pediatric ankle fractures
TRANSCRIPT
Pediatric Ankle Fractures
When to Cast, When to Cut,
When to Treat Like an Adult
John Deegan, DO
No Disclosures
Children’s Healthcare of Atlanta
Background
• 2nd MC physeal injury in kids (long bone)
– 10-25% of all Physeal Injuries Occur About the Ankle
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Background
Goals of Treatment:
• Stable reduction
• Anatomic articular surface (SH III/IV)
• Symmetric mortise
• Preserve physeal growth (+/-)
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Background
• Classification
– Salter Harris
– Lauge-Hansen (Dias-Tachdjian)
• Subtypes
– Transitional fractures
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Classification
• Salter-Harris
– Helpful, prognostic
Copyright Cleveland Clinic
Foundation, 2011, Cleveland, OH.)
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Classification
• Lauge Hansen
Copyright Cleveland Clinic
Foundation, 2011, Cleveland, OH
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Classification
• Lauge Hansen
Copyright Cleveland Clinic
Foundation, 2011, Cleveland, OH
• And the Dias Modification of the Lauge Hansen
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Common Subtype - Transitional Fractures
• Occur near skeletal maturity due to asymmetric closure of the physis
– CML
Anthony Riccio TSRH
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• Occur near skeletal maturity due to asymmetric closure of the physis
– CML
Common Subtype - Transitional Fractures
Anthony Riccio TSRH
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Transitional Fractures
• Triplane
– Complex SH IV
– SER type mechanism• Medial triplane is 2/2 adduction
– Occur ~13 yo (10-17)
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• Tillaux
– SH III distal tibia (AITFL)
– ER twisting force
– Slightly older
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Transitional Fractures
• Triplane fractures
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Transitional Fractures
• Tillaux fractures
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Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.
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Don’t get fooled
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Normal anatomic variants
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Normal anatomic variants
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Kump’s Bump
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Fracture
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Post-op
• Harris lines parallel to physis = symmetric growth
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Goals of Treatment
• Stable reduction
• Anatomic articular surface (SH III/IV)
• Symmetric mortise
• (+/-) Preserve physeal growth
• REMOVE PERIOSTEUM
– Gap >3 mm in SH I/II → growth arrest → ORIF
Barmada A, et al.
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Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.
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Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.
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Anatomic Reduction – get the
periosteum out
• Barmada et al23
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Anatomic Reduction – get the
periosteum out
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Articular/Physeal Ankle Fractures
• Should I get advanced imaging?
– 25 triplane fractures • XR alone vs CT
• Changed definition of the fracture pattern in 46% of cases, degree of displacement in 39%, treatment plan in 27%, and either the number or orientation of screws in 41% of cases after
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Treatment - Triplanes
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Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.
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Treatment - Triplanes
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Treatment - Triplanes
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Treatment - Triplane Fractures
• Non-displaced Triplane fxs
• Less than 2 mm displacement on all views
– LLC, knee flexed 30, foot IR x3wks → SLWC x3-4wks
– CT after cast placement to assure no displacement• (Weekly xrays in cast for first 3 weeks to assure no displacement in
cast)
– FU xrays obtained every 6 months for 2 to 3 yrs
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• Closed reduction
– Knee flexion, ankle PF and IR• Or ER for AM fragment
– Check reduction with CT
• Residual displacement after attempted CR→ ORIF
Treatment - Triplane Fractures
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Treatment - Triplane Fractures
• Ertl (JBJS 1988)
– No successful closed reductions if displaced > 3mm at presentation
– This has not been verified with follow-up studies
– Many recommend attempted reduction despite amt. of initial displacement
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Treatment - Triplane Fractures
• SH III Component Reduction
– Mobilize Fragment
– Reduce Articular Surface Anatomically
– Reduction Clamps or Dental Pick to Hold Reduction
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Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.
