or posterolateral (Fig. 32-9). Less frequently, a transepiphyseal fracture occurs through the medial malleolus (Salter–Harris type II). Such injuries may be associated with diastasis of the ankle joint, which is uncommon in children. 
Figure 32-9
 
A: According to the Dias–Tachdjian classification, this injury in a 12-year-old boy would be considered a pronation–eversion–external rotation injury resulting in a Salter–Harris type II fracture of the distal tibia and a transverse fibular fracture. B: The anterior displacement of the epiphysis, visible on the lateral view, however, makes external rotation an unlikely component of the mechanism of injury; the mechanism is more likely pronation–dorsiflexion.
A: According to the Dias–Tachdjian classification, this injury in a 12-year-old boy would be considered a pronation–eversion–external rotation injury resulting in a Salter–Harris type II fracture of the distal tibia and a transverse fibular fracture. B: The anterior displacement of the epiphysis, visible on the lateral view, however, makes external rotation an unlikely component of the mechanism of injury; the mechanism is more likely pronation–dorsiflexion.
View Original | Slide (.ppt)
Figure 32-9
A: According to the Dias–Tachdjian classification, this injury in a 12-year-old boy would be considered a pronation–eversion–external rotation injury resulting in a Salter–Harris type II fracture of the distal tibia and a transverse fibular fracture. B: The anterior displacement of the epiphysis, visible on the lateral view, however, makes external rotation an unlikely component of the mechanism of injury; the mechanism is more likely pronation–dorsiflexion.
A: According to the Dias–Tachdjian classification, this injury in a 12-year-old boy would be considered a pronation–eversion–external rotation injury resulting in a Salter–Harris type II fracture of the distal tibia and a transverse fibular fracture. B: The anterior displacement of the epiphysis, visible on the lateral view, however, makes external rotation an unlikely component of the mechanism of injury; the mechanism is more likely pronation–dorsiflexion.
View Original | Slide (.ppt)
X

Axial Compression

This results in a Salter–Harris type V injury of the distal tibial physis. Initial radiographs usually show no abnormality, and the diagnosis is established when growth arrest is demonstrated on follow-up radiographs. 

Transitional Fractures of the Distal Tibia and Fibula

Because the distal tibial physis closes in an asymmetric pattern over a period of about 18 months, injuries sustained during this period can produce fracture patterns that are not seen in younger children with completely open physes.126 This group of fractures has been labeled “transitional” fractures because they occur during the transition from a skeletally immature ankle to a skeletally mature ankle. Such fractures, which include juvenile Tillaux and “triplane” fractures with two to four fracture fragments, have been described by Kleiger and Mankin,108 Marmor,131 Cooperman et al.,46 Kärrholm et al.,97 and Denton and Fischer.54 The adolescent pilon fracture has been described by Letts et al.117 The incisural fracture has been described by Cummings and Hahn.52 Syndesmosis injuries have been described by Cummings.51 
Classification of these fractures is even more confusing than that of other distal tibial fractures. Advocates of mechanism-of-injury systems agree that most juvenile Tillaux and triplane fractures are caused by external rotation, but they disagree as to the position of the foot at the time of the injury.55,56,164 Some authors56 classify juvenile Tillaux fractures as stage I injuries, with further external rotation causing triplane fractures, and still further external rotation causing stage II injuries with fibular fracture. Others emphasize the extent of physeal closure as the only determinant of fracture pattern.45 
Advocates of anatomical classifications are handicapped by the different anatomical configurations triplane fractures may exhibit on different radiograph projections, making tomography, computed tomography (CT) scanning, or examination at open reduction necessary to determine fracture anatomy and number of fragments. Because these fractures occur near the end of growth, growth disturbance is rare. Anatomical classification is, therefore, more useful for descriptive purposes than for prognosis. 

Juvenile Tillaux Fracture of the Distal Tibia and Fibula

The juvenile Tillaux fracture is a Salter–Harris type III fracture involving the anterolateral distal tibia. The portion of the physis not involved in the fracture is closed (Fig. 32-10). 
Figure 32-10
 
A: Anteroposterior radiograph of Salter–Harris type III/juvenile Tillaux fracture. B: Lateral radiograph of Salter–Harris type III/juvenile Tillaux fracture.
A: Anteroposterior radiograph of Salter–Harris type III/juvenile Tillaux fracture. B: Lateral radiograph of Salter–Harris type III/juvenile Tillaux fracture.
View Original | Slide (.ppt)
Figure 32-10
A: Anteroposterior radiograph of Salter–Harris type III/juvenile Tillaux fracture. B: Lateral radiograph of Salter–Harris type III/juvenile Tillaux fracture.
A: Anteroposterior radiograph of Salter–Harris type III/juvenile Tillaux fracture. B: Lateral radiograph of Salter–Harris type III/juvenile Tillaux fracture.
View Original | Slide (.ppt)
X

Triplane Fracture of the Distal Tibia and Fibula

A group of fractures that have in common the appearance of a Salter–Harris type III fracture on the anteroposterior radiographs and of a Salter–Harris type II fracture on the lateral radiographs (Fig. 32-11). CT scans can be very helpful to understand the complex anatomy of these fractures (Fig. 32-11).14,49,107 Ipsilateral triplane and diaphyseal fractures have been reported, and one of the fractures can be missed if adequate images are not obtained.14,49,91 
Figure 32-11
 
A: Anteroposterior view of triplane fracture. On this view, the fracture appears to be a Salter–Harris type III configuration. B: Lateral view of triplane fracture. On this view, the fracture appears to be a Salter–Harris type II configuration. C: Three-dimensional CT reconstruction can demonstrate significant metaphyseal displacement. D: Three-dimensional CT reconstruction can demonstrate intra-articular displacement.
A: Anteroposterior view of triplane fracture. On this view, the fracture appears to be a Salter–Harris type III configuration. B: Lateral view of triplane fracture. On this view, the fracture appears to be a Salter–Harris type II configuration. C: Three-dimensional CT reconstruction can demonstrate significant metaphyseal displacement. D: Three-dimensional CT reconstruction can demonstrate intra-articular displacement.
View Original | Slide (.ppt)
Figure 32-11
A: Anteroposterior view of triplane fracture. On this view, the fracture appears to be a Salter–Harris type III configuration. B: Lateral view of triplane fracture. On this view, the fracture appears to be a Salter–Harris type II configuration. C: Three-dimensional CT reconstruction can demonstrate significant metaphyseal displacement. D: Three-dimensional CT reconstruction can demonstrate intra-articular displacement.
A: Anteroposterior view of triplane fracture. On this view, the fracture appears to be a Salter–Harris type III configuration. B: Lateral view of triplane fracture. On this view, the fracture appears to be a Salter–Harris type II configuration. C: Three-dimensional CT reconstruction can demonstrate significant metaphyseal displacement. D: Three-dimensional CT reconstruction can demonstrate intra-articular displacement.
View Original | Slide (.ppt)
X

Adolescent Pilon Fractures of the Distal Tibia and Fibula

The pediatric/adolescent pilon fracture117 is defined as a fracture of the “tibial plafond with articular and physeal involvement, variable talar and fibular involvement, variable comminution, and greater than 5 mm of displacement” (Fig. 32-12). Based upon a small number of cases, Letts et al. developed a three-part classification system. Type I fractures have minimal comminution and no physeal displacement. Type II fractures have marked comminution and less than 5 mm of physeal displacement. Type III fractures have marked comminution and more than 5 mm of physeal displacement. 
Figure 32-12
Anteroposterior and lateral radiographs of a pilon fracture in an adolescent.
Flynn-ch032-image012.png
View Original | Slide (.ppt)
X

Incisura Fractures of the Distal Tibia and Fibula

Incisural fractures are fractures that resemble Tillaux on standard radiographs, but the size of the fragment is smaller than that typically seen with the Tillaux fractures (Fig. 32-13).52 On the CT scan, this fracture does not extend to the anterior cortex of the distal tibia (Fig. 32-14). The mechanism of injury may be an avulsion of the fragment by the interosseous ligament. This may be a variant of an adult tibiofibular diastasis injury. 
Figure 32-13
 
Anteroposterior (A), lateral (B), and oblique (C) views of the ankle demonstrating an apparent small juvenile Tillaux fracture in a 14-year-old girl.
Anteroposterior (A), lateral (B), and oblique (C) views of the ankle demonstrating an apparent small juvenile Tillaux fracture in a 14-year-old girl.
View Original | Slide (.ppt)
Figure 32-13
Anteroposterior (A), lateral (B), and oblique (C) views of the ankle demonstrating an apparent small juvenile Tillaux fracture in a 14-year-old girl.
Anteroposterior (A), lateral (B), and oblique (C) views of the ankle demonstrating an apparent small juvenile Tillaux fracture in a 14-year-old girl.
View Original | Slide (.ppt)
X
Figure 32-14
Incisural fracture: CT scan at the level of the tibiotalar joint demonstrates that the fracture fragment does not include the attachment of the anterior-inferior tibiofibular ligament.
Flynn-ch032-image014.png
View Original | Slide (.ppt)
X

Syndesmosis Injuries of the Distal Tibial and Fibular Fractures

The authors have seen syndesmosis injuries in young patients. These have been associated with fractures of the distal fibula, Tillaux injuries, S-H I fractures, and proximal fibula fractures (Figs. 32-15, 32-16, 32-17). These fractures are probably rare and there is very limited literature on this injury.156 
Figure 32-15
 
A: Syndesmosis injury with distal fibula fracture. Radiographs with comparison of right and left sides. Note the widening of the medial clear space and the syndesmosis. B: Use of two percutaneously placed cannulated screws to reduce the syndesmosis.
A: Syndesmosis injury with distal fibula fracture. Radiographs with comparison of right and left sides. Note the widening of the medial clear space and the syndesmosis. B: Use of two percutaneously placed cannulated screws to reduce the syndesmosis.
View Original | Slide (.ppt)
Figure 32-15
A: Syndesmosis injury with distal fibula fracture. Radiographs with comparison of right and left sides. Note the widening of the medial clear space and the syndesmosis. B: Use of two percutaneously placed cannulated screws to reduce the syndesmosis.
A: Syndesmosis injury with distal fibula fracture. Radiographs with comparison of right and left sides. Note the widening of the medial clear space and the syndesmosis. B: Use of two percutaneously placed cannulated screws to reduce the syndesmosis.
View Original | Slide (.ppt)
X
Figure 32-16
A, B: Injury films. C–E: Postoperative films.
View Original | Slide (.ppt)
Figure 32-16
Triplane with deltoid injury and syndesmosis widening with stress views.
A, B: Injury films. C–E: Postoperative films.
A, B: Injury films. C–E: Postoperative films.
View Original | Slide (.ppt)
X
Figure 32-17
 
A, B: Deltoid and possible syndesmosis injury associated with triplane fracture pattern.
A, B: Deltoid and possible syndesmosis injury associated with triplane fracture pattern.
View Original | Slide (.ppt)
Figure 32-17
A, B: Deltoid and possible syndesmosis injury associated with triplane fracture pattern.
A, B: Deltoid and possible syndesmosis injury associated with triplane fracture pattern.
View Original | Slide (.ppt)
X

Stress Fractures of the Distal Tibia and Fibula

Stress fractures can occur in the distal tibial metaphyseal area (Fig. 32-18), or through the distal fibular physis (Fig. 32-19). These patients may present with warmth, swelling, and pain around the metaphyseal or physeal regions. In our experience, these injuries are more common in gymnasts, ice skaters, and running/endurance athletes. We have seen stress fractures through the distal fibular physeal scar in running athletes. 
Figure 32-18
Distal tibia stress fracture.
 
A 15-year-old male with 6 weeks of pain while running cross-country. Anteroposterior radiograph shows callus formation in the distal tibia metaphysis.
A 15-year-old male with 6 weeks of pain while running cross-country. Anteroposterior radiograph shows callus formation in the distal tibia metaphysis.
View Original | Slide (.ppt)
Figure 32-18
Distal tibia stress fracture.
A 15-year-old male with 6 weeks of pain while running cross-country. Anteroposterior radiograph shows callus formation in the distal tibia metaphysis.
A 15-year-old male with 6 weeks of pain while running cross-country. Anteroposterior radiograph shows callus formation in the distal tibia metaphysis.
View Original | Slide (.ppt)
X
Figure 32-19
Stress fracture of distal fibula.
 
A 16-year-old male with 6 weeks of pain while running track. Anteroposterior radiograph shows widened physis. The clinical examination shows point tenderness over the fibular physis.
A 16-year-old male with 6 weeks of pain while running track. Anteroposterior radiograph shows widened physis. The clinical examination shows point tenderness over the fibular physis.
View Original | Slide (.ppt)
Figure 32-19
Stress fracture of distal fibula.
A 16-year-old male with 6 weeks of pain while running track. Anteroposterior radiograph shows widened physis. The clinical examination shows point tenderness over the fibular physis.
A 16-year-old male with 6 weeks of pain while running track. Anteroposterior radiograph shows widened physis. The clinical examination shows point tenderness over the fibular physis.
View Original | Slide (.ppt)
X

Signs and Symptoms of Distal Tibial and Fibular Fractures

Patients with significantly displaced fractures have severe pain and obvious deformity. The position of the foot relative to the leg may provide important information about the mechanism of injury (Fig. 32-20) and should be considered in planning reduction. The status of the skin, pulses, and sensory and motor function should be determined and recorded. Tenderness, swelling, and deformity in the ipsilateral leg and foot should be noted. In patients with tibial shaft fractures, the ankle should be carefully evaluated clinically and radiographically. 
Figure 32-20
Severe clinical deformity in a 14-year-old boy with an ankle fracture.
 
It is obvious without radiographs that internal rotation will be needed to reduce this fracture.
It is obvious without radiographs that internal rotation will be needed to reduce this fracture.
View Original | Slide (.ppt)
Figure 32-20
Severe clinical deformity in a 14-year-old boy with an ankle fracture.
It is obvious without radiographs that internal rotation will be needed to reduce this fracture.
It is obvious without radiographs that internal rotation will be needed to reduce this fracture.
View Original | Slide (.ppt)
X
Although compartment syndromes are rare, they do occur in these locations.47,139 If patients are admitted to the hospital, discussion with the nursing staff about signs and symptoms of compartment syndrome is important. If patients are treated as outpatients, the patient and family should be informed about the possibility of compartment syndrome and instructed to return to the hospital for evaluation if problems with pain control develop. 

Imaging and Other Diagnostic Studies for Distal Tibial and Fibular Fractures

Patients with nondisplaced or minimally displaced ankle fractures often have no deformity, minimal swelling, and moderate pain. Because of their benign clinical appearance, such fractures may be easily missed if radiographs are not obtained. Petit et al.161 reviewed 2,470 radiographs from pediatric emergency rooms, demonstrating abnormal radiographic findings in 9%. Guidelines known as The Ottawa Ankle Rules have been established for adults to try to determine which injuries require radiographs.199 The Ottawa Ankle Rules have also been evaluated in children over the age of 5. These rules appear to be a reliable tool to exclude fractures in children greater than 5 years of age presenting with ankle and midfoot injuries and may significantly decrease x-ray use with a low likelihood of missing a fracture.59 The indications for radiographs according to the guidelines are complaints of pain near a malleolus with either inability to bear weight or tenderness to palpation at the malleolus. Chande43 prospectively studied 71 children with acute ankle injuries to determine if these guidelines could be applied to pediatric patients with ankle injuries. It was determined that if radiographs were obtained only in children with tenderness over the malleoli, and inability to bear weight, a 25% reduction in radiographic examinations could be achieved without missing any fractures. The physical examination should focus upon physeal areas of the tibia and fibula, when evaluating ankle injuries, to determine if radiographs are necessary. Interpretation of radiographs should focus upon signs of physeal injury, including soft tissue swelling in these regions. 
For patients with obvious deformities, anteroposterior, mortise, and lateral radiographs centered over the ankle may provide sufficient information to plan treatment. Although obtaining views of the joint above and below is recommended for most fractures, obtaining a film centered over the midtibia to include the knee and ankle joints on the radiographs significantly decreases the quality of ankle views and is not recommended. 
For patients without obvious deformities, a high-quality mortise view of the ankle is essential in addition to anteroposterior and lateral views. On a standard anteroposterior view, the lateral portion of the distal tibial physis is usually partially obscured by the distal fibula. The vertical component of a triplane or Tillaux fracture can be hidden behind the overlying fibular cortical shadow.119 A study by Vangsness et al.208 found that diagnostic accuracy was essentially equal when using anteroposterior, lateral, and mortise views compared with using only mortise and lateral views. Therefore, if only two views are to be obtained, the anteroposterior view may be omitted and lateral and mortise views obtained. 
Haraguchi et al.,79 described two special views designed to detect avulsion fractures from the lateral malleolus that are not visible on routine views, and to distinguish whether they represent avulsions of the anterior tibiofibular ligament or the calcaneofibular ligament attachments. The anterior tibiofibular ligament view is made by positioning the foot in 45 degrees of plantarflexion and elevating the medial border of the foot 15 degrees. The calcaneofibular ligament view is obtained by rotating the leg 45 degrees inward. 
Stress views are occasionally recommended historically to rule out ligamentous instability, but the authors see only rare indications for stress radiography in skeletally immature patients. The discomfort of stress views in an acute injury can be avoided by using other imaging options, such as magnetic resonance imaging (MRI). 
Bozic et al.27 studied the age at which the radiographic appearance of the incisura fibularis, tibiofibular clear space, and tibiofibular overlap develops in children.27 The purpose of their study was to facilitate the diagnosis of distal tibiofibular syndesmotic injury in children. They found that the incisura became detectable at a mean age of 8.2 years for girls and 11.2 years for boys. The mean age at which tibiofibular overlap appeared on the AP view was 5 years for both sexes; on the mortise view, it was 10 years for girls and 16 years for boys. The range of clear space measurements in normal children was 2 to 8 mm, with 23% of children having a clear space greater than 6 mm—a distance considered abnormal in adults. 
CT is useful in the evaluation of intra-articular fractures, especially juvenile Tillaux and triplane fractures (Fig. 32-21).7,14,31,49,66,95,107 Transverse images are obtained with thin cuts localized to the joint, and high-quality reconstructions can be produced in the coronal and sagittal planes without repositioning the ankle. Three-dimensional CT reconstructions may add further useful information, and readily available software packages allow easy production of such images (Fig. 32-22). These images can assist with minimally invasive approaches, the use of percutaneous reduction clamps, and positioning of fixation screws. 
Figure 32-21
Coronal and sagittal CT images of Tillaux fracture.
 
A: CT scan sagittal image of juvenile Tillaux fracture. Note the degree of intra-articular displacement. B: CT scan coronal image of juvenile Tillaux fracture. C: CT scan can facilitate screw placement/orientation. D: Reduction with intraepiphyseal screws.
A: CT scan sagittal image of juvenile Tillaux fracture. Note the degree of intra-articular displacement. B: CT scan coronal image of juvenile Tillaux fracture. C: CT scan can facilitate screw placement/orientation. D: Reduction with intraepiphyseal screws.
View Original | Slide (.ppt)
Figure 32-21
Coronal and sagittal CT images of Tillaux fracture.
A: CT scan sagittal image of juvenile Tillaux fracture. Note the degree of intra-articular displacement. B: CT scan coronal image of juvenile Tillaux fracture. C: CT scan can facilitate screw placement/orientation. D: Reduction with intraepiphyseal screws.
A: CT scan sagittal image of juvenile Tillaux fracture. Note the degree of intra-articular displacement. B: CT scan coronal image of juvenile Tillaux fracture. C: CT scan can facilitate screw placement/orientation. D: Reduction with intraepiphyseal screws.
View Original | Slide (.ppt)
X
Figure 32-22
Three-dimensional CT reconstruction of juvenile Tillaux fracture.
 
A: Coronal CT image of minimally displaced juvenile Tillaux fracture. B: Sagittal CT image of minimally displaced juvenile Tillaux fracture. C, D: Three-dimensional reconstruction of juvenile Tillaux fracture.
A: Coronal CT image of minimally displaced juvenile Tillaux fracture. B: Sagittal CT image of minimally displaced juvenile Tillaux fracture. C, D: Three-dimensional reconstruction of juvenile Tillaux fracture.
View Original | Slide (.ppt)
Figure 32-22
Three-dimensional CT reconstruction of juvenile Tillaux fracture.
A: Coronal CT image of minimally displaced juvenile Tillaux fracture. B: Sagittal CT image of minimally displaced juvenile Tillaux fracture. C, D: Three-dimensional reconstruction of juvenile Tillaux fracture.
A: Coronal CT image of minimally displaced juvenile Tillaux fracture. B: Sagittal CT image of minimally displaced juvenile Tillaux fracture. C, D: Three-dimensional reconstruction of juvenile Tillaux fracture.
View Original | Slide (.ppt)
X
MRI may be useful in the evaluation of complex fractures of the distal tibia and ankle in patients with open physes. Smith et al.195 found that of four patients with acute (3 to 10 days) physeal injuries, MRI showed that three had more severe fractures than indicated on plain films (Fig. 32-23). Early MRI studies (3 to 17 weeks after injury) not only added information about the pattern of physeal disruption but also supplied early information about the possibility of growth abnormality. MRI has been reported to be occasionally helpful in the identification of osteochondral injuries to the joint surfaces in children with ankle fractures.105 Although these injuries may be more common in adult fractures, we believe that these types of injuries are very rare in younger patients. 
Figure 32-23
 
A: Follow-up radiograph of a 7-year-old boy 1 week after an initially nondisplaced Salter–Harris type III fracture from a supination–inversion injury of the distal tibia. B: Because of the incomplete ossification of this area and concern that the fracture might have displaced, MRI was performed. Note that the distance between the medial malleolus and the talus is greater than the distance between the talus and the distal tibia or lateral malleolus, confirming displacement of the fracture.
A: Follow-up radiograph of a 7-year-old boy 1 week after an initially nondisplaced Salter–Harris type III fracture from a supination–inversion injury of the distal tibia. B: Because of the incomplete ossification of this area and concern that the fracture might have displaced, MRI was performed. Note that the distance between the medial malleolus and the talus is greater than the distance between the talus and the distal tibia or lateral malleolus, confirming displacement of the fracture.
View Original | Slide (.ppt)
Figure 32-23
A: Follow-up radiograph of a 7-year-old boy 1 week after an initially nondisplaced Salter–Harris type III fracture from a supination–inversion injury of the distal tibia. B: Because of the incomplete ossification of this area and concern that the fracture might have displaced, MRI was performed. Note that the distance between the medial malleolus and the talus is greater than the distance between the talus and the distal tibia or lateral malleolus, confirming displacement of the fracture.
A: Follow-up radiograph of a 7-year-old boy 1 week after an initially nondisplaced Salter–Harris type III fracture from a supination–inversion injury of the distal tibia. B: Because of the incomplete ossification of this area and concern that the fracture might have displaced, MRI was performed. Note that the distance between the medial malleolus and the talus is greater than the distance between the talus and the distal tibia or lateral malleolus, confirming displacement of the fracture.
View Original | Slide (.ppt)
X
Carey et al.36 obtained MRI studies on 14 patients with known or suspected growth plate injury. The MRI detected five radiographically occult fractures in the 14 patients, changed the Salter–Harris classification in two cases, and resulted in a change in treatment plan in 5 of the 14 patients studied. These studies would seem to contradict an earlier study by Petit et al.,1 that showed only one patient in a series of 29 patients in whom MRI revealed a diagnosis different from that made on plain films. Iwinska-Zelder et al.90 found that the MRI changed the management in 4 of 10 patients with ankle fractures seen on plain radiographs. Seifert et al.187 found the MRI identified physeal injuries that were not identified by plain radiographs. At this time, the indications for MRI in the evaluation of ankle fractures in skeletally immature patients are still being defined, but this imaging modality may be a more sensitivity tool for identification of minimally displaced or more complex injuries.14 In a recent prospective study of skeletally immature patients with clinically diagnosed Salter I fractures of the distal fibula, none of the 18 patients imaged by MRI had evidence of physeal injury. The patients had a mean age of 8 years, and over 70% had evidence of ligamentous sprain on MRI. This questions the principle that the physis is the weak link in the musculoskeletal system in this age group.24 If physeal arrest occurs, MRI scans are useful for mapping physeal bars.69,82 
The use of ultrasound to detect radiographically occult fractures may be used for pediatric ankle fractures.192 

Pitfalls in Diagnosis

A number of accessory ossification centers and normal anatomical variations may cause confusion in the interpretation of plain films of the ankle (Fig. 32-24). In a group of 100 children between the ages of 6 and 12 years, Powell165 found accessory ossification centers on the medial side (os subtibiale) in 20% and on the lateral side (os subfibulare) in 1%. If they are asymptomatic on clinical examination, these ossification centers are of little concern, but tenderness localized to them may indicate an injury. Stress views to determine motion of the fragments or MRI scanning may occasionally be considered if an injury to an accessory ossification center is suspected. 
Figure 32-24
Secondary ossification center in the lateral malleolus (arrows) of a 10-year-old girl.
 
