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Review Article Ankle Fractures in Children: Classification and Treatment
Ha-Yong Kim, Yong-Han Cha, Woo-Suk Kim, Won-Sik Choy
Journal of Musculoskeletal Trauma 2021;34(2):87-95.
DOI: https://doi.org/10.12671/jkfs.2021.34.2.87
Published online: April 30, 2021
Department of Orthopaedic Surgery, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea

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Abstract

Pediatric ankle fractures are defined as damage to the metaphysis, epiphyseal plate, and epiphysis of the distal tibia and fibula. Although the injury mechanism could be similar, the fracture patterns and treatment of pediatric ankle fractures are different from those of adults. In children, growth plate injuries are more common with a force that would cause sprains in adults because the ligaments are stronger than the growth plate cartilage in children. In the adolescent period, unique fractures, called “transitional fractures”, occur while the physis is closed. For a diagnosis, plain images of the anteroposterior, lateral, and mortise views are essential. Stress radiographs, ultrasound, and magnetic resonance imaging can be used for suspected ligament injuries. The treatment goal is to restore the articular congruity, normal bony alignment, and preserve the epiphyseal plate to ensure normal growth. Pediatric ankle fractures frequently lead to premature physeal arrest, angular deformities, malunion, and posttraumatic arthritis even after anatomic reduction. Treating surgeons should follow-up children for a sufficient time and explain to the caregiver the possible complications before treatment.


J Korean Fract Soc. 2021 Apr;34(2):87-95. Korean.
Published online Apr 23, 2021.
https://doi.org/10.12671/jkfs.2021.34.2.87
Copyright © 2021 The Korean Fracture Society. All rights reserved.
Review

Ankle Fractures in Children: Classification and Treatment

Ha-Yong Kim, M.D., Ph.D., Yong-Han Cha, M.D., Ph.D., Woo-Suk Kim, M.D. and Won-Sik Choy, M.D., Ph.D.
    • Department of Orthopaedic Surgery, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea.
  • Correspondence to: Yong-Han Cha, M.D., Ph.D. Department of Orthopaedic Surgery, Daejeon Eulji Medical Center, Eulji University, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea. Tel: +82-42-611-3280, Fax: +82-42-611-3283, Email: naababo@hanmail.net
Received March 17, 2021; Revised March 30, 2021; Accepted March 30, 2021.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Pediatric ankle fractures are defined as damage to the metaphysis, epiphyseal plate, and epiphysis of the distal tibia and fibula. Although the injury mechanism could be similar, the fracture patterns and treatment of pediatric ankle fractures are different from those of adults. In children, growth plate injuries are more common with a force that would cause sprains in adults because the ligaments are stronger than the growth plate cartilage in children. In the adolescent period, unique fractures, called “transitional fractures”, occur while the physis is closed. For a diagnosis, plain images of the anteroposterior, lateral, and mortise views are essential. Stress radiographs, ultrasound, and magnetic resonance imaging can be used for suspected ligament injuries. The treatment goal is to restore the articular congruity, normal bony alignment, and preserve the epiphyseal plate to ensure normal growth. Pediatric ankle fractures frequently lead to premature physeal arrest, angular deformities, malunion, and posttraumatic arthritis even after anatomic reduction. Treating surgeons should follow-up children for a sufficient time and explain to the caregiver the possible complications before treatment.

Keywords
Ankle, Pediatric fracture, Classification, Treatment, Complication

Figures

Fig. 1
Ossification centers around the ankle joint in children. Revised from the article of Peterson and Peterson (J Trauma, 12: 275–281, 1972).8)

Fig. 2
Order of physeal closure in the distal tibia. Revised from the article of Mac Nealy et al. (AJR Am J Roentgenol, 138: 683-689, 1982).10)

Fig. 3
A 9-year-old male child suffered a left ankle injury. The patient had minimal swelling on the left ankle. (A) Initial anteroposterior radiography of both ankles showed that the physis of the left side was wider than the right side. (B) On the oblique image, the Thurston Holland sign was positive (+).