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Treatment - Triplane Fractures
• SH II Component Reduction
– Usually Amenable to Manipulative Reduction
– Posterolateral Approach and Clamp Reduction if fail Closed
– 3.5 mm or 4.0 mm Partially Threaded Cannulated Screw +/- Washer
– Direction of Screw Based on fx orientation (CT) - Percutaneous Incision
– Do Not Cross Physis in Younger Children • OK in slightly older kids
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Treatment - Triplane Fractures
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Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.
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Stepwise fixation
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Stepwise fixation
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Stepwise fixation
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Treatment - Tillaux Fractures
• Slightly older
• Less obvious
– Fibula prevents marked displacement and/or swelling
• Mortise view critical
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Treatment - Tillaux Fractures
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Treatment - Tillaux Fractures
• Non-displaced
– <3 mm displacement
– LLC, knee flexed 30, foot IR x3wks → SLWC x3-4wks
– CT scan after cast placement to assure no displacement• (weekly radiographs in cast for first 3 weeks to assure no
displacement in cast)
– FU xrays obtained every 6 months for 2 to 3 yrs
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Treatment - Tillaux Fractures
• Closed Reduction
– Internal rotation (think about the mechanism)
– LLC → same protocol
– CT scan to assess reduction
• ORIF
– displaced (>2mm) after reduction attempt
Lemburg et al Arch Orthop Trauma Surg 2010
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Tillaux Fracture: ORIF
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• Anterior Approach
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Tillaux Fracture: ORIF
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• Anterior Approach
• Reduction– Mobilize Fragment
– Reduce Articular Surface Anatomically
– Reduction Clamps or Dental Pick to Hold Reduction
• Fixation – 3.5 mm or 4.0 mm Partially Threaded Cannulated Screw +/-
Washer
– Screw Trajectory Lateral to Medial - Separate Perc Incision
– OK to cross the physis
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Treatment - Tillaux Fractures
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Treatment - Tillaux Fractures
• Surgical Post-op
– Postop - SLC x3-4wks → SLWC x 3 wks
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• 60% of patients were treated with closed reduction percutaneous fixation, 33% with closed reduction and 5% with ORIF
• Residual articular displacement <2.5 mm, measured on follow-up x-rays or CT
– Functional outcomes comparable to anatomic reduction
– No decline in function was found with longer-term follow-up (4 to 10 y) for residual displacement <2.5 mm
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Treatment - Distal Fibula/Lateral Mal
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Treatment - Distal Fibula/Lateral Mal
• Treatment less well defined
• Isolated fractures stable
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• Sprain vs SHI distal fibula
– Clinical exam
– Normal XR
– Lateral ankle tenderness
• Xrays – Look for soft tissue swelling over the physis– Late findings- widening of physis
(healing)
Treatment - SH I Fibula
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• Sankar et al (JPO 2008)– 37 Children
– All with Open Physes, Lateral Ankle Tenderness + Normal Films
– 18%: Periosteal Bone Formation at 3 Weeks
• Boutis et al (JAMA Pediatr 2016)– 140 Children with Ankle Injuries - Prospectively Enrolled
– All With Normal Films
– 135 Underwent Ankle MRI
– 3%: Salter Harris I Distal Fibula Fractures
– 80%: Isolated Ligamentous Injuries
– All did well with removable ankle brace
Treatment - SH I Fibula
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Non-displaced Distal Fibula Fractures
• Boutis et al (Pediatrics 2007):
– Randomized Single Blind Study
– Short Leg Walking Cast versus Removable Brace
– Brace Group:• Quicker Return to Baseline Activities
• More Cost Effective
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Displaced SH I and II Distal Fibula
• Rarely seen in isolation
– Treatment determined by tibia fracture and mortise symmetry
• Closed reduction