Note the smooth border of the fibula and the ossification center. She also has a secondary ossification center in the medial malleolus.
Note the smooth border of the fibula and the ossification center. She also has a secondary ossification center in the medial malleolus.
View Original | Slide (.ppt)
Figure 32-24
Secondary ossification center in the lateral malleolus (arrows) of a 10-year-old girl.
Note the smooth border of the fibula and the ossification center. She also has a secondary ossification center in the medial malleolus.
Note the smooth border of the fibula and the ossification center. She also has a secondary ossification center in the medial malleolus.
View Original | Slide (.ppt)
X
Clefts in the lateral side of the tibial epiphysis may simulate juvenile Tillaux fractures, and clefts in the medial side may simulate Salter–Harris type III fractures.104 The presence of these clefts on radiographs of a child with an ankle injury may result in overtreatment if they are misdiagnosed as a fracture. Conversely, attributing a painful irregularity in these areas to anatomical variation may lead to undertreatment (Fig. 32-25). Other anatomical variations include a bump on the distal fibula that simulates a torus fracture and an apparent offset of the distal fibular epiphysis that simulates a fracture. These radiographic findings should be correlated with physical examination findings of focal swelling and point tenderness that correspond with the imaging in the diagnosis of skeletal injury. 
Figure 32-25
 
A: Mortise view of the ankle of a 10-year-old girl who had slight swelling and tenderness at the medial malleolus after an “ankle sprain.” The ossicle at the tip of the medial malleolus was correctly identified as an os subtibiale. A subtle line extending from the medial physis to just distal to the medial tibial plafond (arrow) was also believed to be an anatomic variant. B: Four weeks after injury, soreness persisted and radiographs clearly demonstrated a displaced Salter–Harris type III fracture.
A: Mortise view of the ankle of a 10-year-old girl who had slight swelling and tenderness at the medial malleolus after an “ankle sprain.” The ossicle at the tip of the medial malleolus was correctly identified as an os subtibiale. A subtle line extending from the medial physis to just distal to the medial tibial plafond (arrow) was also believed to be an anatomic variant. B: Four weeks after injury, soreness persisted and radiographs clearly demonstrated a displaced Salter–Harris type III fracture.
View Original | Slide (.ppt)
Figure 32-25
A: Mortise view of the ankle of a 10-year-old girl who had slight swelling and tenderness at the medial malleolus after an “ankle sprain.” The ossicle at the tip of the medial malleolus was correctly identified as an os subtibiale. A subtle line extending from the medial physis to just distal to the medial tibial plafond (arrow) was also believed to be an anatomic variant. B: Four weeks after injury, soreness persisted and radiographs clearly demonstrated a displaced Salter–Harris type III fracture.
A: Mortise view of the ankle of a 10-year-old girl who had slight swelling and tenderness at the medial malleolus after an “ankle sprain.” The ossicle at the tip of the medial malleolus was correctly identified as an os subtibiale. A subtle line extending from the medial physis to just distal to the medial tibial plafond (arrow) was also believed to be an anatomic variant. B: Four weeks after injury, soreness persisted and radiographs clearly demonstrated a displaced Salter–Harris type III fracture.
View Original | Slide (.ppt)
X

Pathoanatomy and Applied Anatomy Relating to Distal Tibial and Fibular Fractures

The ankle joint closely approximates a hinge joint. It is the articulation between the talus and the ankle mortise, which is a syndesmosis consisting of the distal tibial articular surface, the medial malleolus, and the distal fibula or lateral malleolus. 
Four ligamentous structures bind the distal tibia and fibula into the ankle mortise (Fig. 32-26). The anterior and posterior-inferior tibiofibular ligaments course inferiorly from the anterior and posterior surfaces of the distal lateral tibia to the anterior and posterior surfaces of the lateral malleolus. The anterior ligament is important in the pathomechanics of “transitional” ankle fractures. Just anterior to the posterior-inferior tibiofibular ligament is the broad, thick inferior transverse ligament, which extends down from the lateral malleolus along the posterior border of the articular surface of the tibia, almost to the medial malleolus. This ligament serves as a part of the articular surface for the talus. Between the anterior and posterior-inferior tibiofibular ligaments, the tibia and fibula are bound by the interosseous ligament, which is continuous with the interosseous membrane above. This ligament may be important in the pathomechanics of what we have termed incisural fractures. 
Figure 32-26
Posterior view of the distal tibia and fibula and the ligaments making up the ankle mortise.
Flynn-ch032-image026.png
View Original | Slide (.ppt)
X
On the medial side of the ankle, the talus is bound to the ankle mortise by the deltoid ligament (Fig. 32-27). This ligament arises from the medial malleolus and divides into superficial and deep layers. Three parts of the superficial layer are identified by their attachments: Tibionavicular, calcaneotibial, and posterior talotibial ligaments. The deep layer is known as the anterior talotibial ligament, again reflecting its insertion and origin. On the lateral side, the anterior and posterior talofibular ligament, with the calcaneofibular ligaments, make up the lateral collateral ligament (Fig. 32-28). 
Figure 32-27
Medial view of the ankle demonstrating the components of the deltoid ligament.
Flynn-ch032-image027.png
View Original | Slide (.ppt)
X
Figure 32-28
Lateral view of the ankle demonstrating the anterior and posterior talofibular ligaments and the calcaneofibular ligament.
Flynn-ch032-image028.png
View Original | Slide (.ppt)
X
In children, all medial and lateral ligaments originate distal to the tibial or fibular physis. Because the ligaments are often stronger than the physes, physeal fractures have generally been viewed as more common than ligamentous injuries in children. Advanced imaging studies have shown that the rate of ankle fractures compared to ligamentous injuries is variable,63 and this is likely dependent on multiple factors such as the mechanism of injury, rate of force application, relative strength of the physis, and age of the patient. When distal tibia and fibular fragments are displaced together, the syndesmosis at the level of the fracture is usually intact (Fig. 32-29). 
Figure 32-29
 
A: Pronation–external rotation injury resulting in a Salter–Harris type I fracture of the distal tibial physis. Note that despite this severe displacement, the relationship between the distal epiphysis of the tibia and distal fibula is preserved, and widening of the syndesmosis between the tibia and fibula is not present in this region. B, C: Anteroposterior and lateral radiographs demonstrate satisfactory closed reduction.
A: Pronation–external rotation injury resulting in a Salter–Harris type I fracture of the distal tibial physis. Note that despite this severe displacement, the relationship between the distal epiphysis of the tibia and distal fibula is preserved, and widening of the syndesmosis between the tibia and fibula is not present in this region. B, C: Anteroposterior and lateral radiographs demonstrate satisfactory closed reduction.
View Original | Slide (.ppt)
Figure 32-29
A: Pronation–external rotation injury resulting in a Salter–Harris type I fracture of the distal tibial physis. Note that despite this severe displacement, the relationship between the distal epiphysis of the tibia and distal fibula is preserved, and widening of the syndesmosis between the tibia and fibula is not present in this region. B, C: Anteroposterior and lateral radiographs demonstrate satisfactory closed reduction.
A: Pronation–external rotation injury resulting in a Salter–Harris type I fracture of the distal tibial physis. Note that despite this severe displacement, the relationship between the distal epiphysis of the tibia and distal fibula is preserved, and widening of the syndesmosis between the tibia and fibula is not present in this region. B, C: Anteroposterior and lateral radiographs demonstrate satisfactory closed reduction.
View Original | Slide (.ppt)
X
The distal tibial ossification center generally appears at 6 to 24 months of age. Its malleolar extension begins to form around the age of 7 or 8 years and is mature or complete at the age of 10 years. The medial malleolus develops as an elongation of the distal tibia ossific nucleus, although in 20% of cases, this may originate from a separate ossification center, the os tibial. This can be mistaken as a fracture.102 The physis usually closes around the age of 15 years in girls and 17 years in boys. This process takes approximately 18 months and occurs first in the central part of the physis, extending next to the medial side, and finally ending laterally. This asymmetric closure sequence is an important anatomical feature of the growing ankle and is responsible for certain fracture patterns in adolescents, especially transitional fractures (Fig. 32-30). 
Figure 32-30
 
Closure of the distal tibial physis begins centrally (A), extends medially (B), and then laterally (C) before final closure (D).
Closure of the distal tibial physis begins centrally (A), extends medially (B), and then laterally (C) before final closure (D).
View Original | Slide (.ppt)
Figure 32-30
Closure of the distal tibial physis begins centrally (A), extends medially (B), and then laterally (C) before final closure (D).
Closure of the distal tibial physis begins centrally (A), extends medially (B), and then laterally (C) before final closure (D).
View Original | Slide (.ppt)
X
The distal fibular ossification center appears around the age of 9 to 24 months. This physis is located at the level of the ankle joint initially, and moves distally with growth.100,214 Closure of this physis generally follows closure of the distal tibial physis by 12 to 24 months. 
The locations of the sensory nerves are important anatomic landmarks, as surgical exposures should aim to protect these structures. The superficial peroneal nerve branches may be most vulnerable around the ankle, especially during arthroscopic and arthrotomy approaches for triplane and Tillaux fractures.15 This is important when arthroscopic and percutaneous reduction techniques are employed for fracture treatment (refer to section on Fracture Reduction Tips, Arthroscopic Assistance, Use of Percutaneous Clamps, Implants). 

Treatment Options for Distal Tibial and Fibular Fractures

Appropriate treatment of ankle fractures in children depends on the location of the fracture, the degree of displacement, and the age of the child (Table 32-1). Nondisplaced fractures may be simply immobilized. A recent randomized clinical trial for minimally displaced low-risk ankle fractures compared a fiberglass posterior splint to a removable ankle stirrup brace. This study demonstrated good outcomes in both groups.8 Closed reduction and cast immobilization may be appropriate for displaced fractures; if the closed reduction cannot be maintained with casting, skeletal fixation may be necessary. If closed reduction is not possible, open reduction may be indicated, followed by internal fixation or cast immobilization. 
 
Table 32-1
Current Treatment Options
View Large
Table 32-1
Current Treatment Options
Fracture Options Pro Cons
Distal tibia physis Above-knee versus below-knee cast Below-knee casts may allow for less knee stiffness and muscle atrophy of the thigh For fractures with potential for displacement, the below-knee cast may increase the risk of displacement.
Local anesthesia with sedation versus general anesthesia (closed reduction of fractures) Local anesthesia techniques combined with sedation in the ER may be less expensive, and allow for early reduction Guidelines for sedation techniques must follow guidelines established by the American Society of Anesthesiologists, and adequate facilities and personnel may not be available in all emergency rooms.
Minimally invasive approaches (including arthroscopic assistance) versus traditional open surgical exposures Arthroscopic-assisted procedures may allow for smaller incisions, and better assessment of articular reductions than open exposures Additional equipment and OR staffing requirements for arthroscopy are necessary. Surgeon experience with arthroscopy may be more limited.
Bioabsorbable versus metal implants Bioabsorbable devices do not require removal, and subsequent imaging studies (CT, MRI) are not affected by these implants First-generation implants have a higher risk of local inflammation, and the quality of fixation may be less secure.
X
The anatomical type of the fracture (usually defined by the Salter–Harris classification), the mechanism of injury, and the amount of displacement of the fragments are important considerations. When the articular surface is disrupted, the amount of articular step-off or separation must be measured. The neurologic and vascular status of the limb or the status of the skin may require emergency treatment of the fracture and associated problems. The general health of the patient and the time since injury must also be considered. 

Distal Tibial Fractures

Salter–Harris Type I and II Fractures

According to Dias and Tachdjian,57,201 Salter–Harris type I fractures of the distal tibia can be caused by any of the four mechanisms: Supination–inversion, supination–plantarflexion, supination–external rotation, or pronation–eversion–external rotation. Spiegel et al.196 reported that these fractures accounted for 15.2% of 237 ankle injuries in their series and occurred in children significantly younger (average age, 10.5 years) than those with other Salter–Harris types of fractures. 
The mechanism of injury is deduced primarily by the direction of displacement of the distal tibial epiphysis; for example, straight posterior displacement indicates a supination–plantarflexion mechanism. The type of associated fibular fracture is also indicative of the mechanism of injury; for example, a high, oblique or transverse fibular fracture indicates a pronation–eversion–external injury, whereas a lower spiral fibular fracture indicates a supination–external rotation injury. Lovell,124 Broock and Greer,27 and Nevelös and Colton145 reported unusual Salter–Harris type I fractures in which the distal tibial epiphysis was externally rotated 90 degrees without fracture of the fibula or displacement of the tibial epiphysis in any direction in the transverse plane. 
Cast immobilization is generally sufficient treatment for nondisplaced Salter–Harris type I fractures of the distal tibia. A below-knee cast worn for 3 to 4 weeks may suffice, with the first 2 to 3 weeks limited to nonweight bearing. An above-knee cast may also be used, although this may not be necessary as these fractures are usually very stable. In very active patients who may not comply with activity/weight-bearing restrictions, this type of cast may be an advantage. After cast removal, use of a removable leg/ankle walking boot may be used, followed by a therapy program in older patients or those trying to return to competitive sports at an earlier time. In our experience, formal supervised therapy is not necessary in younger patients. The normal activity of these children is usually sufficient therapy. 
Most displaced fractures can be treated with closed reduction and cast immobilization. An above-knee non–weight-bearing cast is preferable initially, as this should reduce the risk of displacement after reduction. These casts may be changed to a short-leg walking cast or removable walking boot at 3 to 4 weeks. These fractures can displace in the first 1 to 2 weeks postoperatively, and close follow-up with radiographic surveillance for this is necessary. One of the authors (KS) frequently places one or two Kirschner wires at the time of closed reduction, to prevent displacement after reduction under anesthesia (Fig. 32-31). These pins are usually removed in the clinic 2 to 3 weeks after placement. Under these circumstances, a below-knee cast can be used. 
Figure 32-31
 
A, B: Displaced distal tibial Salter–Harris type II fracture, with distal diaphyseal fibula fracture. C, D: Fracture treated with closed reduction and internal fixation.
A, B: Displaced distal tibial Salter–Harris type II fracture, with distal diaphyseal fibula fracture. C, D: Fracture treated with closed reduction and internal fixation.
View Original | Slide (.ppt)
Figure 32-31
A, B: Displaced distal tibial Salter–Harris type II fracture, with distal diaphyseal fibula fracture. C, D: Fracture treated with closed reduction and internal fixation.
A, B: Displaced distal tibial Salter–Harris type II fracture, with distal diaphyseal fibula fracture. C, D: Fracture treated with closed reduction and internal fixation.
View Original | Slide (.ppt)
X

Salter–Harris Type II Fractures

Salter–Harris type II fractures can also be caused by any of the four mechanisms of injury described by Dias and Giegerich.56 In the series of Spiegel et al.,196 Salter–Harris type II fractures were the most common injuries (44.8%). In addition to the direction of displacement of the distal tibial epiphysis and the nature of any associated fibular fracture, the location of the Thurston–Holland fragment is helpful in determining the mechanism of injury; for example, a lateral fragment indicates a pronation–eversion–external rotation injury; a posteromedial fragment, a supination–external rotation injury; and a posterior fragment, a supination–plantarflexion injury (Fig. 32-32). 
Figure 32-32
 
A: Severe plantarflexion injury with severe swelling of the ankle and foot; the reduction obtained was unstable. B: The reduction was stabilized by two transmetaphyseal screws placed percutaneously. C: Anteroposterior view confirms an anatomic reduction.
A: Severe plantarflexion injury with severe swelling of the ankle and foot; the reduction obtained was unstable. B: The reduction was stabilized by two transmetaphyseal screws placed percutaneously. C: Anteroposterior view confirms an anatomic reduction.
View Original | Slide (.ppt)
Figure 32-32
A: Severe plantarflexion injury with severe swelling of the ankle and foot; the reduction obtained was unstable. B: The reduction was stabilized by two transmetaphyseal screws placed percutaneously. C: Anteroposterior view confirms an anatomic reduction.
A: Severe plantarflexion injury with severe swelling of the ankle and foot; the reduction obtained was unstable. B: The reduction was stabilized by two transmetaphyseal screws placed percutaneously. C: Anteroposterior view confirms an anatomic reduction.
View Original | Slide (.ppt)
X
Nondisplaced fractures can be treated with cast immobilization usually with an above-knee cast for 3 to 4 weeks, followed by a below-knee walking cast or removable cast/walking boot for another 3 to 4 weeks. 
Although most authors agree that closed reduction of significantly displaced Salter–Harris type II ankle fracture should be attempted, opinions differ as to what degree of residual displacement or angulation is unacceptable and requires open reduction. Based on follow-up of 33 Salter–Harris type II ankle fractures, Carothers and Crenshaw37 concluded that “accurate reposition of the displaced epiphysis at the expense of forced or repeated manipulation or operative intervention is not indicated since spontaneous realignment of the ankle occurs even late in the growing period.” They found no residual angulation at follow-up in patients who had up to 12 degrees of tilt after reduction, even in patients as old as 13 years of age at the time of injury. Spiegel et al.,196 however, reported complications at follow-up in 11 of 16 patients with Salter–Harris type II ankle fractures. Because 6 of these 11 patients had angular deformities that were attributed to lack of adequate reduction of the fracture, Spiegel et al. recommend “precise anatomical reduction.” 
Barmada et al.7 reviewed a series of Salter–Harris type I and II fractures. In patients with more than 3 mm of physeal widening, the risk of premature physeal closure was 60%, compared with 17% in patients with less than 3 mm of physeal widening. Although they were unable to demonstrate a significant decrease in partial physeal arrest in those treated with surgery, they recommended open reduction and removal of the entrapped periosteal flap. Leary et al.113 studied 15 distal tibia fractures with premature physeal closure, and found residual gap and number of reduction attempts did not predict early closure, but initial displacement did. The literature on the value of open reduction and removal of interposed periosteum to lower the incidence of premature physeal closure is conflicted in these fractures, and it is likely that multiple variables are involved (energy of initial injury, amount of displacement, number of reduction attempts, age of patient). 
Incomplete reduction is frequently caused by interposition of soft tissue between the fracture fragments. Grace75 reported three patients in whom the interposed soft tissue included the neurovascular bundle, resulting in circulatory embarrassment when closed reduction was attempted. In this situation, open reduction and extraction of the soft tissue obviously is required. As noted above, a less definitive indication for open reduction is interposition of the periosteum, which causes physeal widening with no or minimal angulation. Good results have been reported after open reduction and extraction of the periosteal flap (Fig. 32-33).110 It is not clear that failure to extract the periosteum in such cases results in physeal arrest sufficient to warrant operative treatment. Wattenbarger et al.211 and Phieffer et al.163 have attempted to determine the relationship between physeal bar formation and interposed periosteum, although at this time it is unclear if the periosteal flap increases the risk of physeal arrest. 
Figure 32-33
 
A: Severely displaced pronation–eversion–external rotation injury. B: Closed reduction was unsuccessful, and a valgus tilt of the ankle mortise was noted. At surgery, soft tissue was interposed laterally (arrows). C: Reduction completed and stabilized with two cancellous screws placed above the physis.
A: Severely displaced pronation–eversion–external rotation injury. B: Closed reduction was unsuccessful, and a valgus tilt of the ankle mortise was noted. At surgery, soft tissue was interposed laterally (arrows). C: Reduction completed and stabilized with two cancellous screws placed above the physis.
View Original | Slide (.ppt)
Figure 32-33
A: Severely displaced pronation–eversion–external rotation injury. B: Closed reduction was unsuccessful, and a valgus tilt of the ankle mortise was noted. At surgery, soft tissue was interposed laterally (arrows). C: Reduction completed and stabilized with two cancellous screws placed above the physis.
A: Severely displaced pronation–eversion–external rotation injury. B: Closed reduction was unsuccessful, and a valgus tilt of the ankle mortise was noted. At surgery, soft tissue was interposed laterally (arrows). C: Reduction completed and stabilized with two cancellous screws placed above the physis.
View Original | Slide (.ppt)
X
Because of risk of iatrogenic damage to the distal tibial physis during closed reduction, many authors recommend the use of general anesthesia with adequate muscle relaxation for children with Salter–Harris type II distal tibial fractures. However, no study has compared the frequency of growth abnormalities in patients with these fractures reduced under sedation and local analgesia to those with fractures reduced with the use of general anesthesia. One of the authors (KS) uses general anesthesia, and an arthroscopic ankle distractor to distract the fracture before reduction, with the theoretical advantage of reducing the risk of physeal damage during the reduction maneuver (Fig. 32-34). 
Figure 32-34
Use of ankle distractor.
 
