Pediatric Ankle Fractures: Concepts and Treatment Principles

Abstract

Current clinical concepts are reviewed regarding the epidemiology, anatomy, evaluation, and treatment of pediatric ankle fractures. Correct diagnosis and management relies on appropriate examination, imaging, and knowledge of fracture patterns specific to children. Treatment is guided by patient history, physical examination, plain film radiographs and, in some instances, computed tomography. Treatment goals are to restore acceptable limb alignment, physeal anatomy, and joint congruency. For high-risk physeal fractures, patients should be monitored for growth disturbance as needed until skeletal maturity.

Keywords: Ankle fracture; Ankle trauma; Growth plate injury; Leg length discrepancy; Pediatric sports injury; Physis; Salter-Harris; Transitional fracture.

Fig. 1

(A) Salter-Harris Type I fracture. Note the widening of the physis at the medial side of distal tibia (red arrows) and the adjacent soft tissue swelling (blue arrows), even though no obvious fracture lines were seen. (B) Salter-Harris Type II fracture. The fracture line extended into the metaphysis (red arrows) and was seen clearly in the lateral view. Casting resulted in satisfactory outcome in both patients. (C) Park-Harris line (blue arrows) symmetric to the uninjured ankle (yellow arrows) and parallel to the physis with longitudinal growth at one year follow-up, indicating restoration of normal physeal growth.

Fig. 2

(A) Salter-Harris Type III fracture with a displaced medial tibial epiphyseal fragment (red arrows) was treated by open reduction with two parallel cannulated screws fixation. (B) CT scan excluded extension of the fracture into the tibial metaphysis and confirmed the SH-III diagnosis.

Fig. 3

(A) Salter-Harris Type IV fracture with a displaced medial tibial epiphyseal fragment (red arrows) and a posteromedial metaphyseal fragment (blue arrows), treated by open reduction with cannulated screw fixation. Also note the widening and translation at the distal fibular physis (green arrows) implicating a SH-I fracture. (B) Follow up of the SH-IV fracture in (A) revealed progressive angular deformity, with Park-Harris growth arrest lines (red) that is not symmetric to the normal side (blue arrows). (C) Clinical photo showing varus deformity of the hindfoot on the right. (D) Physeal bar resection and Cranioplast® interposition were performed with radiolucent bone markers to monitor growth. (E) One year following physeal bar resection, a Park-Harris growth resumption line (green arrows) is now visible and the right distal tibial physis has grown.

Fig. 4

(A) Juvenile Tillaux fracture with an avulsion of lateral tibial epiphysis (red arrows) was treated by open reduction with cannulated screw fixation. Also note the co-existing SH-IV distal fibular fracture (green arrows) (B) CT scan confirmed the diagnosis of Tillaux fracture and showed that the physis is closed in the medial side of distal tibia. The tibio-talar joint was visualized during surgery. (blue arrows) (C) Triplane fracture with coronal fracture line (red arrows) in both epiphysis and metaphysis, axial fracture line in the physis as well as metaphyseal fracture line in the sagittal plane (blue arrows), as clearly identified in (D) CT scan.