Steven Rabin, MD
Revised: March 2011
Original authors (2004): Laura Phieffer, MD & Steven Frick, MD
Revised (2006): Steven Frick, MD

• 2nd most common site of physeal fractures in children
• Most occur between ages 8 - 15 y.o.
• Boys > girls
• Direct and indirect mechanisms of injury

• All ligamentous structures attach distal to the physis
• Ligaments are stronger than physis and bone
• Physeal injury more common than ligament injury
• Anterior Tibio-fibular ligament important in transitional fractures when the physis is closing

• Distal tibia ossification center appears between 6 - 24 months
• Distal fibula ossification center appears between 9 - 24 months
• Medial malleolar extension appears at about
7 years

• Distal tibia physis closes:
– About age 12-15 yrs girls
– About age 13-17 yrs boys
• Medial malleolus extension appears ~10 yrs
• Asymmetric closure over ~18 months
– Tibia physis closes in center first then medially and posteriorly.
– Anterolateral portion of physis is the last to close
• Closure of the distal fibula physis follows distal tibia physeal closure by ~12-24 months

Spiegel P, et al. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.

• Salter-Harris
– High interobserver correlation
– Correlated with outcomes

• Mechanism of injury:
Dias L, Tachdjian M. Physeal injuries of the ankle in children: classification. Clin Orthop Relat Res . 1978;136:230-
3.

• Direct/indirect mechanisms
• Acute/subacute
• May have subtle exam findings
• Differentiate sprain from non-displaced fracture by location of tenderness
– (Pain over the physis/bone = physeal injury)
– (Pain over the soft tissues = sprain)

• Radiographs - AP, LAT, Mortise
– know normal anatomic variants
• Stress radiographs
• CT scan – to assess articular involvement
• MRI – role not well defined
• Bone Scan – if in doubt about an accessory ossification center vs. an acute fracture

Accessory Ossification Centers –
Smooth Borders
• Accessory ossification centers usually appear between ages of 7 to 10 yrs
• Fuse by skeletal maturity
• Medial (os subtibiale) in
20% of patients
• Lateral (os subfibulare) in
1% of patients

• Location of fracture
• Mechanism of injury
• Degree of displacement
• Age of child (how much growth remains)
– Distal tibia physis contributes:
• 3-4 mm growth per year
• 35-45% of overall tibial length

• Typically occur in younger pts
• Seen with all mechanisms (SI, SPF, SER,
PER)
• Often missed initially (dx “sprain”):
– Physis weaker than ligaments so physeal injury is more common than a sprain
• Xrays
– Acute – often normal except for soft tissue swelling over physis
– Subacute - reveal widening of physis- healing

Salter I Distal Tibia Fractures:
Treatment
• Less than 3 mm displacement
– Cast
– 4-6 weeks depending on the patient’s age
• Greater than 3 mm displacement
– Gentle closed reduction and casting
– Usually require anesthesia
– If interposed soft tissue, must be removed
– If unstable, pin fixation may be needed.
– More likely to be unstable if fibula also fractured
• Follow x-rays for 6-12 months to evaluate for premature physeal closure

• Salter I fracture of the distal tibia (with metaphyseal fibula fracture)
• Treated with closed reduction and pin fixation

• Most common distal tibia Fx type
• Seen with all mechanisms
(SI, SPF, SER, PER)
• Mechanism deduced by
– Direction of displacement of the tibial epiphysis,
– Type of associated fibula fx
– Location of metaphyseal spike

Salter-Harris Type II fractures:
Treatment
• Non-displaced fractures
– Short leg cast (SLC) for 3 weeks
– Then walking SLC for 3 weeks
• Displaced fractures
– Avoid repeated attempts at reduction
– If unstable consider a long leg cast for 2-3 weeks, otherwise a short leg cast for 3-4 weeks then a short leg walking cast for 2-3 weeks (depending on age)
– Open reduction infrequently indicated
– Follow for growth arrest

Salter II Fracture of the Distal Tibia
• Salter II fracture of the distal tibia
– treated with closed reduction and cannulated screw fixation

• If reduction is incomplete, how much residual displacement is acceptable?
–
Carothers and Crenshaw (1955)
• “accurate reposition of the displaced epiphysis at the expense of forced or repeated manipulation or operative intervention is not indicated”
Carothers C, Crenshaw A. Clinical significance of a classification of epiphyseal injuries at the ankle. Am J Surg . 1955;89(4):879-89.

• If reduction is incomplete, how much residual displacement is acceptable?
–
Spiegel (1978)
• correlated Salter-Harris classification with risk of shortening, angular deformity and joint incongruity
• recommended “precise anatomical reduction”
Spiegel P, et al. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.

• Differing opinions regarding indication for open reduction for interposition of periosteum => widening with minimal angulation
– Kling (1984)
– Phieffer (2000)- Animal model
– Barmada (2005) believes interposed periosteum leads to growth disturbance
-Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57.
-Phieffer et al. Effect of interposed periosteum in an animal physeal fracture model.
Clin Orthop Relat Res . 2000;376:15-25.
-Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop . 2003;23(6):733-9.