A: Thigh positioner to allow for ankle distractor. B: Sterile ankle distractor in place. C: Distractor can remain in place during reduction maneuvers. D: C-arm can be brought into the field to evaluate the reduction.
A: Thigh positioner to allow for ankle distractor. B: Sterile ankle distractor in place. C: Distractor can remain in place during reduction maneuvers. D: C-arm can be brought into the field to evaluate the reduction.
View Original | Slide (.ppt)
Figure 32-34
Use of ankle distractor.
A: Thigh positioner to allow for ankle distractor. B: Sterile ankle distractor in place. C: Distractor can remain in place during reduction maneuvers. D: C-arm can be brought into the field to evaluate the reduction.
A: Thigh positioner to allow for ankle distractor. B: Sterile ankle distractor in place. C: Distractor can remain in place during reduction maneuvers. D: C-arm can be brought into the field to evaluate the reduction.
View Original | Slide (.ppt)
X
When closed reductions are not performed under general anesthesia, they are usually done under IV sedation. Alioto et al. demonstrated significantly improved pain relief with hematoma block for ankle fractures in a study comparing patients treated with IV sedation to patients receiving hematoma block.54 Intravenous regional anesthesia or Bier block has also been reported to be effective for pain relief in lower extremity injuries.114 
One advantage of reduction in the operating room with general anesthesia is the ease with which percutaneous pins can be placed to maintain reduction of the fractures. It is the experience of one of the authors that Salter–Harris I and II fractures will occasionally displace after closed reduction and above-knee casting. If there is any concern about redisplacement or stability, smooth pins can be placed at that time. 
Surgeons using regional block anesthesia within the first 2 to 3 days after the fracture should consider the potential for compartment syndrome. In fractures that have a higher risk of compartment syndrome, regional anesthesia, especially peripheral nerve blocks with longer-acting agents, might delay the recognition of a compartment syndrome.140 

Salter–Harris Type III and IV Fractures

Salter–Harris type III and IV fractures are discussed together because the mechanism of injury is the same (supination–inversion) and their treatment and prognosis are similar. Juvenile Tillaux and triplane fractures are considered separately. In the series of Spiegel et al.,196 24.1% of the fractures were Salter–Harris type III injuries and 1.4% were type IV. These injuries are usually produced by the medial corner of the talus being driven into the junction of the distal tibial articular surface and the medial malleolus. As the talus shears off the medial malleolus, the physis may also be damaged (Fig. 32-35). 
Figure 32-35
 
A: Severe ankle injury sustained by an 8-year-old involved in a car accident. The anteroposterior view in the splint does not clearly show the Salter–Harris type IV fracture of the tibia. The dome of the talus appears abnormal. B: CT scan shows the displaced Salter–Harris type IV fracture of the medial malleolus and a severe displaced intra-articular fracture of the body of the talus. C, D: Open reduction of both fractures was performed, and Herbert screws were used for internal fixation.
 
(Courtesy of Armen Kelikian, MD.)
A: Severe ankle injury sustained by an 8-year-old involved in a car accident. The anteroposterior view in the splint does not clearly show the Salter–Harris type IV fracture of the tibia. The dome of the talus appears abnormal. B: CT scan shows the displaced Salter–Harris type IV fracture of the medial malleolus and a severe displaced intra-articular fracture of the body of the talus. C, D: Open reduction of both fractures was performed, and Herbert screws were used for internal fixation.
View Original | Slide (.ppt)
Figure 32-35
A: Severe ankle injury sustained by an 8-year-old involved in a car accident. The anteroposterior view in the splint does not clearly show the Salter–Harris type IV fracture of the tibia. The dome of the talus appears abnormal. B: CT scan shows the displaced Salter–Harris type IV fracture of the medial malleolus and a severe displaced intra-articular fracture of the body of the talus. C, D: Open reduction of both fractures was performed, and Herbert screws were used for internal fixation.
(Courtesy of Armen Kelikian, MD.)
A: Severe ankle injury sustained by an 8-year-old involved in a car accident. The anteroposterior view in the splint does not clearly show the Salter–Harris type IV fracture of the tibia. The dome of the talus appears abnormal. B: CT scan shows the displaced Salter–Harris type IV fracture of the medial malleolus and a severe displaced intra-articular fracture of the body of the talus. C, D: Open reduction of both fractures was performed, and Herbert screws were used for internal fixation.
View Original | Slide (.ppt)
X
Nondisplaced Salter–Harris types III and IV fractures can be treated with above-knee cast immobilization, but care must be taken to be sure that the significant intra-articular displacement is not present. Radiographs frequently underestimate the degree of intra-articular involvement and step-off of the articular surfaces. CT imaging may be necessary to fully appreciate the degree of displacement (Fig. 32-11). Follow-up radiographs and/or CT scans in the first 2 weeks may also be necessary to confirm that no displacement occurs after casting. 
Salter–Harris type III fractures of the medial malleolus may have a higher risk of physeal arrest. One study suggested that the rate of physeal arrest could be reduced by the use of open reduction and internal fixation.102,111 Luhmann et al.125 have recently studied a series of medial malleolar fractures with growth disturbance following treatment, and recommends anatomic reduction as fractures with as little as 2 mm of step-off went on to premature physeal closure. Others have also emphasized the importance of anatomic reduction and early treatment to reduce the risk of physeal arrest.162 
Based upon principles of fracture treatment in adults, displaced intra-articular fractures are treated with as anatomical a reduction as possible. Studies in children confirming the importance of articular reduction to within 2 mm are few (66), although most recommend anatomic articular reduction in displaced fractures involving the articular surface. Failure to obtain anatomical reduction may result in articular incongruity and posttraumatic arthritis, which often becomes symptomatic 5 to 8 years after skeletal maturity.40 The risk of growth arrest has also been linked to the adequacy of reduction, although the literature is still unclear if anatomic reduction reduces the risk of physeal arrest (Fig. 32-36).111 Some recent series suggest early anatomic reduction is associated with a lower risk of physeal arrest.186 Closed reduction may be attempted but is likely to succeed only in minimally displaced fractures. If closed reduction is obtained, it can be maintained with a cast or with percutaneous pins or screws supplemented by a cast. 
Figure 32-36
 
A: Anteroposterior view of a patient with a pronation–eversion–external rotation fracture. B: Postreduction view shows residual gapping of physis suggesting periosteal interposition. C: Anteroposterior view obtained for a new injury (medial malleolar fracture) shows premature closure of the physis.
A: Anteroposterior view of a patient with a pronation–eversion–external rotation fracture. B: Postreduction view shows residual gapping of physis suggesting periosteal interposition. C: Anteroposterior view obtained for a new injury (medial malleolar fracture) shows premature closure of the physis.
View Original | Slide (.ppt)
Figure 32-36
A: Anteroposterior view of a patient with a pronation–eversion–external rotation fracture. B: Postreduction view shows residual gapping of physis suggesting periosteal interposition. C: Anteroposterior view obtained for a new injury (medial malleolar fracture) shows premature closure of the physis.
A: Anteroposterior view of a patient with a pronation–eversion–external rotation fracture. B: Postreduction view shows residual gapping of physis suggesting periosteal interposition. C: Anteroposterior view obtained for a new injury (medial malleolar fracture) shows premature closure of the physis.
View Original | Slide (.ppt)
X
If anatomical reduction cannot be obtained by closed methods, open reduction and internal fixation or mini-open arthroscopic reduction should be carried out. Lintecum and Blasier120 described a technique of open reduction achieved through a limited exposure of the fracture with the incision centered over the fracture site combined with percutaneous cannulated screw fixation. This technique was performed on 13 patients, 8 Salter–Harris IV fractures, 4 Salter–Harris III fractures, and 1 triplane fracture. The authors reported one growth arrest at follow-up averaging 12 months. Beaty and Linton10 reported a Salter–Harris type III fracture with an intra-articular fragment (Fig. 32-37); these fractures require open reduction for inspection of the joint to ensure that no osteochondral fragments are impeding reduction. Arthroscopic evaluation of the joint may also be an option. Internal fixation devices should be inserted within the epiphysis, parallel to the physis in patients with greater than 2 years of growth remaining, and should avoid entering ankle joint (Figs. 32-21 and 32-38). 
Figure 32-37
 
A: Salter–Harris type III fracture of the medial malleolus and Salter–Harris type I fracture of the fibula in a 9-year-old girl. An intra-articular fragment was visible only on a mortise view radiograph. B: CT scan outlined the Salter–Harris type III fracture of the medial malleolus and the fragment of bone. C: Two years after excision of the osteochondral fragment, open reduction of the malleolar fracture, and internal fixation.
 
(A, B reprinted from Beaty JH, Linton RC. Medial malleolar fracture in a child. A case report. J Bone Joint Surg Am. 1988; 70:1254–1255, with permission.)
A: Salter–Harris type III fracture of the medial malleolus and Salter–Harris type I fracture of the fibula in a 9-year-old girl. An intra-articular fragment was visible only on a mortise view radiograph. B: CT scan outlined the Salter–Harris type III fracture of the medial malleolus and the fragment of bone. C: Two years after excision of the osteochondral fragment, open reduction of the malleolar fracture, and internal fixation.
View Original | Slide (.ppt)
A: Salter–Harris type III fracture of the medial malleolus and Salter–Harris type I fracture of the fibula in a 9-year-old girl. An intra-articular fragment was visible only on a mortise view radiograph. B: CT scan outlined the Salter–Harris type III fracture of the medial malleolus and the fragment of bone. C: Two years after excision of the osteochondral fragment, open reduction of the malleolar fracture, and internal fixation.
View Original | Slide (.ppt)
Figure 32-37
A: Salter–Harris type III fracture of the medial malleolus and Salter–Harris type I fracture of the fibula in a 9-year-old girl. An intra-articular fragment was visible only on a mortise view radiograph. B: CT scan outlined the Salter–Harris type III fracture of the medial malleolus and the fragment of bone. C: Two years after excision of the osteochondral fragment, open reduction of the malleolar fracture, and internal fixation.
(A, B reprinted from Beaty JH, Linton RC. Medial malleolar fracture in a child. A case report. J Bone Joint Surg Am. 1988; 70:1254–1255, with permission.)
A: Salter–Harris type III fracture of the medial malleolus and Salter–Harris type I fracture of the fibula in a 9-year-old girl. An intra-articular fragment was visible only on a mortise view radiograph. B: CT scan outlined the Salter–Harris type III fracture of the medial malleolus and the fragment of bone. C: Two years after excision of the osteochondral fragment, open reduction of the malleolar fracture, and internal fixation.
View Original | Slide (.ppt)
A: Salter–Harris type III fracture of the medial malleolus and Salter–Harris type I fracture of the fibula in a 9-year-old girl. An intra-articular fragment was visible only on a mortise view radiograph. B: CT scan outlined the Salter–Harris type III fracture of the medial malleolus and the fragment of bone. C: Two years after excision of the osteochondral fragment, open reduction of the malleolar fracture, and internal fixation.
View Original | Slide (.ppt)
X
Figure 32-38
 
A: Grade II supination–inversion injury in a 12-year-old girl, resulting in a displaced Salter–Harris type IV fracture of the distal tibia and a nondisplaced Salter–Harris type I fracture of the distal fibula. B: After anatomic open reduction and stable internal fixation.
A: Grade II supination–inversion injury in a 12-year-old girl, resulting in a displaced Salter–Harris type IV fracture of the distal tibia and a nondisplaced Salter–Harris type I fracture of the distal fibula. B: After anatomic open reduction and stable internal fixation.
View Original | Slide (.ppt)
Figure 32-38
A: Grade II supination–inversion injury in a 12-year-old girl, resulting in a displaced Salter–Harris type IV fracture of the distal tibia and a nondisplaced Salter–Harris type I fracture of the distal fibula. B: After anatomic open reduction and stable internal fixation.
A: Grade II supination–inversion injury in a 12-year-old girl, resulting in a displaced Salter–Harris type IV fracture of the distal tibia and a nondisplaced Salter–Harris type I fracture of the distal fibula. B: After anatomic open reduction and stable internal fixation.
View Original | Slide (.ppt)
X
Arthroscopic-assisted fixation of fractures with intra-articular involvement have been described by several centers. Jennings et al.92 presented a series of five triplane and one Tillaux fractures treated with arthroscopic assistance. The outcome was excellent for fracture reduction and ankle function. Kaya et al.103 review 10 patients with juvenile Tillaux fractures treated with arthroscopic assistance, demonstrating excellent reduction and clinical outcomes.153 One of the primary advantages of arthroscopic fixation is that it allows for visualization of the articular surfaces, although the need for open reduction of the metaphyseal and epiphyseal regions may still require open incisions. 
Options for internal fixation include smooth Kirschner wires, small fragment cortical and cancellous screws, and 4-mm cannulated screws (Fig. 32-39). Several reports12,20,32 have advocated the use of absorbable pins for internal fixation of ankle fractures. Benz et al.12 reported no complications or growth abnormalities after the use of absorbable pins with metal screw supplementation for fixation of five ankle fractures in patients between the ages of 5 and 13 years. In reports of the use of absorbable pins without supplemental metal fixation in adults,19,21,68,86 complications have included displacement (14.5%), sterile fluid accumulation requiring incision and drainage (8.1%), pseudarthrosis (8%), distal tibiofibular synostosis (3.8%), and infection (1.6%). Bucholz et al.32 reported few complications in a series of fractures in adults fixed with absorbable screws made of polylactide and suggested that complications in earlier series might be related to the fact that those pins were made of polyglycolide. A report in 1993 by Böstman et al.,20 however, included few complications in a series of fractures in children fixed with polyglycolide pins. A follow-up report by Rokkanen et al.,175 in 1996 reported 3.6% infection and 3.7% failure of fixation. 
Figure 32-39
 
A: Supination–inversion injury with a Salter–Harris type III fracture of the medial malleolus. B: Six months after open reduction and internal fixation with two transepiphyseal cannulated screws. C: Eighteen months after injury, the fracture has healed with no evidence of growth arrest or angular deformity. (Arrows note normal, symmetric Park–Harris growth arrest line.)
A: Supination–inversion injury with a Salter–Harris type III fracture of the medial malleolus. B: Six months after open reduction and internal fixation with two transepiphyseal cannulated screws. C: Eighteen months after injury, the fracture has healed with no evidence of growth arrest or angular deformity. (Arrows note normal, symmetric Park–Harris growth arrest line.)
View Original | Slide (.ppt)
Figure 32-39
A: Supination–inversion injury with a Salter–Harris type III fracture of the medial malleolus. B: Six months after open reduction and internal fixation with two transepiphyseal cannulated screws. C: Eighteen months after injury, the fracture has healed with no evidence of growth arrest or angular deformity. (Arrows note normal, symmetric Park–Harris growth arrest line.)
A: Supination–inversion injury with a Salter–Harris type III fracture of the medial malleolus. B: Six months after open reduction and internal fixation with two transepiphyseal cannulated screws. C: Eighteen months after injury, the fracture has healed with no evidence of growth arrest or angular deformity. (Arrows note normal, symmetric Park–Harris growth arrest line.)
View Original | Slide (.ppt)
X
The main advantage of absorbable pins and screws is that hardware removal is avoided. Böstman compared the cost-effectiveness of absorbable implants in 994 patients treated with absorbable implants to 1,173 patients treated with metallic implants. To be cost-effective, the hardware removal rates required were calculated to range from 19% for metacarpal fractures to 54% for trimalleolar fractures.22 At this time, the indications for absorbable pins remain unclear. 
Recent studies in the adult literature suggest second-generation bioabsorbable screws have lower complication rates, and their use may be increasing.167,194 Additional studies in adult patients using ultrasound and MRI have not detected deleterious effects on healing with newer screw designs.78,132 Because children are typically smaller and lighter than adults, the implants used for fixation may not need to be as strong or large as those required by adult patients. This suggests that younger patients may be better candidates for these bioabsorbable implants. The presence of the physis, and the low-grade inflammation that may accompany the dissolution of these implants, however, may increase the risk of physeal arrest, and additional studies in adult and pediatric patients will be necessary to confirm the effectiveness and safety of these devices.101 

Salter–Harris Type V Fractures

Salter–Harris type V fractures of the ankle are believed to be caused by severe axial compression and crushing of the physis (Fig. 32-40). As originally described, these injuries are not usually associated with significant displacement of the epiphysis relative to the metaphysis, which make diagnosis of acute injury impossible from plain radiographs; the diagnosis can only be made on follow-up radiographs when premature physeal closure is evident. Spiegel et al.196 have designated comminuted fractures that are otherwise unclassifiable as Salter–Harris type V injuries. 
Figure 32-40
Compression-type injury of the tibial physis.
 
Early physeal arrest can cause leg-length discrepancy.
Early physeal arrest can cause leg-length discrepancy.
View Original | Slide (.ppt)
Figure 32-40
Compression-type injury of the tibial physis.
Early physeal arrest can cause leg-length discrepancy.
Early physeal arrest can cause leg-length discrepancy.
View Original | Slide (.ppt)
X
The incidence of Salter–Harris type V ankle fractures is difficult to establish because of the difficulty of diagnosing acute injuries. Spiegel et al.196 included two type V fractures in their series, but both were comminuted fractures rather than the classic crush injury without initial radiographic abnormality. 
Because of the uncertain nature of this injury, no specific treatment recommendations have been formulated. Treatment is usually directed primarily toward the sequelae of growth arrest that invariably follows Salter–Harris type V fractures. Perhaps more sophisticated scanning techniques will eventually allow identification and localization of areas of physeal injury so that irreparable damaged cells can be removed and replaced with interposition materials to prevent growth problems, but at present this diagnosis is made only several months after injury. 

Other Fractures of the Distal Tibia

Accessory ossification centers of the distal tibia (os subtibiale) and distal fibula (os fibulare) are common and may be injured. Treatment usually consists of cast immobilization for 3 to 4 weeks. Ogden and Lee150 reported good results after cast immobilization in 26 of 27 patients with injuries involving the medial side of the tibia; only one patient required surgery. In contrast, 5 to 11 patients with injuries involving the lateral side had persistent symptoms that required excision. 
Injuries to the perichondral ring of the distal tibial and fibular physes, with physeal disruption, have been described.83 Most of these injuries are caused by skiving of the bone by machinery such as lawn mowers. They may result in growth arrest or retardation and in angular deformities. (See Open Fractures and Lawn Mower Injuries.) 

Juvenile Tillaux Fractures

This fracture is the adolescent counterpart of the fracture described in adults by the French surgeon Tillaux. It occurs when with external rotation of the foot, the anterior-inferior tibiofibular ligament through its attachments to the anterolateral tibia, avulses a fragment of bone corresponding to the portion of the distal tibial physis that is still open (Fig. 32-41). In the series of Spiegel et al.,196 these fractures occurred in 2.9% of patients. 
Figure 32-41
Juvenile Tillaux fracture.
 
Mechanism of injury: The anteroinferior tibiofibular ligament avulses a fragment of the lateral epiphysis (A) corresponding to the portion of the physis that is still open (B).
Mechanism of injury: The anteroinferior tibiofibular ligament avulses a fragment of the lateral epiphysis (A) corresponding to the portion of the physis that is still open (B).
View Original | Slide (.ppt)
Figure 32-41
Juvenile Tillaux fracture.
Mechanism of injury: The anteroinferior tibiofibular ligament avulses a fragment of the lateral epiphysis (A) corresponding to the portion of the physis that is still open (B).
Mechanism of injury: The anteroinferior tibiofibular ligament avulses a fragment of the lateral epiphysis (A) corresponding to the portion of the physis that is still open (B).
View Original | Slide (.ppt)
X
Tillaux fractures may be isolated injuries or may be associated with ipsilateral tibial shaft fractures.48 The fibula usually prevents marked displacement of the fracture and clinical deformity is generally absent. Swelling is usually slight, and local tenderness is at the anterior lateral joint line, in contrast to ankle sprains where the tenderness tends to be below the level of the ankle joint. 
A mortise view is essential to see the distal tibial epiphysis unobstructed by the fibula (Fig. 32-42). Steinlauf et al.197 reported a patient in whom the Tillaux fragment became entrapped between the distal tibia and fibula producing apparent diastasis of the ankle joint. To allow measurement of displacement from plain films, the radiograph beam would have to be directly in line with the fracture site, which makes CT confirmation of reduction desired after all closed reductions of these fractures. 
Figure 32-42
Anteroposterior mortise view of a 14-year-old who sustained a juvenile Tillaux fracture.
Flynn-ch032-image042.png
View Original | Slide (.ppt)
X
Both below-knee and above-knee casts have been used for immobilization of nondisplaced juvenile Tillaux and triplane fractures. Fractures with more than 2 mm of displacement, especially those associated with articular incongruity, may be best treated with closed or open reduction.49,103 Closed reduction is attempted by internally rotating the foot and applying direct pressure over the anterolateral tibia. If necessary, percutaneous pins can be used for stabilization of the reduction. If closed reduction is not successful, open reduction or percutaneous reduction with arthroscopic assistance may be needed. Occasionally, percutaneously inserted pins can be used to manipulate the displaced fragment into anatomical position and then advanced to fix the fragment in place.184 Screw fixation within the epiphysis is usually the preferred fixation method (Fig. 32-21; see section on Fracture Reduction Tips, Arthroscopic Assistance, Use of Percutaneous Clamps, Implants). 

Triplane Fracture

Kärrholm attributes the original description of this injury to Bartl,9 in 1957, and notes that Gerner-Smidt,71 in 1963, described triplane and Tillaux fractures as different stages of the same injury. In 1957, Johnson and Fahl93 described a triplane fracture in their report of 27 physeal ankle injuries and reported that they had seen 10 such fractures. Despite these earlier reports, the nature of triplane fractures was not appreciated until Marmor's131 report in 1970 of an irreducible ankle fracture that at surgery was found to consist of three parts (Fig. 32-43). Two years after Marmor's report, Lynn126 reported two additional such fractures and coined the term triplane fracture. He described the fracture as consisting of three major fragments: (1) The anterolateral quadrant of the distal tibial epiphysis, (2) the medial and posterior portions of the epiphysis in addition to a posterior metaphyseal spike, and (3) the tibial metaphysis. Cooperman et al.,46 however, in their 1978 report of 15 such fractures concluded that, based on tomographic studies, most were two-part fractures produced by external rotation (Fig. 32-44). Variations in fracture patterns were attributed to the extent of physeal closure at the time of injury. Kärrholm et al.97 reported that CT evaluation of four adolescents with triplane fractures confirmed the existence of two-part and three-part fractures and also revealed four-part fractures (Fig. 32-45). Denton and Fischer54 described a two-part “medial triplane fracture” that they believed was caused by adduction and axial loading, and Peiró et al.155 reported a three-part medial triplane fracture. 
Figure 32-43
Anatomy of a three-part lateral triplane fracture (left ankle).
 