Fig. 4
A 6-year-old girl suffered a medial malleolus fracture on her right ankle. (A) Initial C-arm image of right ankle taken intraoperatively. (B) Stress C-arm image showed varus instability, meaning ligamentous injury in supination-inversion type of Dias–Tachdjian classification.

Fig. 5
(A) Salter–Harris physeal injury classification. (B) Type VI physeal missing injury. Revised from the article of Salter and Harris (J Bone Joint Surg Am, 45: 587-622, 1963).18)

Fig. 6
A 6-year-old male child was hit by a truck and suffered an open crushing injury of the right foot and ankle. (A) In the initial images, some bone defects of the distal tibia were observed (Peterson type VI physeal injury). (B, C) Emergent Ilizarov fixation, open reduction and internal fixation with plate and K-wires, and wound repair were performed. (D) On the 6-year follow-up, the patient had a 2 cm leg length discrepancy, and epiphysiodesis on the left proximal tibia was performed. (E) On the 9-year follow-up, leg length discrepancy was reduced to less than 1 cm. The fracture healed without complication at the 9-year follow-up.

Fig. 7
Dias–Tachdjian classification of ankle fractures in children. (a, b) Supination-inversion pattern includes Salter–Harris (SH) type I distal fibular fracture in Stage 1 injury with the addition of medial distal tibial fracture (SH type IIV) in Stage 2 injury. (c) Pronation-eversion external rotation injury demonstrates SH type II fracture of the lateral distal tibia with distal fibular diaphyseal fracture. (d) Supination-plantar flexion injury reveals SH type II fracture of the posterior distal tibia. (e, f) Supination-external rotation injury includes spiral SH type II fracture of the distal tibia in Stage 1 with the addition of spiral fracture of the distal fibular metadiaphysis in Stage 2. Revised from the article of Dias and Tachdjian (Clin Orthop Relat Res, (136): 230-233, 1978).20)

Fig. 8
An 11-year-old male child suffered distal tibia and lateral malleolus fractures. (A) Thick periosteal flap was interposed in the fracture gap. The white arrow refers to the periosteum detached from distal metaphysis, and the black arrow refers to the periosteum pulled out from the gap. (B) Salter–Harris type II epiphyseal injury was observed initially in the distal tibia. (C) Periosteal repair and open reduction and internal fixation with tension band wiring were done. (D) The fracture healed without complications at the 6-year follow-up.

Fig. 9
A 10-year-old female child suffered a left ankle fracture. (A) The initial anteroposterior image showed Salter–Harris type III physeal injury. (B) The initial computed tomography image showed “Tillaux fracture” caused by an avulsion of the anterior tibiofibular ligament. (C) The fragment was fixed with a cannulated screw placed in the epiphysis. (D) The fracture healed without complications at the 1-year follow-up.

Fig. 10
A 15-year-old male child suffered a left ankle fracture. (A) The initial anteroposterior and lateral images of the distal tibia showed a complex fracture line, extending from metaphysis to the epiphysis (Salter–Harris type IV). (B) Computed tomography showed Salter–Harris type III injury on the coronal image and Salter–Harris type II on the sagittal image (triplane fracture). (C) The fragments were fixed with an epiphyseal cannulated screw and a metaphyseal cannulated screw (4.0 mm). (D) The fracture healed without complication at the 1-year follow-up.

Fig. 11
A 9-year-old male child suffered a medial malleolus fracture. (A) The initial anteroposterior (AP) image showed Salter–Harris type III physeal injury. (B) Tension band wiring was done. (C) The 1-year follow-up AP image showed premature physeal arrest (peripheral type, white arrow) and 15° of ankle varus deformity. (D) Computed tomography (CT) images. (E, F) Physeal bar was resected using intra-operative CT. (G) One year after the Langenskiold procedure, normal growth was restored, and the ankle varus was corrected spontaneously.

Notes

Financial support:None.

Conflict of interests:None.

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    Ankle Fractures in Children: Classification and Treatment
    J Korean Fract Soc. 2021;34(2):87-95.   Published online April 30, 2021
    DOI: https://doi.org/10.12671/jkfs.2021.34.2.87
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