– Acceptable:• NWB SLC ~ 6 weeks
– Unacceptable:• Open reduction
– Perc Pinning if >2 years remaining
– Internal fixation <2 years remaining
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Treatment – Medial Epiphysis
(Medial mal) fractures
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• Commonly a supination-inversion mechanism
• Common in younger kids too
– Respect the physis
• Salter Harris III & IV
Treatment – Medial Epiphysis
(Medial mal) fractures
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• Risk for Nonunion Due to Intra-articular Nature of Fracture
• Risk for Delayed Union and Late Displacement
• Abbott et al (POSNA 2015)– 42 Pediatric Medial Malleolus Fractures with > 3 Months Follow-Up
– 52% Developed a Physeal Bar
– SH Classification and Amount of Displacement not Predictive of Bar
– Adequacy of Reduction = Only Predictive Factor of Bar Formation
KEY = Low Threshold to TX Operatively and Careful F/U for Physeal Arrest
Treatment – Medial Epiphysis
(Medial mal) fractures
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Treatment – Medial Epiphysis
(Medial mal) fractures
• Nondisplaced:
– Short Leg Cast
– Non-Weightbearing
– Close Follow-Up
• Prone to late displacement
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Treatment – Medial Epiphysis
(Medial mal) fractures
• Displaced:
– Open Reduction
– Anatomic Restoration of Physis and Joint Line
– Screw, K-Wire or Hybrid Fixation
– Avoid Screws Across Open Physis Unless Absolutely Necessary
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Treatment – Medial Epiphysis
(Medial mal) fractures
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Treatment – Medial Epiphysis
(Medial mal) fractures
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Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.
Children’s Healthcare of Atlanta
Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 5th Ed. 2014. Elsevier. Philadelphia, PA.
Children’s Healthcare of Atlanta
Medial mal fractures
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Medial mal fractures
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Medial Mal Fractures
• Surgical Post-op
– Postop - SLC x3-4wks => SLWC x3wk
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Summary
• Pediatric Ankle Fractures cover a wide spectrum of injuries
• Non-operative management is still a mainstay for many
• Know when to respect the physis
• Always respect the articular surface
– <2 mm important
• Follow injuries through maturity (esp medial mal)
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References
• Peterson CA, Peterson HA (1972) Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma 12: 275-281.
• Spiegel PG, Cooperman DR, Laros GS (1978) Epiphyseal fractures of the distal ends of the tibia and bula. A retrospective study of two hundred and thirty-seven cases in children. J Bone Joint Surg Am 60: 1046-1050.
• Dias LS, Tachdjian MO (1978) Physeal injuries of the ankle in children: classi cation. Clin Orthop Relat Res 136: 230-233.
• Goldberg VM, Aadalen R (1978) Distal tibial epiphyseal injuries: the role of athletics in 53 cases. Am J Sports Med 6: 263-268.
• Rohmiller MT, Gaynor TP, Pawelek J, Mubarak SJ (2006) Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure? J Pediatr Orthop 26: 322-328.
• Aslam N, Gwilym S, Apostolou C, Birch N, Natarajan R, et al. (2004) Microscooter injuries in the paediatricpopulation. Eur J Emerg Med 11: 148- 150.
• Ebbeling CB, Pawlak DB, Ludwig DS (2002) Childhood obesity: Public-health crisis, common sense cure. Lancet 360: 473-482.
• McHugh MP (2010) Oversized young athletes: a weighty concern. Br J Sports Med 44: 45-49.
• Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, et al. (2006) Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295: 1549-1555.
• Tyler TF, McHugh MP, Mirabella MR, Mullaney MJ, Nicholas SJ (2005) Risk factors for noncontact ankle sprains in
high school football players: the role of previous ankle sprains and body mass index. Am J Sports Med 34: 471-475.
• Zonfrillo MR, Seiden JA, House EM, Shapiro ED, Dubrow R, et al. (2008) The association of overweight and ankle injuries in children. Ambul Pediatr 8: 66-69.
• Kay RM, Matthys GA (2001) Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg 9: 268-278.
• Ogden JA, Lee J (1990) Accessory ossi cation patterns and injuries of the malleoli. J Pediatr Orthop 10: 306-316
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Thank You