Note the large epiphyseal fragment with its metaphyseal component and the smaller anterolateral epiphyseal fragment.
Note the large epiphyseal fragment with its metaphyseal component and the smaller anterolateral epiphyseal fragment.
View Original | Slide (.ppt)
Figure 32-43
Anatomy of a three-part lateral triplane fracture (left ankle).
Note the large epiphyseal fragment with its metaphyseal component and the smaller anterolateral epiphyseal fragment.
Note the large epiphyseal fragment with its metaphyseal component and the smaller anterolateral epiphyseal fragment.
View Original | Slide (.ppt)
X
Figure 32-44
Anatomy of a two-part lateral triplane fracture (left ankle).
 
Note the large posterolateral epiphyseal fragment with its posterior metaphyseal fragment. The anterior portion of the medial malleolus remains intact.
Note the large posterolateral epiphyseal fragment with its posterior metaphyseal fragment. The anterior portion of the medial malleolus remains intact.
View Original | Slide (.ppt)
Figure 32-44
Anatomy of a two-part lateral triplane fracture (left ankle).
Note the large posterolateral epiphyseal fragment with its posterior metaphyseal fragment. The anterior portion of the medial malleolus remains intact.
Note the large posterolateral epiphyseal fragment with its posterior metaphyseal fragment. The anterior portion of the medial malleolus remains intact.
View Original | Slide (.ppt)
X
Figure 32-45
Anatomy of a four-part lateral triplane fracture (left ankle).
 
The anterior epiphysis has split into two fragments, and the posterior epiphysis is the larger fragment with its metaphyseal component.
The anterior epiphysis has split into two fragments, and the posterior epiphysis is the larger fragment with its metaphyseal component.
View Original | Slide (.ppt)
Figure 32-45
Anatomy of a four-part lateral triplane fracture (left ankle).
The anterior epiphysis has split into two fragments, and the posterior epiphysis is the larger fragment with its metaphyseal component.
The anterior epiphysis has split into two fragments, and the posterior epiphysis is the larger fragment with its metaphyseal component.
View Original | Slide (.ppt)
X
El-Karef et al.61 studied 21 triplane fractures, identifying 19 as lateral triplane variants, and two as medial variants. Twelve were two-part fractures, six were three-part fractures, and three were four-part. 
Von Laer209 described a subgroup of two-part and three-part triplane fractures in which the fracture line on the anteroposterior radiographs did not extend into the ankle joint but into the medial malleolus instead (Fig. 32-46). Feldman et al.64 also reported a case of an extra-articular triplane fracture in a skeletally immature patient. Shin et al.,189 reported five patients with intramalleolar triplane variants. They divided these into three types: Type I, an intramalleolar intra-articular fracture; type II, an intramalleolar, intra-articular fracture outside the weight-bearing surface; and type III, an intramalleolar, extra-articular fracture (Fig. 32-47). These authors found that CT scans with three-dimensional reconstruction were helpful in determining displacement and deciding if surgery is indicated. 
Figure 32-46
 
A, B: Anteroposterior and lateral radiographs of an “intramalleolar” variant triplane fracture in a 14-year-old boy. C, D: CT scans demonstrate extra-articular nature of the fracture.
A, B: Anteroposterior and lateral radiographs of an “intramalleolar” variant triplane fracture in a 14-year-old boy. C, D: CT scans demonstrate extra-articular nature of the fracture.
View Original | Slide (.ppt)
Figure 32-46
A, B: Anteroposterior and lateral radiographs of an “intramalleolar” variant triplane fracture in a 14-year-old boy. C, D: CT scans demonstrate extra-articular nature of the fracture.
A, B: Anteroposterior and lateral radiographs of an “intramalleolar” variant triplane fracture in a 14-year-old boy. C, D: CT scans demonstrate extra-articular nature of the fracture.
View Original | Slide (.ppt)
X
Figure 32-47
Schematic drawing of the immature distal tibial physis demonstrating types I, II, and III intramalleolar triplane fractures.
 
A: Type I intramalleolar, intra-articular fracture at the junction of the tibial plafond and the medial malleolus. B: Type II intramalleolar, intra-articular fracture outside the weight-bearing zone of the tibial plafond. C: Type III intramalleolar, extra-articular fracture.
 
(Adapted from Shin AY, Moran ME, Wenger DR. Intramalleolar triplane fractures of the distal tibial epiphysis. J Pediatr Orthop. 1997; 17:352–355, with permission.)
A: Type I intramalleolar, intra-articular fracture at the junction of the tibial plafond and the medial malleolus. B: Type II intramalleolar, intra-articular fracture outside the weight-bearing zone of the tibial plafond. C: Type III intramalleolar, extra-articular fracture.
View Original | Slide (.ppt)
Figure 32-47
Schematic drawing of the immature distal tibial physis demonstrating types I, II, and III intramalleolar triplane fractures.
A: Type I intramalleolar, intra-articular fracture at the junction of the tibial plafond and the medial malleolus. B: Type II intramalleolar, intra-articular fracture outside the weight-bearing zone of the tibial plafond. C: Type III intramalleolar, extra-articular fracture.
(Adapted from Shin AY, Moran ME, Wenger DR. Intramalleolar triplane fractures of the distal tibial epiphysis. J Pediatr Orthop. 1997; 17:352–355, with permission.)
A: Type I intramalleolar, intra-articular fracture at the junction of the tibial plafond and the medial malleolus. B: Type II intramalleolar, intra-articular fracture outside the weight-bearing zone of the tibial plafond. C: Type III intramalleolar, extra-articular fracture.
View Original | Slide (.ppt)
X
In the series of Spiegel et al.,196 7.3% were triplane fractures. Kärrholm96 reviewed 209 triplane fracture patients and found the mean age at the time of injury was 14.8 for boys and 12.8 for girls. This type of injury did not occur in children younger than 10 or older than 16.7 years. The incidence is higher in males than females.185 Patients with triplane fractures may have completely open physes. Swelling is usually more severe than with Tillaux fractures, and deformity may be more severe, especially if the fibula is also fractured. Radiographic views should include anteroposterior, lateral, and mortise views. Rapariz et al.,169 found that 48% of triplane fractures were associated with fibular fracture and 8.5% were associated with ipsilateral tibial shaft fracture. Healy et al.,84 reported a triplane fracture associated with a proximal fibula fracture and syndesmotic injury (Maisonneuve equivalent). Failure to detect such injury may lead to chronic instability. Therefore, tenderness proximal to the ankle should be sought and if found is an indication for radiographs of the proximal leg. CT scans have largely replaced plain tomograms for evaluation of the articular surface and the fracture anatomy (Fig. 32-48). 
Figure 32-48
 
Preoperative (A, B) and postoperative (C, D) anteroposterior and lateral views of a pilon fracture in an adolescent.
Preoperative (A, B) and postoperative (C, D) anteroposterior and lateral views of a pilon fracture in an adolescent.
View Original | Slide (.ppt)
Figure 32-48
Preoperative (A, B) and postoperative (C, D) anteroposterior and lateral views of a pilon fracture in an adolescent.
Preoperative (A, B) and postoperative (C, D) anteroposterior and lateral views of a pilon fracture in an adolescent.
View Original | Slide (.ppt)
X
Nondisplaced triplane fractures, those with less than 2 mm of displacement, as well as extra-articular fractures can be treated with long-leg cast immobilization with the foot in internal rotation for lateral fractures and in eversion for medial fractures. These are rotational injuries, so the ability of a well-molded below-knee cast to maintain the reduction is questioned by some; a comparative study of below-knee and above-knee casts has not been done. Fractures with more than 2 mm of displacement (65% of the injuries in Kärrholm's series) require reduction; this may be attempted in the emergency department or in the operating room with the use of general anesthesia. Closed reduction of lateral triplane fractures is attempted by internally rotating the foot. Based on the mechanism of injury, the most logic maneuver for reduction of medial triplane fractures is abduction. If closed reduction is shown to be adequate by image intensification as is the case in about half the time, a long-leg cast is applied or percutaneous screws are inserted for fixation if necessary. Well-placed percutaneous screws will prevent secondary displacement in a cast, and may make follow-up radiographs and clinical visits less frequent. If closed reduction is done in the emergency department, a limited CT scan of the ankle joint in the cast is helpful to confirm adequate reduction. If closed reduction is unsuccessful, open reduction is required. This can be accomplished through an anterolateral approach for lateral triplane fractures or through an anteromedial approach for medial triplane fractures. Additional incisions may be necessary for adequate exposure. 
The use of well-placed percutaneous clamps and arthroscopic assistance may help with the reduction and minimize the need for incisions. Careful review of the CT scans can help guide percutaneous clamp and screw placement that improves the biomechanics of clamp reduction and screw placement.95 Care should be taken to avoid injury to neurologic and vascular structures during clamp or percutaneous screw placement. (See section on Fracture Reduction Tips, Arthroscopic Assistance, Use of Percutaneous Clamps, Implants.) 

Pilon Fractures

Although these fractures are relatively rare in young patients, they can be associated with severe soft tissue swelling and edema. Similar to the treatment in adults with these injuries, management of the soft tissues is critical to prevent complications of skin loss, infection, wound healing problems, etc.60,203 Initial approaches may consist of application of external fixation, or dressings to address swelling and edema, with delay in surgical intervention for 5 to 15 days (Fig. 32-49).60 
Figure 32-49
Pilon fracture treated with spatial frame.
 
A, B: Preoperative anteroposterior and lateral view of adolescent pilon fracture with depressed articular region. C: Axial CT scan showing comminution of articular surface. D, E: Sagittal CT scan and coronal CT scan showing comminution of metaphysic and involvement of articular surface. F, G: Reduction of fracture with Taylor Spatial Frame and placement of percutaneous screws to reduce the articular surface.
A, B: Preoperative anteroposterior and lateral view of adolescent pilon fracture with depressed articular region. C: Axial CT scan showing comminution of articular surface. D, E: Sagittal CT scan and coronal CT scan showing comminution of metaphysic and involvement of articular surface. F, G: Reduction of fracture with Taylor Spatial Frame and placement of percutaneous screws to reduce the articular surface.
View Original | Slide (.ppt)
A, B: Preoperative anteroposterior and lateral view of adolescent pilon fracture with depressed articular region. C: Axial CT scan showing comminution of articular surface. D, E: Sagittal CT scan and coronal CT scan showing comminution of metaphysic and involvement of articular surface. F, G: Reduction of fracture with Taylor Spatial Frame and placement of percutaneous screws to reduce the articular surface.
View Original | Slide (.ppt)
Figure 32-49
Pilon fracture treated with spatial frame.
A, B: Preoperative anteroposterior and lateral view of adolescent pilon fracture with depressed articular region. C: Axial CT scan showing comminution of articular surface. D, E: Sagittal CT scan and coronal CT scan showing comminution of metaphysic and involvement of articular surface. F, G: Reduction of fracture with Taylor Spatial Frame and placement of percutaneous screws to reduce the articular surface.
A, B: Preoperative anteroposterior and lateral view of adolescent pilon fracture with depressed articular region. C: Axial CT scan showing comminution of articular surface. D, E: Sagittal CT scan and coronal CT scan showing comminution of metaphysic and involvement of articular surface. F, G: Reduction of fracture with Taylor Spatial Frame and placement of percutaneous screws to reduce the articular surface.
View Original | Slide (.ppt)
A, B: Preoperative anteroposterior and lateral view of adolescent pilon fracture with depressed articular region. C: Axial CT scan showing comminution of articular surface. D, E: Sagittal CT scan and coronal CT scan showing comminution of metaphysic and involvement of articular surface. F, G: Reduction of fracture with Taylor Spatial Frame and placement of percutaneous screws to reduce the articular surface.
View Original | Slide (.ppt)
X
Letts et al.117 have described a small series of pilon fractures in the skeletally immature. The patients in this series did not have wound/skin complications, and only 2/8 developed postoperative osteoarthritis at short-term follow-up. As these fractures may be at higher risk for complications, we believe that treatment principles used in adult patients should be applied to this patient population as well.6,16,116,117,154,172 

Fractures of the Incisura

One of the authors (JC) has seen two patients with fractures of the incisura injuries.52 Despite 12 weeks of immobilization, these fractures had not healed. Despite the appearance of nonunion on radiographs, these patients remained symptom free at 2 years follow-up. One patient developed mild symptoms of ankle pain several years later. If there is evidence of syndesmotic injury, syndesmosis reduction and internal fixation should probably be considered. 

Syndesmosis Injuries

Several publications have described triplane fracture in association with a syndesmosis injury,84,193 and the authors have identified a small series of syndesmosis type injuries in their practice.51 These have been associated with the following fracture patterns: Distal fibula, Salter I and II, triplane, and Tillaux. Medial joint space widening may be an important anatomic factor to evaluate during treatment of external rotation mechanism injuries, and this should improve after surgical treatment.74 During surgical treatment of pediatric/adolescent ankle fractures, evaluation for syndesmosis injuries should probably be performed in a manner similar to the treatment of adult fractures. Syndesmosis reduction and fixation may be necessary (Fig. 32-15), in some cases. 

Open Fractures and Lawn Mower Injuries

Severe open ankle fractures are often produced by high-velocity motor vehicular accidents or lawn mower injuries (Fig. 32-50).76,83 Approximately 25,000 lawn mower injuries occur each year, 20% of which are in children. Ride-on mowers produce the most severe injuries, requiring more surgical procedures and resulting in more functional limitations.1,4,58,179,210 Loder et al.,121 reviewed 144 children injured by lawn mowers. The average age at the time of injury was 7 years. The child was a bystander in 84 cases. Sixty-seven children required amputation. Soft tissue infection occurred in 8 of 118 and osteomyelitis in 6 of 117. 
Figure 32-50
 
A: Severe lawn mower injury in a 5-year-old boy. B: One year after initial treatment with debridement, free flap, and skin graft coverage.
A: Severe lawn mower injury in a 5-year-old boy. B: One year after initial treatment with debridement, free flap, and skin graft coverage.
View Original | Slide (.ppt)
Figure 32-50
A: Severe lawn mower injury in a 5-year-old boy. B: One year after initial treatment with debridement, free flap, and skin graft coverage.
A: Severe lawn mower injury in a 5-year-old boy. B: One year after initial treatment with debridement, free flap, and skin graft coverage.
View Original | Slide (.ppt)
X
Principles of treatment are the same as in adults: Copious irrigation and debridement, tetanus toxoid, and intravenous antibiotics. Gaglani et al.,70 reported the bacteriologic findings in three children with infections secondary to lawn mower injuries. They found that organisms infecting the wounds were frequently different than those found on initial debridement, calling into question the value of intraoperative cultures. Gram-negative organisms were common and all three patients were infected with fungi as well. In children with lawn mower injuries, grass, dirt, and debris are pushed and blown into the wound under pressure, and removal of these embedded foreign objects requires meticulous mechanical debridement. 
In most patients, the articular surface and physis should be aligned and fixed with smooth pins that do not cross the physis at the time of initial treatment. Exposed physeal surfaces can be covered with local fat to help prevent union of the metaphysis to the epiphysis. An external fixator may be used if neurovascular structures are injured, but small pins should be used through the metaphysis and epiphysis, avoiding the physis.87,94,123,170,178 Wound closure may be a problem in cases with significant soft tissue injury and exposed bone. Skin coverage with local tissue is ideal; but if local coverage is not possible, split-thickness skin grafting is generally the next choice. Free vascular flaps and rotational flaps may be required for adequate coverage. Klein et al.,109 reported two cases that had associated vascular injury precluding such flaps, that were covered successfully with local advancement flaps made possible by multiple relaxing incisions. Mooney et al.,138 reported cross-extremity flaps for such cases. They found external fixation for linkage of the lower extremities during the procedure to be valuable. After fixation removal, range of motion returned readily. 
Vosburgh et al.210 reported 33 patients with lawn mower injuries to the foot and ankle. They found that the most severe injuries were to the posterior plantar aspect of the foot and ankle. Of their patients, five required split-thickness skin grafts and one vascularized flap for soft tissue coverage. Two ultimately required Syme amputation. Four of the patients had complete disruption of the Achilles tendon. Three had no repair or reconstruction of the triceps surae tendon, and one had delayed reconstruction 3 months after injury. Vosburgh et al.210 speculate that dense scarring in the posterior ankle results in a “physiologic tendon” and that extensive reconstructive surgery is not always necessary for satisfactory function. Boyer et al.,26 reported a patient with deltoid ligament loss because of a severe grinding injury that was reconstructed with a free plantaris tendon graft. Soft tissue coverage was achieved using a free muscle transfer. Rinker et al.171 have also described the use of soft tissue transfer to assist pediatric patients with severe soft tissue loss. 
The development of vacuum-assisted closure devices had been a dramatic improvement in the treatment of these injuries, and may reduce the need for tissue transfers.85 Referral to centers with experience with these treatment protocols may be necessary for these severe injuries. Our experience with the use of vacuum-assisted closure devices in high-energy trauma with severe soft tissue injury has shown very good results for limb salvage. 

Distal Fibula Fracture

Fractures involving the fibular physis are most commonly Salter–Harris type I or II fractures that are caused by a supination–inversion injury. Isolated fibular fractures are usually minimally displaced and can be treated with immobilization in a below-knee cast for 3 to 4 weeks. Significantly displaced fibular fractures often accompany Salter–Harris types III and IV tibial fractures and usually reduce when the tibial fracture is reduced. Internal fixation of the tibial fracture generally results in stability of the fibular fracture such that cast immobilization is sufficient. If the fibular fracture is unstable after reduction and fixation of the tibial fracture, fixation with a smooth intramedullary or obliquely inserted Kirschner wire is recommended (Fig. 32-51). In older adolescents in whom growth is not a consideration, an intramedullary rod, screw, or plate-and-screw device may be used as in adults (Fig. 32-52). 
Figure 32-51
 
A: Anteroposterior view of displaced Salter–Harris type I fibula fracture and Salter–Harris type IV intra-articular medial malleolus fracture. B: Use of percutaneous clamps to facilitate reduction of medial malleolus fracture. C: Use of percutaneous clamps to facilitate reduction. D: Use of two pins as “joysticks” to guide reduction of the displaced medial malleolus fracture. E: Use of percutaneous clamps to facilitate reduction and compression across the epiphyseal fracture. F: Use of percutaneous epiphyseal screws to gain compression across the fracture and to facilitate reduction.
A: Anteroposterior view of displaced Salter–Harris type I fibula fracture and Salter–Harris type IV intra-articular medial malleolus fracture. B: Use of percutaneous clamps to facilitate reduction of medial malleolus fracture. C: Use of percutaneous clamps to facilitate reduction. D: Use of two pins as “joysticks” to guide reduction of the displaced medial malleolus fracture. E: Use of percutaneous clamps to facilitate reduction and compression across the epiphyseal fracture. F: Use of percutaneous epiphyseal screws to gain compression across the fracture and to facilitate reduction.
View Original | Slide (.ppt)
Figure 32-51
A: Anteroposterior view of displaced Salter–Harris type I fibula fracture and Salter–Harris type IV intra-articular medial malleolus fracture. B: Use of percutaneous clamps to facilitate reduction of medial malleolus fracture. C: Use of percutaneous clamps to facilitate reduction. D: Use of two pins as “joysticks” to guide reduction of the displaced medial malleolus fracture. E: Use of percutaneous clamps to facilitate reduction and compression across the epiphyseal fracture. F: Use of percutaneous epiphyseal screws to gain compression across the fracture and to facilitate reduction.
A: Anteroposterior view of displaced Salter–Harris type I fibula fracture and Salter–Harris type IV intra-articular medial malleolus fracture. B: Use of percutaneous clamps to facilitate reduction of medial malleolus fracture. C: Use of percutaneous clamps to facilitate reduction. D: Use of two pins as “joysticks” to guide reduction of the displaced medial malleolus fracture. E: Use of percutaneous clamps to facilitate reduction and compression across the epiphyseal fracture. F: Use of percutaneous epiphyseal screws to gain compression across the fracture and to facilitate reduction.
View Original | Slide (.ppt)
X
Figure 32-52
 
A: Salter–Harris type II fracture of the distal fibula in a 15-year-old. B: Lateral view shows the fibular metaphyseal fragment (arrow). Considerable soft tissue swelling was noted in the medial aspect of the ankle. C: Stress films showed complete disruption of the deltoid ligament. D: The fibular fracture was fixed with a cannulated screw; the deltoid ligament was not repaired.
A: Salter–Harris type II fracture of the distal fibula in a 15-year-old. B: Lateral view shows the fibular metaphyseal fragment (arrow). Considerable soft tissue swelling was noted in the medial aspect of the ankle. C: Stress films showed complete disruption of the deltoid ligament. D: The fibular fracture was fixed with a cannulated screw; the deltoid ligament was not repaired.
View Original | Slide (.ppt)
A: Salter–Harris type II fracture of the distal fibula in a 15-year-old. B: Lateral view shows the fibular metaphyseal fragment (arrow). Considerable soft tissue swelling was noted in the medial aspect of the ankle. C: Stress films showed complete disruption of the deltoid ligament. D: The fibular fracture was fixed with a cannulated screw; the deltoid ligament was not repaired.
View Original | Slide (.ppt)
Figure 32-52
A: Salter–Harris type II fracture of the distal fibula in a 15-year-old. B: Lateral view shows the fibular metaphyseal fragment (arrow). Considerable soft tissue swelling was noted in the medial aspect of the ankle. C: Stress films showed complete disruption of the deltoid ligament. D: The fibular fracture was fixed with a cannulated screw; the deltoid ligament was not repaired.
A: Salter–Harris type II fracture of the distal fibula in a 15-year-old. B: Lateral view shows the fibular metaphyseal fragment (arrow). Considerable soft tissue swelling was noted in the medial aspect of the ankle. C: Stress films showed complete disruption of the deltoid ligament. D: The fibular fracture was fixed with a cannulated screw; the deltoid ligament was not repaired.
View Original | Slide (.ppt)
A: Salter–Harris type II fracture of the distal fibula in a 15-year-old. B: Lateral view shows the fibular metaphyseal fragment (arrow). Considerable soft tissue swelling was noted in the medial aspect of the ankle. C: Stress films showed complete disruption of the deltoid ligament. D: The fibular fracture was fixed with a cannulated screw; the deltoid ligament was not repaired.
View Original | Slide (.ppt)
X
Avulsion fractures from the lateral malleolus are seen in children with inversion “sprain” type injuries to the ankle. These may fail to unite with cast immobilization. Patients with such nonunions may have pain without associated instability. In such patients simple excision of the ununited fragment usually relieves their pain.54,81 When the nonunions are associated with instability, reconstruction of one or more of the lateral ankle ligaments is needed.29,30 (See Lateral Ankle Sprains.) 
Avulsion fracture of the accessory ossification centers of the distal fibula (os subfibulare) is also common. In the series report by Ogden and Lee,150 5 of 11 patients with injuries treated with casting had persistent symptoms and required excision. 

Lateral Ankle Sprains

In 1984 Vahvanen published a prospective study of 559 children who presented with severe supination injuries or sprains of the ankle.212 Forty patients, 28 boys and 12 girls, with an average age of 12 years (range 5 to 14) were surgically explored. The indications for surgery included swelling, pain over the anterior talofibular ligament, limp, clinical instability, and when visible, a displaced avulsion fracture. Such fractures were visible radiographically in only 8 patients but were found at surgery in 19. Thirty-six ankles were found to have injury of the anterior talofibular ligament at surgery. Only 16 of these had either a positive lateral or anterior drawer stress test. At follow-up all patients were pain free and none complained of instability. Based upon the incidence of residual disability after such injuries in adults reported in the literature (21% to 58%), these authors suggested primary surgical repair may be indicated in some cases. In our clinical experience, acute surgical repair of ankle sprains is very rarely indicated in the skeletally immature. 
In cases with residual laxity and associated symptoms, delayed surgical repair may be necessary in older patients. Busconi and Pappas35 reported 60 skeletally immature children with chronic ankle pain and instability. Fifty of these children responded to rehabilitation, but 10 had persistent symptoms. Although three of these patients' initial radiographs were within normal limits, all patients with persistent symptoms eventually were found to have ununited osteochondral fractures of the fibular epiphysis. All 10 patients with persistent symptoms were treated with excision of the ununited osteochondral fracture and a Broström reconstruction of the lateral collateral ligament. All were able to return to activities and none reported further pain or instability. 

Ankle Dislocations

Nusem et al.,148 reported a 12-year-old girl who was seen with a posterior dislocation of the ankle without associated fracture. This was a closed injury and resulted from forced inversion of a maximally plantarflexed foot. The dislocation was reduced under IV sedation and the ankle immobilized in a short-leg cast for 5 weeks. The patient was asymptomatic at follow-up 4 years postinjury. The inversion stress views at that time revealed only a three-degree increase laxity compared to the uninjured side. The anterior drawer sign was negative. There was no evidence of avascular necrosis of the talus on follow-up radiographs. Mazur et al.133 have also reported ankle dislocation without a fracture in a pediatric patient. 
For current treatment options, see Table 32-1

Author's Preferred Treatment of Distal Tibial and Fibular Fractures

Salter–Harris Type I and II Fractures of the Distal Tibia

We prefer to treat nondisplaced Salter–Harris type I and II fractures initially with immobilization using either an above-knee or below-knee cast dependent on patient characteristics. Nonweight bearing is continued until 2 to 4 weeks postinjury, when the cast is changed to a below-knee walking cast or walking boot which is worn for an additional 2 to 3 weeks. Follow-up radiographs are obtained every 6 months for 1 to 2 years or until a Park–Harris growth arrest line parallel to the physis is visible and there is no evidence of physeal deformity. 
For displaced fractures in children with at least 3 years of growth remaining, our objective is to obtain no more than 10 to 15 degrees of plantar tilt for posteriorly displaced fractures, 5 to 10 degrees of valgus for laterally displaced fractures, and 0 degrees of varus for medially displaced fractures (Fig. 32-53). Studies in the adult literature suggest that minor alteration in alignment of the ankle joint may have significant effect on tibiotalar contact pressures.102,204,206 If there is a question about the ability to remodel the fracture, it is probably best to perform a reduction. For children with 2 years or less of growth remaining, the amount of acceptable angulation is reduced to 5 degrees or less. We recognize that all of the recommendations about acceptable alignment are based on clinical experience and judgment, and none have been rigorously studied. 
Figure 32-53
 
A: Displaced pronation–eversion–external rotation fracture of the distal tibia in a 12-year-old boy was treated with closed reduction and cast immobilization. B: After cast removal, a 10-degree valgus tilt was present. C: At maturity, the deformity has completely resolved.
A: Displaced pronation–eversion–external rotation fracture of the distal tibia in a 12-year-old boy was treated with closed reduction and cast immobilization. B: After cast removal, a 10-degree valgus tilt was present. C: At maturity, the deformity has completely resolved.
View Original | Slide (.ppt)
Figure 32-53
A: Displaced pronation–eversion–external rotation fracture of the distal tibia in a 12-year-old boy was treated with closed reduction and cast immobilization. B: After cast removal, a 10-degree valgus tilt was present. C: At maturity, the deformity has completely resolved.
A: Displaced pronation–eversion–external rotation fracture of the distal tibia in a 12-year-old boy was treated with closed reduction and cast immobilization. B: After cast removal, a 10-degree valgus tilt was present. C: At maturity, the deformity has completely resolved.
View Original | Slide (.ppt)
X
If resources are available, we may attempt reduction of markedly displaced fractures with the use of general anesthesia with good muscle relaxation and image intensifier control. The use of an ankle distractor can facilitate distraction across the fracture, and may facilitate reduction (Fig. 32-34). In children with mildly displaced fractures, especially if anesthesia is not going to be available for many hours, an attempt at gentle closed reduction under a hematoma block supplemented as needed by well-monitored intravenous sedation is a good option. Many emergency rooms are well equipped and have adequate staff to perform appropriate and safe sedation for treatment of fractures and dislocation. This approach may allow for more timely treatment, especially if operating room access is limited. Once adequately reduced, the fractures are usually stable and a long-leg cast can be used for immobilization. Rarely, for markedly unstable fractures or severe soft tissue injuries that require multiple debridements, percutaneous screws are used when the Thurston–Holland fragment is large enough to accept screw fixation. When the fragment is too small, smooth wire fixation across the physis is the only alternative. Repeated attempts at closed manipulation of these fractures may increase the risk of growth abnormality and should be avoided. In patients with fractures that are not seen until 7 to 10 days after injury, residual displacement is probably best accepted, unless significant deformity or angulation is present. If growth does not sufficiently correct malunion, corrective osteotomy can be performed later. 
Open reduction of these fractures is occasionally indicated. The exception usually has been pronation–eversion–external rotation fractures with interposed soft tissue, which may include lateral and posterior displacement. For cases that have undergone an attempt at closed reduction, close inspection of the medial physis should be performed with image intensification. In some cases, the medial physeal space will appear abnormally widened, which may suggest incarceration of a large flap of periosteum in the physis. For these fractures, a small anteromedial incision is made and any interposed soft tissues, such as periosteum or tendons, are extracted. Even though reduction is usually stable, we generally use internal fixation. Fixation options include screw fixation through both the metaphyseal and epiphyseal fragments, avoiding fixation across the physis if possible (Fig. 32-54). Percutaneous smooth pins can also be placed from the medial malleolus, oriented proximally to engage the metaphysis (Figs. 32-31 and 32-55). 
Figure 32-54
Salter–Harris type II distal tibial fracture with fibular fracture.
 
A: Lateral view. B: Anteroposterior view. C, D: After percutaneous placement of tibial screws and plating of fibular fracture.
A: Lateral view. B: Anteroposterior view. C, D: After percutaneous placement of tibial screws and plating of fibular fracture.
View Original | Slide (.ppt)
Figure 32-54
Salter–Harris type II distal tibial fracture with fibular fracture.
A: Lateral view. B: Anteroposterior view. C, D: After percutaneous placement of tibial screws and plating of fibular fracture.
A: Lateral view. B: Anteroposterior view. C, D: After percutaneous placement of tibial screws and plating of fibular fracture.
View Original | Slide (.ppt)
X
Figure 32-55
Salter–Harris type II distal tibial fracture with fibular fracture.
 
A: Anteroposterior view. B: Lateral view. C, D: Percutaneous placement of Kirschner wires.
A: Anteroposterior view. B: Lateral view. C, D: Percutaneous placement of Kirschner wires.
View Original | Slide (.ppt)
Figure 32-55
Salter–Harris type II distal tibial fracture with fibular fracture.
A: Anteroposterior view. B: Lateral view. C, D: Percutaneous placement of Kirschner wires.
A: Anteroposterior view. B: Lateral view. C, D: Percutaneous placement of Kirschner wires.
View Original | Slide (.ppt)
X

Salter–Harris Types III and IV Fractures of the Distal Tibia

Treatment of nondisplaced Salter–Harris type III and IV fractures is the same as for nondisplaced type I and II fractures with three modifications. First, after casting with a long-leg cast, the alignment is confirmed with a CT scan and/or radiographs. Second, these patients are examined more frequently (once a week) for the first 2 to 3 weeks after cast application to ensure that the fragments do not become displaced. Third, these patients are examined every 6 to 12 months after cast removal for 24 to 36 months to detect any growth abnormality. 
Fractures with 2 mm or more of displacement after the best possible closed reduction may be treated with open reduction and internal fixation with anatomical alignment of the physis and intra-articular fracture fragments. 
For minimally displaced fractures, closed reduction is attempted in the emergency room or the operating room, depending on local resources and practices. Reduction may be attempted by applying longitudinal traction to the foot, followed by eversion of the foot and direct digital pressure over the medial malleolus. If image intensification confirms anatomical reduction, but the fracture is unstable, the fracture may be fixed with two percutaneous smooth wires placed in the epiphysis parallel to the physis. Reduction is confirmed by a short, continuous fluoroscopic examination. Percutaneous clamp placement may also facilitate reduction in some of these cases. Cannulated screws can be inserted if the epiphysis is large enough. For fractures that are seen more than 7 to 14 days after injury, we may accept up to 2 mm of displacement without attempting closed or open reduction. Reliable patients whose fractures are fixed with pins and/or screws may be immobilized in below-knee casts. Above-knee casts are used for other patients. 
In cases where arthroscopic assistance is used, the visualization of the ankle joint can also assist with the evaluation of reduction. In some cases, the fractures may still have a small gap present with the articular surface, but the presence of step-off or intra-articular incongruity can be clearly evaluated with the scope visualization of the articular surface. It has been our experience that the C-arm views may show excellent reduction of the subchondral bone of the articular surface, and the arthroscopic views may show that the cartilage surfaces are not as well reduced as one would expect based upon these radiographic images. 
Fractures with more than 2 mm of displacement or step-off should be reduced, regardless of whether the fracture is acute or not. Closed reduction can be attempted, but these fractures may require open reduction, arthroscopic-assisted reduction, or mini-open reduction with arthroscopic assistance. Occasionally, primary debridement of callus and soft tissue back to normal-appearing physis and fat grafting has been successful for fractures that are more than 2 weeks old. 
For fractures stabilized with internal fixation, below-knee casts may be used. If there is concern about fracture stability, above-knee casts can be used. 

Open Reduction and Internal Fixation of Salter–Harris Type III or IV Fracture of the Distal Tibia

The patient is placed supine on an operating table that is radiolucent at the lower extremity. For wide exposure, a hockey-stick incision is made, extending from approximately 4 cm above the ankle joint to 1 cm posterior to the tip of the medial malleolus. The image intensifier can be used to locate the vertical incision for articular exposure directly over the fracture line in the sagittal plane, and this can limit the length of incision needed. Alternatively, if more anterior exposure is required, a 4- to 6-cm transverse incision is made from the posterior aspect of the medial malleolus to the anterior aspect of the ankle. The saphenous vein is identified, dissected free, and retracted. The fracture site is identified, and an anteromedial capsulotomy of the ankle joint is performed. The fracture surfaces are exposed and gently cleaned with irrigation and forceps (curettage is not used). 
For Salter–Harris type IV fractures, the periosteum may be elevated several millimeters from the metaphyseal fracture edges. The epiphyseal edges and joint surfaces are examined through the arthrotomy. The perichondral ring should not be elevated from the physis. For Salter–Harris type III fractures, the reduction is evaluated by checking the joint surface and epiphyseal fracture edges through the arthrotomy. The epiphyseal fragment is grasped with a small towel clip or reduction forceps, and the fracture is reduced. Internal fixation is performed under direct vision and fluoroscopic control. It is important to view both the lateral and anteroposterior projections because of the curved shape of the distal tibial articular surface. If the fragment is large enough, 4-mm cannulated lag screws are inserted through the epiphyseal fragment; if the fragment is too small for screws, smooth Kirschner wires are used. The reduction and the position of the internal fixation are checked through the arthrotomy. In fractures with a significant Thurston–Holland fragment, a metaphyseal screw may be used if a gap exists after the epiphyseal screws are inserted. After reduction of the tibial fracture, an associated Salter–Harris type I or II fibular fracture usually reduces and is stable. If it is not, closed reduction and fixation with percutaneous oblique smooth Kirschner wires are performed. 
The patient is kept nonweight bearing for 3 weeks, and then the cast is changed to a below-knee walking cast, which is worn for an additional 3 weeks. Frequent follow-up evaluations (every 3 to 6 months for the first year and yearly thereafter until normal growth resumes) are necessary to detect growth abnormalities. 

Salter–Harris Type V Fractures of the Distal Tibia

These injuries are quite rare. The risk of physeal arrest is thought to be quite high for this injury pattern, because of direct damage of the germinal layer of the physis.102 We have seen a variant of these fractures associated with a varus load to the ankle joint, leading to a crush-type injury to the medial malleolus (Figs. 32-56 and 32-57). These fractures can be treated with reduction of the joint and physeal surface, using minimally invasive techniques that avoid the physis and perichondral ring (Fig. 32-57). 
Figure 32-56
Salter–Harris type V distal fibula fracture.
 
A: Anteroposterior ankle radiograph of crush injury to the medial malleolus. B: Coronal CT scan of medial malleolus crush injury. C: Sagittal CT scan of medial malleolus crush injury.
A: Anteroposterior ankle radiograph of crush injury to the medial malleolus. B: Coronal CT scan of medial malleolus crush injury. C: Sagittal CT scan of medial malleolus crush injury.
View Original | Slide (.ppt)
Figure 32-56
Salter–Harris type V distal fibula fracture.
A: Anteroposterior ankle radiograph of crush injury to the medial malleolus. B: Coronal CT scan of medial malleolus crush injury. C: Sagittal CT scan of medial malleolus crush injury.
A: Anteroposterior ankle radiograph of crush injury to the medial malleolus. B: Coronal CT scan of medial malleolus crush injury. C: Sagittal CT scan of medial malleolus crush injury.
View Original | Slide (.ppt)
X
Figure 32-57
Salter–Harris type V patterns with crush injury to medial malleolus.
 
A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture.
A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture.
View Original | Slide (.ppt)
Figure 32-57
Salter–Harris type V patterns with crush injury to medial malleolus.
A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture.
A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture.
View Original | Slide (.ppt)
X
The prognosis for this injury is poor, and treatment is usually focused upon treating the complications of angular deformity and/or physeal arrest.102 

Juvenile Tillaux Fractures

For nondisplaced fractures and fractures displaced less than 2 mm, we prefer immobilization in an above-knee cast with the knee flexed 30 degrees and the foot neutral or internally rotated. If the position appears acceptable on plain films, CT scanning in the transverse plane with coronal and sagittal reconstructions may be used to confirm acceptable reduction. For fractures with more than 2 mm of initial displacement, manipulation may be attempted by internal rotation of the foot and application of direct pressure over the anterolateral joint line. If reduction is not obtained with this maneuver, reduction can be attempted by dorsiflexing the pronated foot and then internally rotating the foot.128 If successful reduction is obtained, percutaneous fixation (screws or pins) can be placed with C-arm guidance. Percutaneous clamps can be used to obtain and hold reduction during screw placement. If there are questions about the adequacy of reduction, this can be confirmed by use of an arthrotomy or ankle arthroscope. 
In cases where the reduction is not ideal, there are several options. Schlesinger and Wedge184 have described a technique using percutaneous manipulation of a Tillaux fragment with a Steinmann pin.102 Small Kirschner wires or the threaded tip wires from a cannulated screw set can be inserted into the Tillaux fragment under fluoroscopic control, to act as a “joystick” to reduce the fracture (Fig. 32-58). Ideally, one or both of these pins can then be passed across the fracture site after reduction has been obtained if the guidewire is carefully placed initially, and the cannulated screw can then be placed over the pins (Figs. 32-59 and 32-60). 
Figure 32-58
Technique for reduction of a Salter–Harris type IV fracture of the distal tibia.
Flynn-ch032-image058.png
View Original | Slide (.ppt)
X
Figure 32-59
Advancement of pin after reduction of juvenile Tillaux fracture.
Flynn-ch032-image059.png
View Original | Slide (.ppt)
X
Figure 32-60
Percutaneous insertion of 4-mm cannulated screw over pin that has been advanced into the medial distal tibia after reduction of the juvenile Tillaux fracture fragment.
Flynn-ch032-image060.png
View Original | Slide (.ppt)
X
If reduction is not successful, open reduction is performed through an anterolateral approach, again using fluoroscopy to position the incision over the vertically oriented fracture line. Arthroscopic assistance can also be used to obtain anatomic reduction. For open techniques, the following protocol is used. The patient is placed in a supine position, and a vertical incision is placed over the fracture. A small incision is made, perhaps 2 to 3 cm, to allow for visualization. The fracture plane is identified, and direct pressure or clamps can be applied to maintain the reduction. If necessary, a small arthrotomy or arthroscope can be used to evaluate the articular reduction. A guidewire from the cannulated screw system (a 4-mm cannulated system usually works well in this age group) is placed, followed by placement of the screw. 
A short-leg, non–weight-bearing cast is worn for 3 weeks, followed by a weight-bearing cast or walking boot for another 3 weeks. 

Triplane Fractures

For nondisplaced or minimally displaced (less than 2 mm) fractures, we prefer immobilization in a long-leg cast with the knee flexed 30 to 40 degrees. The position of the foot is determined by whether the fracture is lateral (internal rotation) or medial (eversion). A CT scan may be obtained after reduction and casting to document adequate reduction. Plain films or CT scans are obtained approximately 7 days after cast application to verify that displacement has not recurred. At 3 to 4 weeks, the cast is changed to a below-knee walking cast or walking boot, which is worn another 3 to 4 weeks. 
The ability to reduce fractures in the ER with appropriate conscious sedation varies among institutions. For institutions that have such capabilities, fracture reduction can be attempted in the ER. For fractures with more than 2 mm of displacement, an attempt closed reduction with sedation in the emergency department. An above-knee cast is applied. If plain radiographs show satisfactory reduction, a CT scan is obtained. If reduction is acceptable, treatment is the same as for nondisplaced fractures. 
If the reduction is unacceptable, closed reduction is attempted in the operating room with the use of general anesthesia. If fluoroscopy shows an acceptable reduction, percutaneous screws are inserted, avoiding the physis, and a short-leg cast is applied. If closed reduction is unacceptable, open reduction or mini-open reduction with the use of percutaneous clamps is performed. Preoperative CT scanning may be helpful for evaluating the position of the fracture fragments in the anteroposterior and lateral planes and for determining the appropriate skin incisions, percutaneous clamp placements, and screw location. 

Open Reduction of Triplane Fracture

The patient is placed supine on a radiolucent operating table with padded elevation behind the hip on the affected side. The surgical approach depends on the fracture anatomy as determined by the preoperative CT scan. A two-part medial triplane fracture can be approached through a hockey-stick anteromedial incision. The fracture fragments are irrigated to remove debris, and any interposed periosteum is removed. The fracture is reduced, and reduction is confirmed by direct observation through an anteromedial arthrotomy and by image intensification. Two 4-mm cancellous screws are inserted from medial to lateral or from anterior to posterior or both, depending on the fracture pattern (Fig. 32-61). Anterior-to-posterior screw placement may require an additional anterolateral incision or the screws may be inserted percutaneously. Arthroscopic-assisted techniques, with the use of percutaneous clamps and screws may also be used (Fig. 32-62). 
Figure 32-61
 
A, B: Irreducible three-part triplane fracture in a 13-year-old girl. A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture. C, D: After open reduction with internal fixation. Note anterior-to-posterior and medial-to-lateral screw placement that avoids the physis.
A, B: Irreducible three-part triplane fracture in a 13-year-old girl. A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture. C, D: After open reduction with internal fixation. Note anterior-to-posterior and medial-to-lateral screw placement that avoids the physis.
View Original | Slide (.ppt)
A, B: Irreducible three-part triplane fracture in a 13-year-old girl. A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture. C, D: After open reduction with internal fixation. Note anterior-to-posterior and medial-to-lateral screw placement that avoids the physis.
View Original | Slide (.ppt)
Figure 32-61
A, B: Irreducible three-part triplane fracture in a 13-year-old girl. A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture. C, D: After open reduction with internal fixation. Note anterior-to-posterior and medial-to-lateral screw placement that avoids the physis.
A, B: Irreducible three-part triplane fracture in a 13-year-old girl. A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture. C, D: After open reduction with internal fixation. Note anterior-to-posterior and medial-to-lateral screw placement that avoids the physis.
View Original | Slide (.ppt)
A, B: Irreducible three-part triplane fracture in a 13-year-old girl. A: Crush injury to medial malleolus and distal tibia metaphysis. B: The percutaneous pins can be used to manipulate the fracture. C, D: After open reduction with internal fixation. Note anterior-to-posterior and medial-to-lateral screw placement that avoids the physis.
View Original | Slide (.ppt)
X
Figure 32-62
 
A, B: Anteroposterior and lateral radiograph of triplane fracture with involvement of medial malleolus. C, D: Use of percutaneous clamps for reduction, viewed in the anteroposterior plane (C) and in the lateral plane (D). E, F: Use of percutaneous clamps for reduction, followed by placement of guidewires to hold reduction. G, H: Percutaneous and mini-open placement of cannulated screws, anteroposterior view (G) and lateral view (H).
A, B: Anteroposterior and lateral radiograph of triplane fracture with involvement of medial malleolus. C, D: Use of percutaneous clamps for reduction, viewed in the anteroposterior plane (C) and in the lateral plane (D). E, F: Use of percutaneous clamps for reduction, followed by placement of guidewires to hold reduction. G, H: Percutaneous and mini-open placement of cannulated screws, anteroposterior view (G) and lateral view (H).
View Original | Slide (.ppt)
Figure 32-62
A, B: Anteroposterior and lateral radiograph of triplane fracture with involvement of medial malleolus. C, D: Use of percutaneous clamps for reduction, viewed in the anteroposterior plane (C) and in the lateral plane (D). E, F: Use of percutaneous clamps for reduction, followed by placement of guidewires to hold reduction. G, H: Percutaneous and mini-open placement of cannulated screws, anteroposterior view (G) and lateral view (H).
A, B: Anteroposterior and lateral radiograph of triplane fracture with involvement of medial malleolus. C, D: Use of percutaneous clamps for reduction, viewed in the anteroposterior plane (C) and in the lateral plane (D). E, F: Use of percutaneous clamps for reduction, followed by placement of guidewires to hold reduction. G, H: Percutaneous and mini-open placement of cannulated screws, anteroposterior view (G) and lateral view (H).
View Original | Slide (.ppt)
X
For two-part lateral triplane fractures, these can be approached with a hockey-stick anterolateral approach. The fracture is reduced and stabilized with two screws placed from lateral to medial or from anterior to posterior or both, and reduction is confirmed through direct observation and by image intensification. In addition to open techniques, arthroscopic-assisted techniques with the use of percutaneous clamps and screws may also be used (Fig. 32-62). 
Fractures with three or more parts may occasionally require more exposure for reduction and internal fixation. If the fibula is fractured, posterior exposure of the tibial fracture can be readily obtained by detaching the anterior and posterior-inferior tibiofibular ligaments and turning down the distal fibula on the lateral collateral ligament (Fig. 32-63). If the fibula is not fractured, a fibular osteotomy may be needed in rare circumstances for adequate visualization of the articular surface. Careful dissection is necessary to avoid iatrogenic fractures through the physis of the fibula. Medial exposure is obtained through an anteromedial or posteromedial incision. Reduction and internal fixation are carried out in a stepwise fashion. For typical three-part fractures, the Salter–Harris type II fracture may be reduced first by provisional fixation to the distal tibia through the metaphyseal fragment. Usually, the Salter–Harris type III fragment can then be reduced and provisionally fixed to the stabilized type II fragment (Fig. 32-64). Occasionally, the order of reduction and fixation should be reversed. Fractures with four or more fragments require additional steps, but fixation of the Salter–Harris type II or IV fragment through the metaphysis to the distal tibia is usually best performed first. This step can be followed by fixation of the Salter–Harris type III fragment or fragments (Fig. 32-65). After reduction, reliable patients may be treated with immobilization in a short-leg, non–weight-bearing cast for 3 to 4 weeks. At 3 to 4 weeks, they may be converted to a weight-bearing cast or walking boot for an additional 3 to 4 weeks. 
Figure 32-63
Transfibular approach to a complex triplane fracture.
Flynn-ch032-image063.png
View Original | Slide (.ppt)
X
Figure 32-64
Open reduction with internal fixation of a three-part lateral triplane fracture.
 
A, B: Reduction and fixation of the Salter–Harris type II fragment to the metaphysis. C, D: Reduction and internal fixation of the Salter–Harris type III fragment to the Salter–Harris type II fragment.
A, B: Reduction and fixation of the Salter–Harris type II fragment to the metaphysis. C, D: Reduction and internal fixation of the Salter–Harris type III fragment to the Salter–Harris type II fragment.
View Original | Slide (.ppt)
Figure 32-64
Open reduction with internal fixation of a three-part lateral triplane fracture.
A, B: Reduction and fixation of the Salter–Harris type II fragment to the metaphysis. C, D: Reduction and internal fixation of the Salter–Harris type III fragment to the Salter–Harris type II fragment.
A, B: Reduction and fixation of the Salter–Harris type II fragment to the metaphysis. C, D: Reduction and internal fixation of the Salter–Harris type III fragment to the Salter–Harris type II fragment.
View Original | Slide (.ppt)
X
Figure 32-65
 
A, B: Irreducible three-part lateral triplane fracture in a 14-year-old boy. C, D: After open reduction through a transfibular approach and internal fixation with anterior-to-posterior and lateral-to-medial screws.
A, B: Irreducible three-part lateral triplane fracture in a 14-year-old boy. C, D: After open reduction through a transfibular approach and internal fixation with anterior-to-posterior and lateral-to-medial screws.
View Original | Slide (.ppt)
Figure 32-65
A, B: Irreducible three-part lateral triplane fracture in a 14-year-old boy. C, D: After open reduction through a transfibular approach and internal fixation with anterior-to-posterior and lateral-to-medial screws.
A, B: Irreducible three-part lateral triplane fracture in a 14-year-old boy. C, D: After open reduction through a transfibular approach and internal fixation with anterior-to-posterior and lateral-to-medial screws.
View Original | Slide (.ppt)
X

Fracture Reduction Tips, Arthroscopic Assistance, Use of Percutaneous Clamps, Implants

Ankle Distraction

Use of the ankle distractor (normally used for arthroscopy procedures) can assist with reduction of displaced extra-articular fractures, such as Salter–Harris type I or II patterns. When combined with the relaxation of general anesthesia, a few minutes of distraction across the physis can facilitate reduction. The distraction across the fracture may increase the likelihood that the first attempt at reduction will be successful; this may reduce the trauma to the physis during the reduction, perhaps reducing the risk of physeal arrest. Juvenile Tillaux and triplane fracture reduction can also be facilitated with ankle distraction, and this will also facilitate arthroscopic ankle visualization. The ankle distractor obviates the need to have the surgeon pull manually for several minutes. The surgeon can then focus on the application of other forces, such as rotation or varus/valgus to facilitate fracture reduction. Although skeletal traction using a calcaneal pin is an option,39 we prefer to use an ankle strap and special distractor routinely used for arthroscopy (Arthrex, Naples, Florida). The ankle distractor can be positioned to allow for anteroposterior and lateral mini C-arm images (Fig. 32-34). 

Imaging Studies

Use of CT scans can be very beneficial for evaluating intra-articular fractures or multiplanar fractures. High resolution scans with three-dimensional reconstructions provide excellent anatomic detail. For minimally invasive approaches using percutaneous screw fixation, these images can be used for precise screw placement during surgery. The CT scan can also facilitate percutaneous placement of clamps, to allow for compression perpendicular to the plane of the fracture. A clear preoperative evaluation should determine optimal screw position and orientation, and these images should also be available during the procedure to assist with screw placement. 

Arthroscopy

The use of arthroscopy can facilitate minimally invasive procedures. Several clinical series document the effectiveness of arthroscopic assistance for Tillaux fractures92,135,153 and triplane fractures.89,92 The joint surfaces can be readily visualized through small incisions, avoiding the need for a larger arthrotomy. Even in cases where an arthrotomy is used, the scope can be utilized either with or without fluid to visualize the reduction of the fragments (Fig. 32-66). The fluid of the arthroscopy pump can also be used to wash out the fracture site, increasing visualization during reduction. Avoidance of high pump pressure will minimize the risks of soft tissue infiltration. 
Figure 32-66
Ankle arthroscopy.
 
A: Arthroscopic view of fracture gap in distal tibia articular surface. B: Arthroscopic view of fracture gap in distal tibial articular surface after reduction.
A: Arthroscopic view of fracture gap in distal tibia articular surface. B: Arthroscopic view of fracture gap in distal tibial articular surface after reduction.
View Original | Slide (.ppt)
Figure 32-66
Ankle arthroscopy.
A: Arthroscopic view of fracture gap in distal tibia articular surface. B: Arthroscopic view of fracture gap in distal tibial articular surface after reduction.
A: Arthroscopic view of fracture gap in distal tibia articular surface. B: Arthroscopic view of fracture gap in distal tibial articular surface after reduction.
View Original | Slide (.ppt)
X
Different size scopes are available, including 2.8 and 5 mm. We prefer to use smaller diameter scopes, especially in younger patients. The smaller scope has a smaller field of view, but this does not seem to be much of a disadvantage for viewing the displaced cartilage surfaces. The smaller scope also delivers less fluid to the joint, which may require additional time to clean the hematoma from the joint and fracture, but has a lower risk of causing soft tissue infiltration around the joint. 

Use of Small C-Arm Unit

The small C-arm unit will also assist with minimally invasive approaches. This can be easily rotated to allow for AP or lateral views. If the ankle distractor is used, position the foot and distractor to allow easy access by the C-arm (Fig. 32-34). 

Percutaneous Clamps

Precise placement of clamps can facilitate the reduction of fractures. Careful study of imaging studies, especially CT scans, can guide precise placement of clamps to provide maximal compression across fracture planes. Forces normal or near normal to the fracture planes are ideal. Care should be taken during placement, to prevent injury to neurologic and vascular structures, including sensory nerves. The skin can be divided, and then deeper dissection through the subcutaneous tissues can be performed with a hemostat. The hemostat is used to bluntly distract the tissues away from the skin portal, and then advanced to the bone surface. The tips of the clamp can now be placed with minimal risk to neurovascular structures. The clamp can be compressed, to facilitate reduction of triplane and Tillaux fractures (Figs. 32-51 and 32-62). 

Implants

Different implants are available for fixation of ankle fractures. Smooth pins have the advantage that they do not place a threaded tip across the physis, therefore reducing the risk of iatrogenic physeal arrest. The main disadvantage of smooth pins is that they do not allow for compression. These pins can also migrate through bone, and into soft tissues. Bending the ends at the surface of the bone to prevent migration is important. These pins should be removed early, as soon as the fracture stability is adequate. In most cases, we remove the pins between 14 and 21 days after surgery. Careful management of the pin/skin interface with dressings that limit motion is believed to lower the risk of pin inflammation and infection. 
In most physeal injuries, the use of screws or threaded devices across the physis should be avoided when possible. In some cases, a screw implant may be necessary to cross a physis, to maintain an articular reduction. The adequacy of reduction of the joint surface is probably more important than the physis. In patients approaching skeletal maturity, the use of screw implants across a physis that is approaching closure is probably a reasonable choice, especially in case where compression and/or stability are important, such as juvenile Tillaux fractures (Fig. 32-67). 
Figure 32-67
 
A, B: Displaced juvenile Tillaux fracture. Closed reduction was not successful. C: After open reduction with internal fixation with a small fragment screw.
A, B: Displaced juvenile Tillaux fracture. Closed reduction was not successful. C: After open reduction with internal fixation with a small fragment screw.
View Original | Slide (.ppt)
A, B: Displaced juvenile Tillaux fracture. Closed reduction was not successful. C: After open reduction with internal fixation with a small fragment screw.
View Original | Slide (.ppt)
Figure 32-67
A, B: Displaced juvenile Tillaux fracture. Closed reduction was not successful. C: After open reduction with internal fixation with a small fragment screw.
A, B: Displaced juvenile Tillaux fracture. Closed reduction was not successful. C: After open reduction with internal fixation with a small fragment screw.
View Original | Slide (.ppt)
A, B: Displaced juvenile Tillaux fracture. Closed reduction was not successful. C: After open reduction with internal fixation with a small fragment screw.
View Original | Slide (.ppt)
X

Fractures Involving the Distal Fibula

We usually treat nondisplaced fibular physeal fractures with immobilization in a below-knee walking cast for 3 to 4 weeks. Recent studies found use of a removable ankle brace to be as effective, and to be preferable from a patient satisfaction and economic standpoint when compared to fiberglass posterior splints.8,25 Closed reduction of displaced Salter–Harris types I and II fibular fractures, is usually successful. In cases where reduction is unsuccessful, one may accept up to 50% displacement without problems at long-term follow-up, especially in those with 3 to 4 years of growth remaining. Acceptance of this displacement may be more reasonable in young patients with significant remodeling potential, although in older patients, displaced fractures may have more effect on ankle function, and more anatomic reduction may be advantageous. Dias and Giegerich,56 however, reported a patient with a symptomatic spike that required excision after incomplete reduction. 

Lateral Ankle Sprains and Lateral Ligament Avulsion Injuries

The diagnosis of an ankle sprain is less common in younger patients, although recognition of ankle sprain injuries in children is becoming more common with advanced imaging using ultrasound and MRI. If the pain can be localized to the ligaments, and there is no pain over the distal fibular physis, then ankle sprain is the likely diagnosis. The authors prefer functional treatment for ankle sprains, allowing weight bearing as tolerated in a supportive device until the patient is pain free (typically 3 weeks), and then progressive return to activities. Surgical treatment is reserved for those patients who develop late symptoms. Chronic pain and instability can occur in young patients, especially adolescents. In these cases, a Broström-type reconstruction30 may be appropriate, although Letts et al.118 have described nonanatomic reconstruction in younger patients (Evans, Watson–Jones, Chrisman, and Snook). 
Avulsion fractures can be identified that originate from the distal fibula, and special radiographic views may facilitate diagnosis.79 These avulsion-type injuries can lead to symptoms, and a high index of suspicion is important in younger patients. Haraguchi et al.80 evaluated a series of severe ankle sprains, and found that 26% had evidence of distal fibular avulsion injury. Children and adults over 40 years of age had the highest incidence of this injury. Patients were treated with weight-bearing casts for 3 to 4 weeks. Nonoperative treatment yielded satisfactory results in this series. 

Rehabilitation

For patients treated with cast immobilization, quadriceps, hamstring, and abductor exercises are begun as soon as pain and swelling allow. Usually a below-knee cast is worn during the last 2 to 3 weeks of immobilization, and weight bearing to tolerance is allowed during this time. After immobilization is discontinued, ankle range-of-motion exercises and strengthening exercises are begun. Protective splinting or bracing is usually not required after cast removal. Running is restricted until the patient demonstrates an essentially full, painless range of ankle and foot motion and can walk without a limp. Running progresses from jogging to more strenuous running and jumping as soreness and endurance dictate. For athletes, unrestricted running and jumping ability should be achieved before returning to sports. Protective measures such as taping or bracing may be beneficial for return to sports. 
Younger patients with physeal ankle fractures recover quickly and require little or no formal physical therapy. For this reason, and because of compliance considerations, fractures treated with internal fixation are usually protected with below-knee casting instead of starting an early range-of-motion program in a removable splint. In older patients who may have a higher risk of arthrofibrosis, we may start early motion in a removable boot, and have them start a formal supervised physical therapy program. 

Management of Expected Adverse Outcomes and Unexpected Complications of Distal Tibial and Fibular Fractures

Delayed Union and Nonunion

Delayed union and nonunion are extremely rare after distal tibial physeal fractures (Fig. 32-68). Dias and Giegerich56 reported one patient with a delayed union and one patient with a previous physeal bar excision who had a nonunion that healed after open reduction, internal fixation, and bone grafting. Siffert and Arkin191 reported nonunion in a patient with avascular necrosis of the distal tibial epiphysis. We have seen two younger patients with Salter–Harris type III fractures that appeared to be progressing to nonunion. Because neither patient had any complaints of pain nor any evidence of progressive displacement of the fracture and stress views showed no instability, no treatment was undertaken. Both fractures eventually united. We have seen one patient with a nonunion after open reduction and internal fixation in whom pin fixation and cast immobilization were discontinued prematurely. The fracture healed after repeat open reduction and internal fixation. 
Figure 32-68
Complex nonunion of a Salter–Harris type III fracture of the medial malleolus in an 8-year-old boy.
 
Note that the distal tibial epiphysis is in valgus, whereas the talus is in varus.
 
(Courtesy of Brent Broztman, MD.)
Note that the distal tibial epiphysis is in valgus, whereas the talus is in varus.
View Original | Slide (.ppt)
Figure 32-68
Complex nonunion of a Salter–Harris type III fracture of the medial malleolus in an 8-year-old boy.
Note that the distal tibial epiphysis is in valgus, whereas the talus is in varus.
(Courtesy of Brent Broztman, MD.)
Note that the distal tibial epiphysis is in valgus, whereas the talus is in varus.
View Original | Slide (.ppt)
X
Nonunion of a fracture of the fibular epiphysis has been reported by Mirmiran and Schuberth.136 This was treated successfully with open reduction and internal fixation. 

Deformity Secondary to Malunion

Rotational malunion usually occurs after triplane fractures that are either incompletely reduced or are initially immobilized in below-knee casts. It has also been reported after Salter–Harris type I and II injuries. Phan et al. reported an increase in the outward foot progression angle in children following transitional fractures, but it is not known if perhaps an outwardly rotated foot predisposes one to these fractures. Derotational osteotomy may be performed for extra-articular fractures if discomfort and stiffness occur. Guille et al.,77 reported a rotational malunion of lateral malleolar fracture that lead to a stress fracture of the distal fibula that went on to delayed union. Their patient improved after correction of the malrotated distal fibula and bone grafting of the delayed union site. 
Anterior angulation or plantarflexion deformity usually occurs after supination–plantarflexion Salter–Harris type II fractures. Theoretically, an equinus deformity might occur if the angulation exceeds the range of ankle dorsiflexion before fracture, but this is very rare, probably because the deformity is in the plane of joint motion and tends to remodel with growth. 
Valgus deformity is most common after external rotation Salter–Harris type II fractures. The degree to which the deformity may spontaneously resolve or remodel with growth is controversial. Carothers and Crenshaw37 reported resolution of a 12-degree valgus deformity in a 13½-year-old boy, but Spiegel et al.196 reported persistent residual deformity in a significant number of their patients (Fig. 32-69). Varus deformity most often results from growth abnormality and infrequently is the result of simple malunion. 
Figure 32-69
Radiograph of a 14-year-old boy, 4 months after pronation–eversion–external rotation injury, reveals 16 degrees of valgus angulation.
Flynn-ch032-image069.png
View Original | Slide (.ppt)
X
If significant angular deformity persists at the completion of growth, supramalleolar osteotomy can be performed.11 
Moon et al.,137 followed nine children with posttraumatic varus deformities of the ankle secondary to supination–inversion injuries. These patients developed medial subluxation of their ankles with associated internal rotational deformity. Takakura et al.,202 described successful open wedge osteotomy for varus deformity in nine patients. Scheffer and Peterson181 recommend opening wedge osteotomy when the angular deformity is 25 degrees or less and the limb length discrepancy is or will be 25 mm or less at maturity. Preoperative planning should include templating the various types of osteotomies to determine which technique will maintain the proper mechanical alignment of the tibia and ankle joint and will not make the malleoli unduly prominent. Osteotomy is not recommended for malunion of intra-articular fractures because it cannot correct the joint incongruity that results from malunion (Fig. 32-70). 
Figure 32-70
 
A: This apparently nondisplaced medial malleolar fracture in an 11-year-old boy was treated with immobilization in a long-leg cast. B: Fourteen months after injury, there is a clear medial osseous bridge and asymmetric growth of the Park–Harris growth arrest lines (black arrows). Note the early inhibition of growth on the subchondral surface of the fracture (open arrow). C: Five years after injury, the varus deformity has increased significantly and fibular overgrowth is apparent. D: The deformity was treated with a medial opening-wedge osteotomy of the tibia, an osteotomy of the fibula, and epiphysiodesis of the most lateral portion of the tibial physis and fibula. E: Three months after surgery, the osteotomies are healed and the varus deformity is corrected; the joint surface remains irregular.
 
(Courtesy of Earl A. Stanley, Jr., MD.)
A: This apparently nondisplaced medial malleolar fracture in an 11-year-old boy was treated with immobilization in a long-leg cast. B: Fourteen months after injury, there is a clear medial osseous bridge and asymmetric growth of the Park–Harris growth arrest lines (black arrows). Note the early inhibition of growth on the subchondral surface of the fracture (open arrow). C: Five years after injury, the varus deformity has increased significantly and fibular overgrowth is apparent. D: The deformity was treated with a medial opening-wedge osteotomy of the tibia, an osteotomy of the fibula, and epiphysiodesis of the most lateral portion of the tibial physis and fibula. E: Three months after surgery, the osteotomies are healed and the varus deformity is corrected; the joint surface remains irregular.
View Original | Slide (.ppt)
Figure 32-70
A: This apparently nondisplaced medial malleolar fracture in an 11-year-old boy was treated with immobilization in a long-leg cast. B: Fourteen months after injury, there is a clear medial osseous bridge and asymmetric growth of the Park–Harris growth arrest lines (black arrows). Note the early inhibition of growth on the subchondral surface of the fracture (open arrow). C: Five years after injury, the varus deformity has increased significantly and fibular overgrowth is apparent. D: The deformity was treated with a medial opening-wedge osteotomy of the tibia, an osteotomy of the fibula, and epiphysiodesis of the most lateral portion of the tibial physis and fibula. E: Three months after surgery, the osteotomies are healed and the varus deformity is corrected; the joint surface remains irregular.
(Courtesy of Earl A. Stanley, Jr., MD.)
A: This apparently nondisplaced medial malleolar fracture in an 11-year-old boy was treated with immobilization in a long-leg cast. B: Fourteen months after injury, there is a clear medial osseous bridge and asymmetric growth of the Park–Harris growth arrest lines (black arrows). Note the early inhibition of growth on the subchondral surface of the fracture (open arrow). C: Five years after injury, the varus deformity has increased significantly and fibular overgrowth is apparent. D: The deformity was treated with a medial opening-wedge osteotomy of the tibia, an osteotomy of the fibula, and epiphysiodesis of the most lateral portion of the tibial physis and fibula. E: Three months after surgery, the osteotomies are healed and the varus deformity is corrected; the joint surface remains irregular.
View Original | Slide (.ppt)
X
The use of the Taylor Spatial Frame continues to evolve. Its use for correction of complex deformities can allow for multiplanar corrections, including rotation, length, and angular deformity. For more complex deformities, this device may be useful for correction.65,190 

Physeal Arrest or Growth Disturbance

Deformity caused by growth arrest usually occurs after Salter–Harris types III and IV fractures in which a physeal bar develops at the fracture site, leading to varus deformity that progresses with continued growth. Spiegel et al.196 reported growth problems in 9 of 66 patients with Salter–Harris type II fractures. 
Earlier reports37,50,72 attributed the development of physeal bars to crushing of the physis at the time of injury, but more recent reports93,111 discount this explanation and claim that with anatomical reduction (open reduction and internal fixation if needed), the incidence of physeal bar formation can be decreased. The validity of this claim is difficult to determine from published reports. One problem is the small numbers of patients in all series, and the even smaller numbers within each group in each series. Another problem is the age of the patients in operative and nonoperative groups in the various series; for example, many children reported to do well with a particular treatment method and have so little growth remaining that treatment may have had little or no effect on growth. 
A recent study by Rohmiller et al.174 analyzed the outcome of 91 Salter–Harris I and II fractures of the distal tibia. They identified premature physeal closure in 40%. This series identified a trend toward increased premature physeal closure in fractures that had worse displacement after reduction. They recommended operative reduction to restore anatomic alignment, to reduce the risk of premature physeal closure. 
Kling et al.111 reported physeal bars in two of five patients treated nonoperatively and in none of three patients treated operatively in children 10 years of age and younger. In another series of 65 physeal ankle fractures, Kling110 concluded that the frequency of growth-related deformities could be reduced by open reduction and internal fixation of Salter–Harris III and IV fractures. 
However, in one of the authors experience with eight patients (JC), two of five treated operatively developed physeal bars, whereas none of the three patients treated nonoperatively had physeal bars. This supports the conclusion of Cass and Peterson,38 Ogden,149 and others that growth problems after these injuries may not always be prevented by open reduction and internal fixation. Open reduction of displaced Salter–Harris type III and IV ankle fractures would seem advisable to restore joint congruity, regardless of whether growth potential can be preserved. 
Harris growth lines have been reported to be reliable predictors of growth abnormality,88 but one of the authors (JC) has found that, although lines parallel to the physis are reliable, lines that appear to diverge from the physis may be misleading (Fig. 32-71). The use of MRI and/or CT scan may assist with evaluation of physeal bars. Spontaneous resolution of physeal bars has been reported23,42 but is rare. Most patients require excision of small bony bars and may require correction of significant angular deformity with osteotomy (Fig. 32-72). Another option to treat secondary deformity is the use of “guided growth,” the use of medial malleolar screws or medial stapling devices.197 
Figure 32-71
 
A: Six months after cast immobilization of a nondisplaced supination–inversion Salter–Harris type III fracture of the right distal tibia in an 8-year-old boy. The Park–Harris growth arrest line (arrow) appears to end in the physis medially and diverge from the physis laterally. B: Two years later, no physeal bar is present and growth is normal.
A: Six months after cast immobilization of a nondisplaced supination–inversion Salter–Harris type III fracture of the right distal tibia in an 8-year-old boy. The Park–Harris growth arrest line (arrow) appears to end in the physis medially and diverge from the physis laterally. B: Two years later, no physeal bar is present and growth is normal.
View Original | Slide (.ppt)
Figure 32-71
A: Six months after cast immobilization of a nondisplaced supination–inversion Salter–Harris type III fracture of the right distal tibia in an 8-year-old boy. The Park–Harris growth arrest line (arrow) appears to end in the physis medially and diverge from the physis laterally. B: Two years later, no physeal bar is present and growth is normal.
A: Six months after cast immobilization of a nondisplaced supination–inversion Salter–Harris type III fracture of the right distal tibia in an 8-year-old boy. The Park–Harris growth arrest line (arrow) appears to end in the physis medially and diverge from the physis laterally. B: Two years later, no physeal bar is present and growth is normal.
View Original | Slide (.ppt)
X
Figure 32-72
 
A: One year after open reduction and internal fixation of a Salter–Harris type III fracture of the distal tibia in a 7-year-old boy, varus deformity has been caused by a physeal bar. B: Two years after excision of the physeal bar and insertion of cranioplast, satisfactory growth has resumed and the deformity has resolved.
A: One year after open reduction and internal fixation of a Salter–Harris type III fracture of the distal tibia in a 7-year-old boy, varus deformity has been caused by a physeal bar. B: Two years after excision of the physeal bar and insertion of cranioplast, satisfactory growth has resumed and the deformity has resolved.
View Original | Slide (.ppt)
Figure 32-72
A: One year after open reduction and internal fixation of a Salter–Harris type III fracture of the distal tibia in a 7-year-old boy, varus deformity has been caused by a physeal bar. B: Two years after excision of the physeal bar and insertion of cranioplast, satisfactory growth has resumed and the deformity has resolved.
A: One year after open reduction and internal fixation of a Salter–Harris type III fracture of the distal tibia in a 7-year-old boy, varus deformity has been caused by a physeal bar. B: Two years after excision of the physeal bar and insertion of cranioplast, satisfactory growth has resumed and the deformity has resolved.
View Original | Slide (.ppt)
X
Kärrholm et al.100 reported progressive ankle deformity caused by complete growth arrest of the fibula with normal growth of the tibia (Fig. 32-73). They found that continued fibular growth with complete arrest of tibial growth was usually compensated by proximal migration of the fibula so that varus deformity did not occur. 
Figure 32-73
Valgus deformity of the ankle, lateral displacement of the talus with widening of the joint medially, and severe shortening of the fibula after early physeal arrest in a child who sustained an ankle injury at 6 years of age.
(Courtesy of James Roach, MD.)
(Courtesy of James Roach, MD.)
View Original | Slide (.ppt)
X
Because the amount of growth remaining in the distal tibial physis is small (approximately 0.25 in per year) in most older patients with these injuries, the amount of leg-length discrepancy resulting from complete growth arrest tends to be relatively small. Treatment may be required if the anticipated discrepancy is projected to be clinically significant. 
Imaging techniques to identify physeal arrest and bars include plane radiographs, tomography, computerized tomography, and MRI. In most imaging departments, standard tomography has been replaced by computerized tomography. CT scans can be useful for clear delineation of the anatomy, especially in cases in which surgical intervention is necessary. Recent studies have also used MRI scans.69,122,180 Although the resolution capability is more limited, the avoidance of ionizing radiation is a major advantage of MRI scans over CT scans. 
Physeal arrest of the distal tibia has been reported after fracture of the tibial diaphysis, in the absence of obvious physeal injury.142 

Medial Malleolus Overgrowth

Overgrowth of the medial malleolus has been reported after fractures of the distal tibia metaphysis and epiphysis. A recent series of 83 patients with fractures in this region demonstrated 2 patients with medial malleolus overgrowth. In both cases, there was no evidence of functional impairment.144 

Arthritis

Epiphyseal ankle fractures that do not extend into the joint have a low risk of posttraumatic arthritis, but injuries that extend into the joint may produce this complication. Caterini et al.40 found that 8 of 68 (12%) patients had pain and stiffness that began from 5 to 8 years after skeletal maturity. Ertl et al.62 found that 18 to 36 months after injury, 20 patients with triplane fractures were asymptomatic, but at 36 months to 13 years after injury only 8 of 15 patients evaluated were asymptomatic. 
Ramsey and Hamilton168 demonstrated in a cadaver study that 1 mm of lateral talar displacement decreases tibiotalar contact area by 42%, which greatly increases the stress on this weight-bearing joint. More recently, Michelson et al.134 reported that a cadaver study using unconstrained specimens suggested that some lateral talar displacement occurs with normal weight bearing. Because of their findings, they questioned the current criterion of 2 mm of displacement for unstable ankle fractures. However, the results of Ramsey and Hamilton's study correlate well with other studies that have shown increased symptoms in patients in whom more than 2 mm of displacement was accepted.40,62 
Implant removal after fracture surgery remains controversial, and the indications for removal are not well defined in the literature.34 Charlton et al.44 have demonstrated that the periepiphyseal or subchondral screws may alter the joint contact pressures about the ankle. After removal of the screws from the subchondral bone, the contact pressure is normalized. For hardware in the subchondral bone, Charlton's study suggests that implant removal of transepiphyseal screws may be appropriate. 

Chondrolysis

Chondrolysis is a rare complication of adolescent ankle fractures.18,180 Treatment options include therapy, nonsteroidal anti-inflammatories, etc. Recent clinical studies have evaluated the effects of joint distraction for posttraumatic chondrolysis, although experience with this technique in young patients is very limited.180 

Osteonecrosis of the Distal Tibial Epiphysis

Siffert and Arkin191 in 1950, were the first to call attention to this complication of distal tibial fractures. In their patient, the combination of nonunion of a medial malleolar fracture and avascular necrosis caused pain that required an arthrodesis 14 months after injury. Dias55 and Pugely et al.166 have recently reported this complication, which can lead to significant growth disturbance. We have seen few patients with this complication. One patient had significant joint stiffness and developed a valgus deformity secondary to collapse. After revascularization of the epiphysis, the ankle was realigned with a supramalleolar osteotomy, and 5 years later the patient had satisfactory function without pain. 

Compartment Syndrome

This complication is discussed in detail in Chapter 6. Fractures of the distal tibia and ankle joint are infrequently associated with compartment syndromes,47,139 unlike more proximal leg fractures. Mubarak139 has described a unique compartment syndrome associated with distal tibial physeal fractures in six patients. These patients had clinical symptoms of severe pain and swelling, with associated sensory and motor deficits. The compartment pressure below the superior extensor retinaculum was above 40 mm in all cases, and the pressure was less than 20 mm in the anterior compartment. These patients were treated with limited fascial release of the superior extensor retinaculum and fracture stabilization. 
The development of claw toes after tibial fracture has been described, and this development may be related to a subclinical compartment syndrome which develops in the distal part of the deep posterior compartment.67 

Osteochondral Defects

Osteochondral injuries, primarily of the talus, are increasingly recognized after ankle injury in adults and the skeletally immature.127,151,183 MRI may play a role in identification of treatment of these injuries.14 

Synostosis

Posttraumatic tibiofibular synostosis is a rare complication of fractures in this region. This can lead to growth disturbance, including angular deformity and lower extremity length discrepancy.142,214 Synostosis in this area alters the normal pattern of movement between the tibia and fibula, and has been associated with pain in some patients. In a small clinical series, Mubarak et al.141 demonstrated symptoms of pain, prominence of the fibula, and ankle deformity in 5/8 patients with this synostosis. In this series, the normal growth pattern of distal migration of the fibula was altered, resulting in decreased distances between the proximal physes of the tibia and fibula, and proximal positioning of the distal fibula with respect to the distal tibia. Munjal et al.142 demonstrated successful synostosis excision in a 7-year-old patient, which lead to normalization of the ankle joint at 16 months post surgery. 

Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

Reflex sympathetic dystrophy or complex regional pain syndrome occasionally develops after ankle injuries, and is treated initially with an intensive formal physical therapy regimen that encourages range of motion and weight bearing.102,213 For patients who do not respond quickly to such a program, physical therapy in association with continuous epidural analgesia may be considered.213 

Osteopenia

Recent studies have identified the development of osteopenia after ankle fracture treatment in the pediatric population.41 Although the implications of osteopenia are not clear, appropriate return to early weight bearing may be an important factor to minimize this complication. 

Summary, Controversies, and Future Directions Related to Distal Tibial and Fibular Fractures

Many questions remain unanswered about the optimal treatment of ankle fractures in skeletally immature patients and will have to be answered with clinical trials. The relationship between physeal displacement and the development of subsequent physeal arrest is still unclear. Interposition of periosteum in the fracture may play a role in physeal arrest, although this has not been clarified in animal models or clinical trials. 
Recent studies in the adult literature have suggested that minimally angular deformities about the distal tibia can have pronounced effects on the tibiotalar contact pressures.102,204,206 The limits of fracture remodeling and the magnitude of acceptable deformity in growing children are still not well defined in the literature. 
Advanced imaging techniques have improved our understanding of these fractures, and may play an increasing role in the use of computer-aided reduction techniques and other forms of minimally invasive surgery. CT scanning requires ionizing radiation, but provides high resolution model reconstruction. Future MRI modalities may allow for higher-quality images, including three-dimensional reconstructions; this would avoid the need for ionizing radiation. In addition, recent studies utilizing advanced imaging have cast doubt on the commonly accepted principle that the physis is always weaker than ankle ligaments. It appears that ankle sprain injuries are more common than previously believed, and are often misdiagnosed as Salter I fractures of the distal fibula. 
The use of cultured chondrocytes and gene therapy may eventually play a role in the treatment of these fractures, either to prevent or treat a physeal arrest.106 The surgical treatment of physeal bars to restore normal growth remains unsuccessful in a substantial percentage of cases, and further understanding of the basic mechanisms controlling physeal growth may help us develop more successful strategies. 

Acknowledgments

The authors and editors wish to acknowledge Drs. Luciano Dias and Jay Cummings, for the past contributions to this chapter. 

References

1.
Adler P. Ride on Mower Hazard Analysis 1987-1990. Washington, DC: Directorate for Epidemiology, USA Consumer Product Safety Commission; 1993:1–65.
2.
Aitken AP. The end results of the fractured distal tibial epiphysis. J Bone Joint Surg. 1936; 18:685–691.
3.
Alioto RJ, Furia JP, Marquardt JD. Hematoma block for ankle fractures: a safe and efficacious technique for manipulations. J Orthop Trauma. 1995; 9(2):113–116.
4.
Alonso JE, Sanchez FL. Lawn mower injuries in children: A preventable impairment. J Pediatr Orthop. 1995; 15:83–89.
5.
Ashhurst APC, Bromer RS. Classification and mechanism of fractures of the leg bones involving the ankle. Arch Surg. 1922; 4:51–129.
6.
Assal M, Ray A, Stern R. The extensile approach for the operative treatment of high-energy pilon fractures: Surgical technique and soft-tissue healing. J Orthop Trauma. 2007; 21:198–206.
7.
Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop. 2003; 23:733–739.
8.
Barnett PL, Lee MH, Oh L, et al. Functional outcome after air-stirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: A randomized observer-blinded controlled trial. Pediatr Emerg Care. 2012; 28:745–749.
9.
Bartl R. Die traumatische epiphysenlosung am distalen ende des schienbeines und des wadenbeines. Hefte Unfallheilkd. 1957; 54:228–257.
10.
Beaty JH, Linton RC. Medial malleolar fracture in a child. A case report. J Bone Joint Surg Am. 1988; 70:1254–1255.
11.
Becker AS, Myerson MS. The indications and technique of supramalleolar osteotomy. Foot Ankle Clin. 2009; 14:549–561.
12.
Benz G, Kallieris D, Seeböck T, et al. Bioresorbable pins and screws in paediatric traumatology. Eur J Pediatr Surg. 1994; 4:103–107.
13.
Bishop PA. Fractures and epiphyseal separation fractures of the ankle: Classification of 332 cases according to mechanism of their production. AJR Am J Roentgenol. 1932; 28:49–67.
14.
Blackburn EW, Aronsson DD, Rubright JH, et al. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94:1234–1244.
15.
Blair JM, Botte MJ. Surgical anatomy of the superficial peroneal nerve in the ankle and foot. Clin Orthop Relat Res. 1994:229–238.
16.
Blauth M, Bastian L, Krettek C, et al. Surgical options for the treatment of severe tibial pilon fractures: A study of three techniques. J Orthop Trauma. 2001; 15:153–160.
17.
Blitzer CM, Johnson RJ, Ettlinger CF, et al. Downhill skiing injuries in children. Am J Sports Med. 1984; 12:142–147.
18.
Bojescul JA, Wilson G, Taylor DC. Idiopathic chondrolysis of the ankle. Arthroscopy. 2005; 21:224–227.
19.
Böstman O, Hirvensalo E, Vainionpää S, et al. Degradable polyglycolide rods for the internal fixation of displaced bimalleolar fractures. Int Orthop. 1990; 14:1–8.
20.
Böstman O, Mäkelä EA, Södergård J, et al. Absorbable polyglycolide pins in internal fixation of fractures in children. J Pediatr Orthop. 1993; 13:242–245.
21.
Böstman OM. Distal tibiofibular synostosis after malleolar fractures treated using absorbable implants. Foot Ankle. 1993; 14:38–43.
22.
Böstman OM. Metallic or absorbable fracture fixation devices. A cost minimization analysis. Clin Orthop Relat Res. 1996:233–239.
23.
Bostock SH, Peach BG. Spontaneous resolution of an osseous bridge affecting the distal tibial epiphysis. J Bone Joint Surg Br. 1996; 78:662–663.
24.
Boutis K, Narayanan UG, Dong FF, et al. Magnetic resonance imaging of clinically suspected Salter-Harris I fracture of the distal fibula. Injury. 2010; 41:852–856.
25.
Boutis K, Willan AR, Babyn P, et al. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007; 119:e1256–e1263.
26.
Boyer MI, Bowen V, Weiler P. Reconstruction of a severe grinding injury to the medial malleolus and the deltoid ligament of the ankle using a free plantaris tendon graft and vascularized gracilis free muscle transfer: Case report. J Trauma. 1994; 36:454–457.
27.
Bozic KJ, Jaramillo D, DiCanzio J, et al. Radiographic appearance of the normal distal tibiofibular syndesmosis in children. J Pediatr Orthop. 1999; 19:14–21.
28.
Broock GJ, Greer RB. Traumatic rotational displacements of the distal tibial growth plate. A case report. J Bone Joint Surg Am. 1970; 52:1666–1668.
29.
Broström L. Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand. 1966; 132:537–550.
30.
Broström L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966; 132:551–565.
31.
Brown SD, Kasser JR, Zurakowski D, et al. Analysis of 51 tibial triplane fractures using CT with multiplanar reconstruction. AJR Am J Roentgenol. 2004; 183:1489–1495.
32.
Bucholz RW, Henry S, Henley MB. Fixation with bioabsorbable screws for the treatment of fractures of the ankle. J Bone Joint Surg Am. 1994; 76:319–324.
33.
Burstein AH. Fracture classification systems: Do they work and are they useful? J Bone Joint Surg Am. 1993; 75:1743–1744.
34.
Busam ML, Esther RJ, Obremskey WT. Hardware removal: Indications and expectations. J Am Acad Orthop Surg. 2006; 14:113–120.
35.
Busconi BD, Pappas AM. Chronic, painful ankle instability in skeletally immature athletes. Ununited osteochondral fractures of the distal fibula. Am J Sports Med. 1996; 24:647–651.
36.
Carey J, Spence L, Blickman H, et al. MRI of pediatric growth plate injury: Correlation with plain film radiographs and clinical outcome. Skeletal Radiol. 1998; 27:250–255.
37.
Carothers CO, Crenshaw AH. Clinical significance of a classification of epiphyseal injuries at the ankle. Am J Surg. 1955; 89:879–889.
38.
Cass JR, Peterson HA. Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg Am. 1983; 65:1059–1070.
39.
Casteleyn PP, Handelberg F. Distraction for ankle arthroscopy. Arthroscopy. 1995; 11:633–634.
40.
Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to the ankle. Foot Ankle. 1991; 11:372–383.
41.
Ceroni D, Martin X, Delhumeau C, et al. Effects of cast-mediated immobilization on bone mineral mass at various sites in adolescents with lower-extremity fracture. J Bone Joint Surg Am. 2012; 94:208–216.
42.
Chadwick CJ. Spontaneous resolution of varus deformity at the ankle following adduction injury of the distal tibial epiphysis. A case report. J Bone Joint Surg Am. 1982; 64:774–776.
43.
Chande VT. Decision rules for roentgenography of children with acute ankle injuries. Arch Pediatr Adolesc Med. 1995; 149:255–258.
44.
Charlton M, Costello R, Mooney JF 3rd, et al. Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia. J Pediatr Orthop. 2005; 25:635–640.
45.
Clement DA, Worlock PH. Triplane fracture of the distal tibia. A variant in cases with an open growth plate. J Bone Joint Surg Br. 1987; 69:412–415.
46.
Cooperman DR, Spiegel PG, Laros GS. Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture. J Bone Joint Surg Am. 1978; 60:1040–1046.
47.
Cox G, Thambapillay S, Templeton PA. Compartment syndrome with an isolated Salter Harris II fracture of the distal tibia. J Orthop Trauma. 2008; 22:148–150.
48.
Cox PJ, Clarke NM. Juvenile Tillaux fracture of the ankle associated with a tibial shaft fracture: A unique combination. Injury. 1996; 27:221–222.
49.
Crawford AH. Triplane and Tillaux fractures: Is a 2 mm residual gap acceptable? J Pediatr Orthop. 2012; 32(Suppl 1):S69–S73.
50.
Crenshaw AH. Injuries of the distal tibial epiphysis. Clin Orthop Relat Res. 1965; 41:98–107.
51.
Cummings RJ. Triplane ankle fracture with deltoid ligament tear and syndesmotic disruption. J Child Orthop. 2008; 2:11–14.
52.
Cummings RJ, Hahn GA Jr. The incisural fracture. Foot Ankle Int. 2004; 25:132–135.
53.
Damore DT, Metzl JD, Ramundo M, et al. Patterns in childhood sports injury. Pediatr Emerg Care. 2003; 19:65–67.
54.
Denton JR, Fischer SJ. The medial triplane fracture: Report of an unusual injury. J Trauma. 1981; 21:991–995.
55.
Dias L. Fractures of the tibia and fibula. In: Rockwood CA, Wilkins KE, King RE, eds. Fractures in Children. 3rd ed. Philadelphia, PA: JB Lippincott; 1991.
56.
Dias LS, Giegerich CR. Fractures of the distal tibial epiphysis in adolescence. J Bone Joint Surg Am. 1983; 65:438–444.
57.
Dias LS, Tachdjian MO. Physeal injuries of the ankle in children: Classification. Clin Orthop Relat Res. 1978:230–233.
58.
Dormans JP, Azzoni M, Davidson RS, et al. Major lower extremity lawn mower injuries in children. J Pediatr Orthop. 1995; 15(1):78–82.
59.
Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: A meta-analysis. Acad Emerg Med. 2009; 16:277–287.
60.
Dunbar RP, Barei DP, Kubiak EN, et al. Early limited internal fixation of diaphyseal extensions in select pilon fractures: Upgrading AO/OTA type C fractures to AO/OTA type B. J Orthop Trauma. 2008; 22:426–429.
61.
El-Karef E, Sadek HI, Nairn DS, et al. Triplane fracture of the distal tibia. Injury. 2000; 31:729–736.
62.
Ertl JP, Barrack RL, Alexander AH, et al. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg Am. 1988; 70:967–976.
63.
Farley FA, Kuhns L, Jacobson JA, et al. Ultrasound examination of ankle injuries in children. J Pediatr Orthop. 2001; 21:604–607.
64.
Feldman DS, Otsuka NY, Hedden DM. Extra-articular triplane fracture of the distal tibial epiphysis. J Pediatr Orthop. 1995; 15:479–481.
65.
Feldman DS, Shin SS, Madan S, et al. Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor Spatial Frame. J Orthop Trauma. 2003; 17:549–554.
66.
Feldman F, Singson RD, Rosenberg ZS, et al. Distal tibial triplane fractures: Diagnosis with CT. Radiology. 1987; 164:429–435.
67.
Fitoussi F, Ilharreborde B, Guerin F, et al. Claw toes after tibial fracture in children. J Child Orthop. 2009; 3:339–343.
68.
Frøkjaer J, Møller BN. Biodegradable fixation of ankle fractures. Complications in a prospective study of 25 cases. Acta Orthop Scand. 1992; 63:434–436.
69.
Gabel GT, Peterson HA, Berquist TH. Premature partial physeal arrest. Diagnosis by magnetic resonance imaging in two cases. Clin Orthop Relat Res. 1991:242–247.
70.
Gaglani MJ, Friedman J, Hawkins EP, et al. Infections complicating lawn mower injuries in children. Pediatr Infect Dis J. 1996; 15:452–455.
71.
Gerner-Smidt M. Ankelbrud Hos Born. Copenhagen: Nytt Nordiskt Forlaz; 1963.
72.
Gill GG, Abbott LC. Varus deformity of ankle following injury to distal epiphyseal cartilage of tibia in growing children. Surg Gynecol Obstet. 1941; 72:659–666.
73.
Goldberg VM, Aadalen R. Distal tibial epiphyseal injuries: The role of athletics in 53 cases. Am J Sports Med. 1978; 6:263–268.
74.
Gourineni P, Gupta A. Medial joint space widening of the ankle in displaced Tillaux and Triplane fractures in children. J Orthop Trauma. 2011; 25:608–611.
75.
Grace DL. Irreducible fracture-separations of the distal tibial epiphysis. J Bone Joint Surg Br. 1983; 65:160–162.
76.
Grosfeld JL, Morse TS, Eyring EJ. Lawn mower injuries in children. Arch Surg. 1970; 100:582–583.
77.
Guille JT, Lipton GE, Bowen JR, et al. Delayed union following stress fracture of the distal fibula secondary to rotational malunion of lateral malleolar fracture. Am J Orthop (Belle Mead NJ). 1997; 26:442–445.
78.
Handolin L, Kiljunen V, Arnala I, et al. Effect of ultrasound therapy on bone healing of lateral malleolar fractures of the ankle joint fixed with bioabsorbable screws. J Orthop Sci. 2005; 10:391–395.
79.
Haraguchi N, Kato F, Hayashi H. New radiographic projections for avulsion fractures of the lateral malleolus. J Bone Joint Surg Br. 1998; 80:684–688.
80.
Haraguchi N, Toga H, Shiba N, et al. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: Incidence and clinical outcome. Am J Sports Med. 2007; 35:1144–1152.
81.
Haramati N, Roye DP, Adler PA, et al. Non-union of pediatric fibula fractures: Easy to overlook, painful to ignore. Pediatr Radiol. 1994; 24:248–250.
82.
Havránek P, Lízler J. Magnetic resonance imaging in the evaluation of partial growth arrest after physeal injuries in children. J Bone Joint Surg Am. 1991; 73:1234–1241.
83.
Havranek P, Pesl T. Salter (Rang) type 6 physeal injury. Eur J Pediatr Surg. 2010; 20:174–177.
84.
Healy WA 3rd, Starkweather KD, Meyer J, et al. Triplane fracture associated with a proximal third fibula fracture. Am J Orthop (Belle Mead NJ). 1996; 25:449–451.
85.
Herscovici D Jr, Sanders RW, Scaduto JM, et al. Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma. 2003; 17:683–688.
86.
Hirvensalo E. Fracture fixation with biodegradable rods. Forty-one cases of severe ankle fractures. Acta Orthop Scand. 1989; 60:601–606.
87.
Horowitz JH, Nichter LS, Kenney JG, et al. Lawnmower injuries in children: Lower extremity reconstruction. J Trauma. 1985; 25:1138–1146.
88.
Hynes D, O'Brien T. Growth disturbance lines after injury of the distal tibial physis. Their significance in prognosis. J Bone Joint Surg Br. 1988; 70:231–233.
89.
Imade S, Takao M, Nishi H, et al. Arthroscopy-assisted reduction and percutaneous fixation for triplane fracture of the distal tibia. Arthroscopy. 2004; 20:e123–e128.
90.
Iwinska-Zelder J, Schmidt S, Ishaque N, et al. [Epiphyseal injuries of the distal tibia. Does MRI provide useful additional information?]. Radiologe. 1999; 39:25–29.
91.
Jarvis JG, Miyanji F. The complex triplane fracture: Ipsilateral tibial shaft and distal triplane fracture. J Trauma. 2001; 51:714–716.
92.
Jennings MM, Lagaay P, Schuberth JM. Arthroscopic assisted fixation of juvenile intra-articular epiphyseal ankle fractures. J Foot Ankle Surg. 2007; 46:376–386.
93.
Johnson EW Jr, Fahl JC. Fractures involving the distal epiphysis of the tibia and fibula in children. Am J Surg. 1957; 93:778–781.
94.
Johnstone BR, Bennett CS. Lawn mower injuries in children. Aust N Z J Surg. 1989; 59:713–718.
95.
Jones S, Phillips N, Ali F, et al. Triplane fractures of the distal tibia requiring open reduction and internal fixation. Pre-operative planning using computed tomography. Injury. 2003; 34:293–298.
96.
Kärrholm J. The triplane fracture: Four years of follow-up of 21 cases and review of the literature. J Pediatr Orthop B. 1997; 6:91–102.
97.
Kärrholm J, Hansson LI, Laurin S. Computed tomography of intraarticular supination–eversion fractures of the ankle in adolescents. J Pediatr Orthop. 1981; 1:181–187.
98.
Kärrholm J, Hansson LI, Laurin S. Supination–eversion injuries of the ankle in children: A retrospective study of radiographic classification and treatment. J Pediatr Orthop. 1982; 2:147–159.
99.
Kärrholm J, Hansson LI, Laurin S. Pronation injuries of the ankle in children. Retrospective study of radiographical classification and treatment. Acta Orthop Scand. 1983; 54:1–17.
100.
Kärrholm J, Hansson LI, Selvik G. Changes in tibiofibular relationships due to growth disturbances after ankle fractures in children. J Bone Joint Surg Am. 1984; 66:1198–1210.
101.
Kaukonen JP, Lamberg T, Korkala O, et al. Fixation of syndesmotic ruptures in 38 patients with a malleolar fracture: A randomized study comparing a metallic and a bioabsorbable screw. J Orthop Trauma. 2005; 19:392–395.
102.
Kay RM, Matthys GA. Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg. 2001; 9:268–278.
103.
Kaya A, Altay T, Ozturk H, et al. Open reduction and internal fixation in displaced juvenile Tillaux fractures. Injury. 2007; 38:201–205.
104.
Keats TE. Atlas of Normal Roentgen Variants That May Simulate Disease. 5th ed. St Louis, MO: Year Book; 1992.
105.
Kerr R, Forrester DM, Kingston S. Magnetic resonance imaging of foot and ankle trauma. Orthop Clin North Am. 1990; 21:591–601.
106.
Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005; 13:47–58.
107.
Kim JR, Song KH, Song KJ, et al. Treatment outcomes of triplane and Tillaux fractures of the ankle in adolescence. Clin Orthop Surg. 2010; 2:34–38.
108.
Kleiger B, Mankin HJ. Fracture of the lateral portion of the distal tibial epiphysis. J Bone Joint Surg Am. 1964; 46:25–32.
109.
Klein DM, Caligiuri DA, Katzman BM. Local-advancement soft-tissue coverage in a child with ipsilateral grade IIIB open tibial and ankle fractures. J Orthop Trauma. 1996; 10:577–580.
110.
Kling T. Fractures of the ankle and foot. In: Drennan JC, ed. The Child's Foot and Ankle. New York, NY: Raven Press; 1992.
111.
Kling TF Jr, Bright RW, Hensinger RN. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. 1984; 66:647–657.
112.
Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950; 60:957–985.
113.
Leary JT, Handling M, Talerico M, et al. Physeal fractures of the distal tibia: Predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop. 2009; 29:356–361.
114.
Lehman WL, Jones WW. Intravenous lidocaine for anesthesia in the lower extremity. A prospective study. J Bone Joint Surg Am. 1984; 66:1056–1060.
115.
Leininger RE, Knox CL, Comstock RD. Epidemiology of 1.6 million pediatric soccer-related injuries presenting to US emergency departments from 1990 to 2003. Am J Sports Med. 2007; 35:288–293.
116.
Lerner A, Stein H. Hybrid thin wire external fixation: An effective, minimally invasive, modular surgical tool for the stabilization of periarticular fractures. Orthopedics. 2004; 27:59–62.
117.
Letts M, Davidson D, McCaffrey M. The adolescent pilon fracture: Management and outcome. J Pediatr Orthop. 2001; 21:20–26.
118.
Letts M, Davidson D, Mukhtar I. Surgical management of chronic lateral ankle instability in adolescents. J Pediatr Orthop. 2003; 23:392–397.
119.
Letts RM. The hidden adolescent ankle fracture. J Pediatr Orthop. 1982; 2:161–164.
120.
Lintecum N, Blasier RD. Direct reduction with indirect fixation of distal tibial physeal fractures: A report of a technique. J Pediatr Orthop. 1996; 16:107–112.
121.
Loder RT, Brown KL, Zaleske DJ, et al. Extremity lawn-mower injuries in children: Report by the Research Committee of the Pediatric Orthopaedic Society of North America. J Pediatr Orthop. 1997; 17:360–369.
122.
Lohman M, Kivisaari A, Vehmas T, et al. MRI in the assessment of growth arrest. Pediatr Radiol. 2002; 32:41–45.
123.
Love SM, Grogan DP, Ogden JA. Lawn-mower injuries in children. J Orthop Trauma. 1988; 2:94–101.
124.
Lovell ES. An unusual rotating injury of the ankle. J Bone Joint Surg. 1968; 50A:163–165.
125.
Luhmann SJ, Oda JE, O'Donnell J, et al. An analysis of suboptimal outcomes of medial malleolus fractures in skeletally immature children. Am J Orthop (Belle Mead NJ). 2012; 41:113–116.
126.
Lynn MD. The triplane distal tibial epiphyseal fracture. Clin Orthop Relat Res. 1972; 86:187–190.
127.
Malanga GA, Ramirez-Del Toro JA. Common injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am. 2008; 19:347–371, ix.
128.
Manderson EL, Ollivierre CO. Closed anatomic reduction of a juvenile tillaux fracture by dorsiflexion of the ankle. A case report. Clin Orthop Relat Res. 1992;(276):262–266.
129.
Mankovsky AB, Mendoza-Sagaon M, Cardinaux C, et al. Evaluation of scooter-related injuries in children. J Pediatr Surg. 2002; 37:755–759.
130.
Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop. 1990; 10:713–716.
131.
Marmor L. An unusual fracture of the tibial epiphysis. Clin Orthop Relat Res. 1970; 73:132–135.
132.
Marumo K, Sato Y, Suzuki H, et al. MRI study of bioabsorbable poly-L-lactic acid devices used for fixation of fracture and osteotomies. J Orthop Sci. 2006; 11:154–158.
133.
Mazur JM, Loveless EA, Cummings RJ. Ankle dislocation without fracture in a child. Am J Orthop (Belle Mead NJ). 2007; 36:E138–E140.
134.
Michelson JD, Clarke HJ, Jinnah RH. The effect of loading on tibiotalar alignment in cadaver ankles. Foot Ankle. 1990; 10:280–284.
135.
Miller MD. Arthroscopically assisted reduction and fixation of an adult Tillaux fracture of the ankle. Arthroscopy. 1997; 13:117–119.
136.
Mirmiran R, Schuberth JM. Nonunion of an epiphyseal fibular fracture in a pediatric patient. J Foot Ankle Surg. 2006; 45:410–412.
137.
Moon MS, Kim I, Rhee SK, et al. Varus and internal rotational deformity of the ankle secondary to distal tibial physeal injury. Bull Hosp Jt Dis. 1997; 56:145–148.
138.
Mooney JF 3rd, DeFranzo A, Marks MW. Use of cross-extremity flaps stabilized with external fixation in severe pediatric foot and ankle trauma: An alternative to free tissue transfer. J Pediatr Orthop. 1998; 18:26–30.
139.
Mubarak SJ. Extensor retinaculum syndrome of the ankle after injury to the distal tibial physis. J Bone Joint Surg Br. 2002; 84:11–14.
140.
Mubarak SJ, Wilton NC. Compartment syndromes and epidural analgesia. J Pediatr Orthop. 1997; 17:282–284.
141.
Munjal K, Kishan S, Sabharwal S. Posttraumatic pediatric distal tibiofibular synostosis: A case report. Foot Ankle Int. 2004; 25:429–433.
142.
Navascués JA, González-López JL, López-Valverde S, et al. Premature physeal closure after tibial diaphyseal fractures in adolescents. J Pediatr Orthop. 2000; 20:193–196.
143.
Nenopoulos SP, Papavasiliou VA, Papavasiliou AV. Outcome of physeal and epiphyseal injuries of the distal tibia with intra-articular involvement. J Pediatr Orthop. 2005; 25:518–522.
144.
Nevelös AB, Colton CL. Rotational displacement of the lower tibial epiphysis due to trauma. J Bone Joint Surg Br. 1977; 59:331–332.
145.
Nguyen D, Letts M. In-line skating injuries in children: A 10-year review. J Pediatr Orthop. 2001; 21:613–618.
146.
Nilsson S, Roaas A. Soccer injuries in adolescents. Am J Sports Med. 1978; 6:358–361.
147.
Nusem I, Ezra E, Wientroub S. Closed posterior dislocation of the ankle without associated fracture in a child. J Trauma. 1999; 46:350–351.
148.
Ogden JA. Skeletal Injury in the Child. Philadelphia, PA: Lea & Febiger; 1982.
149.
Ogden JA, Lee J. Accessory ossification patterns and injuries of the malleoli. J Pediatr Orthop. 1990; 10:306–316.
150.
O'Loughlin PF, Heyworth BE, Kennedy JG. Current concepts in the diagnosis and treatment of osteochondral lesions of the ankle. Am J Sports Med. 2010; 38:392–404.
151.
Orava S, Saarela J. Exertion injuries to young athletes: A follow-up research of orthopaedic problems of young track and field athletes. Am J Sports Med. 1978; 6:68–74.
152.
Panagopoulos A, van Niekerk L. Arthroscopic assisted reduction and fixation of a juvenile Tillaux fracture. Knee Surg Sports Traumatol Arthrosc. 2007; 15:415–417.
153.
Papadokostakis G, Kontakis G, Giannoudis P, et al. External fixation devices in the treatment of fractures of the tibial plafond: A systematic review of the literature. J Bone Joint Surg Br. 2008; 90:1–6.
154.
Peiró A, Aracil J, Martos F, et al. Triplane distal tibial epiphyseal fracture. Clin Orthop Relat Res. 1981;(160):196–200.
155.
Pesl T, Havranek P. Rare injuries to the distal tibiofibular joint in children. Eur J Pediatr Surg. 2006; 16:255–259.
156.
Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972; 12:275–281.
157.
Peterson HA. Physeal fractures: Part 3. Classification. J Pediatr Orthop. 1994; 14:439–448.
158.
Peterson HA, Madhok R, Benson JT, et al. Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979-1988. J Pediatr Orthop. 1994; 14:423–430.
159.
Petit P, Panuel M, Faure F, et al. Acute fracture of the distal tibial physis: Role of gradient-echo MR imaging versus plain film examination. AJR Am J Roentgenol. 1996; 166:1203–1206.
160.
Petit P, Sapin C, Henry G, et al. Rate of abnormal osteoarticular radiographic findings in pediatric patients. AJR Am J Roentgenol. 2001; 176:987–990.
161.
Petratos DV, Kokkinakis M, Ballas EG, et al. Prognostic factors for premature growth plate arrest as a complication of the surgical treatment of fractures of the medial malleolus in children. Bone Joint J. 2013; 95-B:419–423.
162.
Phieffer LS, Meyer RA Jr, Gruber HE, et al. Effect of interposed periosteum in an animal physeal fracture model. Clin Orthop Relat Res. 2000:15–25.
163.
Pollen AG. Fractures involving the epiphyseal plate. Reconstr Surg Traumatol. 1979; 17:25–39.
164.
Powell H. Extra centre of ossification for the medial malleolis in children: Incidence and significance. J Bone Joint Surg Br. 1961;43B.
165.
Pugely AJ, Nemeth BA, McCarthy JJ, et al. Osteonecrosis of the distal tibia metaphysis after a Salter-Harris I injury: A case report. J Orthop Trauma. 2012; 26:e11–e15.
166.
Raikin SM, Ching AC. Bioabsorbable fixation in foot and ankle. Foot Ankle Clin. 2005; 10:667–684, ix.
167.
Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976; 58:356–357.
168.
Rapariz JM, Ocete G, González-Herranz P, et al. Distal tibial triplane fractures: Long-term follow-up. J Pediatr Orthop. 1996; 16:113–118.
169.
Reff RB. The use of external fixation devices in the management of severe lower-extremity trauma and pelvic injuries in children. Clin Orthop Relat Res. 1984;(188):21–33.
170.
Rinker B, Amspacher JC, Wilson PC, et al. Subatmospheric pressure dressing as a bridge to free tissue transfer in the treatment of open tibia fractures. Plast Reconstr Surg. 2008; 121:1664–1673.
171.
Ristiniemi J. External fixation of tibial pilon fractures and fracture healing. Acta Orthop Suppl. 2007; 78:3:5–34.
172.
Rogers LF. The radiography of epiphyseal injuries. Radiology. 1970; 96:289–299.
173.
Rohmiller MT, Gaynor TP, Pawelek J, et al. Salter-Harris I and II fractures of the distal tibia: Does mechanism of injury relate to premature physeal closure? J Pediatr Orthop. 2006; 26:322–328.
174.
Rokkanen P, Böstman O, Vainionpää S, et al. Absorbable devices in the fixation of fractures. J Trauma. 1996; 40:S123–S127.
175.
Rosenbaum AJ, DiPreta JA, Uhl RL. Review of distal tibial epiphyseal transitional fractures. Orthopedics. 2012; 35:1046–1049.
176.
Roser LA, Clawson DK. Football injuries in the very young athlete. Clin Orthop Relat Res. 1970; 69:219–223.
177.
Ross PM, Schwentker EP, Bryan H. Mutilating lawn mower injuries in children. JAMA. 1976; 236:480–481.
178.
Rougraff BT, Kernek CB. Lawn mower injury resulting in Chopart amputation in a young child. Orthopedics. 1996; 19:689–691.
179.
Sabharwal S, Schwechter EM. Five-year followup of ankle joint distraction for post-traumatic chondrolysis in an adolescent: A case report. Foot Ankle Int. 2007; 28:942–948.
180.
Sailhan F, Chotel F, Guibal AL, et al. Three-dimensional MR imaging in the assessment of physeal growth arrest. Eur Radiol. 2004; 14:1600–1608.
181.
Scheffer MM, Peterson HA. Opening-wedge osteotomy for angular deformities of long bones in children. J Bone Joint Surg Am. 1994; 76:325–334.
182.
Schenck RC Jr, Goodnight JM. Osteochondritis dissecans. J Bone Joint Surg Am. 1996; 78:439–456.
183.
Schlesinger I, Wedge JH. Percutaneous reduction and fixation of displaced juvenile Tillaux fractures: A new surgical technique. J Pediatr Orthop. 1993; 13:389–391.
184.
Schnetzler KA, Hoernschemeyer D. The pediatric triplane ankle fracture. J Am Acad Orthop Surg. 2007; 15:738–747.
185.
Schurz M, Binder H, Platzer P, et al. Physeal injuries of the distal tibia: Long-term results in 376 patients. Int Orthop. 2010; 34:547–552.
186.
Seifert J, Laun R, Paris S, et al. [Value of magnetic resonance tomography (MRI) in diagnosis of triplane fractures of the distal tibia]. Unfallchirurg. 2001; 104:524–529.
187.
Shankar A, Williams K, Ryan M. Trampoline-related injury in children. Pediatr Emerg Care. 2006; 22:644–646.
188.
Shin AY, Moran ME, Wenger DR. Intramalleolar triplane fractures of the distal tibial epiphysis. J Pediatr Orthop. 1997; 17:352–355.
189.
Siapkara A, Nordin L, Hill RA. Spatial frame correction of anterior growth arrest of the proximal tibia: Report of three cases. J Pediatr Orthop B. 2008; 17:61–64.
190.
Siffert RS, Arkin AM. Post-traumatic aseptic necrosis of the distal tibial epiphysis; report of a case. J Bone Joint Surg Am. 1950; 32-A:691–694.
191.
Simanovsky N, Lamdan R, Hiller N, et al. Sonographic detection of radiographically occult fractures in pediatric ankle and wrist injuries. J Pediatr Orthop. 2009; 29:142–145.
192.
Singleton TJ, Cobb M. High fibular fracture in association with triplane fracture: Reexamining this unique pediatric fracture pattern. J Foot Ankle Surg. 2010; 49:491–494.
193.
Sinisaari IP, Lüthje PM, Mikkonen RH. Ruptured tibio-fibular syndesmosis: Comparison study of metallic to bioabsorbable fixation. Foot Ankle Int. 2002; 23:744–748.
194.
Smith BG, Rand F, Jaramillo D, et al. Early MR imaging of lower-extremity physeal fracture-separations: A preliminary report. J Pediatr Orthop. 1994; 14:526–533.
195.
Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of two hundred and thirty-seven cases in children. J Bone Joint Surg Am. 1978; 60:1046–1050.
196.
Steinlauf SD, Stricker SJ, Hulen CA. Juvenile Tillaux fracture simulating syndesmosis separation: A case report. Foot Ankle Int. 1998; 19:332–335.
197.
Stevens PM, Kennedy JM, Hung M. Guided growth for ankle valgus. J Pediatr Orthop. 2011; 31:878–883.
198.
Stiell IG, Greenberg GH, McKnight RD, et al. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992; 21:384–390.
199.
Sullivan JA, Gross RH, Grana WA, et al. Evaluation of injuries in youth soccer. Am J Sports Med. 1980; 8:325–327.
200.
Tachdjian MO. The Child's Foot. Philadelphia, PA: WB Saunders; 1985.
201.
Takakura Y, Takaoka T, Tanaka Y, et al. Results of opening-wedge osteotomy for the treatment of a post-traumatic varus deformity of the ankle. J Bone Joint Surg Am. 1998; 80:213–218.
202.
Tarkin IS, Clare MP, Marcantonio A, et al. An update on the management of high-energy pilon fractures. Injury. 2008; 39:142–154.
203.
Tarr RR, Resnick CT, Wagner KS, et al. Changes in tibiotalar joint contact areas following experimentally induced tibial angular deformities. Clin Orthop Relat Res. 1985;(199):72–80.
204.
Thomsen NO, Overgaard S, Olsen LH, et al. Observer variation in the radiographic classification of ankle fractures. J Bone Joint Surg Br. 1991; 73:676–678.
205.
Ting AJ, Tarr RR, Sarmiento A, et al. The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle. 1987; 7:290–299.
206.
Vahvanen V, Aalto K. Classification of ankle fractures in children. Arch Orthop Trauma Surg. 1980; 97:1–5.
207.
Vangsness CT Jr, Carter V, Hunt T, et al. Radiographic diagnosis of ankle fractures: Are three views necessary? Foot Ankle Int. 1994; 15:172–174.
208.
von Laer L. Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia. J Bone Joint Surg Am. 1985; 67:687–698.
209.
Vosburgh CL, Gruel CR, Herndon WA, et al. Lawn mower injuries of the pediatric foot and ankle: Observations on prevention and management. J Pediatr Orthop. 1995; 15:504–509.
210.
Wattenbarger JM, Gruber HE, Phieffer LS. Physeal fractures, part I: Histologic features of bone, cartilage, and bar formation in a small animal model. J Pediatr Orthop. 2002; 22:703–709.
211.
Whipple TL, Martin DR, McIntyre LF, et al. Arthroscopic treatment of triplane fractures of the ankle. Arthroscopy. 1993; 9:456–463.
212.
Wilder RT, Berde CB, Wolohan M, et al. Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients. J Bone Joint Surg Am. 1992; 74:910–919.
213.
Wuerz TH, Gurd DP. Pediatric physeal ankle fracture. J Am Acad Orthop Surg. 2013; 21:234–244.
214.
Zaricznyj B, Shattuck LJ, Mast TA, et al. Sports-related injuries in school-aged children. Am J Sports Med. 1980; 8:318–324.
215.
Zonfrillo MR, Seiden JA, House EM, et al. The association of overweight and ankle injuries in children. Ambul Pediatr. 2008; 8:66–69.