Closed reduction with incomplete reduction because of interposed soft tissues – removed at ORIF

• Displaced subacute (>7-10 days out) fxs
– Residual displacement may have to be accepted
– If growth does not sufficiently correct malunion, corrective osteotomy performed

•
Salter II Fracture of the Distal Tibia

• Mechanism of injury similar for both fx patterns (typically supination-inversion)
• Usually produced by medial corner of talus being driven into the junction of distal tibial articular surface and the medial malleolus
• Can see central and lateral fx patterns

• Treatment and prognosis are similar
• Anatomic restoration of the articular surface is a high priority
• Medial pattern appears to be at higher risk for developing partial growth arrest and subsequent varus deformity
-Spiegel P, Cooperman D, Laros G. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.
-Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57.
-Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to the ankle. Foot Ankle . 1991;11(6):372-83.

• Non-displaced fractures (<1 mm)
– Cast for 3-4 wks => SLWC x 3 wks
– May need CT after cast placement to assess displacement
– Follow with x-rays in cast to assure no displacement
– Percutaneous fixation is an option
– Follow for growth arrest

Salter IV Minimally Displaced
Distal Tibia Fracture
*Fixation avoids physis

• Displaced fractures (>2 mm)
– Require Anatomic reduction
– Closed reduction under general anesthesia
– If continued > 2 mm displacement => open reduction
– Open reduction with epiphyseal fixation parallel to growth plate if possible, especially if significant growth remaining
– Postop: Cast (NWB) for 3-4 wks => SLWC x 3 wks
– Follow for growth arrest: 15% incidence of growth arrest even with anatomic reduction

Salter III Injury- Closed reduction with percutaneous internal fixation

Salter IV Distal Tibia Fracture

• Subacute displaced fxs
– Accept up to 2 mm displacement
– Greater than 2 mm displacement
• Goal to restore joint congruity
• Recommend reduction regardless of time from injury
• Debridement and interposition graft, if necessary

Delayed diagnosis Salter IV medial malleolus fracture in 6 yr multi-trauma patient
• Initial radiographs 15 days out from injury

• ORIF 16 days after injury
• Anterior approach

Note Harris growth line parallels physis and increased distance between markers – normal growth
• Nine months post-operative

• Crush injury to physis
• No associated displacement
• Diagnosis made with follow-up xrays revealing premature physeal closure
• Treatment directed primarily at sequelae of growth arrest

High energy injuries to distal tibia
• Uncommon
• Severe injury to distal tibial articular surface – poor prognosis
• Restore articular surface, if possible
• Length and alignment – bridging external fixation can be helpful

High energy distal tibia fracture/subluxation
11 year old female in MVC

CT scan demonstrates significantly comminuted articular surface and anterior subluxation of talus

Intraop views – bridging external fixation and ORIF with pin fixation

12 Year Old – High Velocity GSW
– loss of tibial epiphysis/anterior soft tissues/tendons
- bridging external fixator
- latissimus free flap
-ankle fusion

• Fractures occurring during asymmetric closure of distal tibial physis
– Triplane fx
• Fracture appears to be in multiple planes
• May be 2, 3 or 4 part fractures
– Tillaux fx
• Fracture of the anterolateral epiphysis

• Triplane fx
– Tend to be seen in younger pts than those with Tillaux fx
– More displacement/swelling
– Appear as Salter III on AP view and Salter II on lateral view
– Treatment decisions usually based on articular displacement
– CT scan often helpful

• Combination of Salter II and III fractures: usually near end of growth
(Complex type IV fracture)
• Anterior epiphseal fracture with large posteriomedial metaphyseal fragment…fibula may also be fractured

• Overall results are good following adequate reduction
– Von Laer (1985)
– Clement and Warlock (1987) Good early results
– Erlt (1988) Decline in results over time
-von Laer L. Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia. J Bone Joint Surg Am. 1985;67(5):687-98.
-Clement D, Worlock P. Triplane fracture of the distal tibia. A variant in cases with an open growth plate. J Bone Joint Surg Br . 1987;69(3):412-5.
-Ertl J, Barrack R, Alexander A, VanBuecken K. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg Am . 1988;70(7):967-76.

• Non-displaced
– Cast (NWB) 3-4 wks, then SLWC x 3-4 wks
– Monitor in cast to assure no displacement
– FU x-rays every 6-12 months for 2 to 3 yrs to assess for growth arrest

• Displaced Triplane Fractures (>2 mm)
– Anatomic reduction required
– If closed reduction successful
• Cast: consider a long leg cast with 30  of knee flexion and foot internally rotated, if unstable
– If closed reduction unsuccessful => ORIF
• Reduction/internal fixation done in step-wise fashion with small fragment or 4.0 cannulated screws
– Postop - SLC x 3-4 wks, then SLWC x 3 wks

• CT gives 3D visualization of fracture patterns
• Essential for planning

• Surgical Correction

• Juvenile Tillaux fractures
– Patients tend to be older than those with triplane fx
– Fibula prevents marked displacement: may be subtle
– Local tenderness at anteriolateral joint line
– Mortise view essential
– May need CT scan
– Although literature based on small series, excellent results with anatomic reduction noted

• Non-displaced
– Cast (NWB) x 3 wks, then SLWC x 3-4 wks
– CT scan after cast placement may be needed to assure no displacement
– Radiographs in cast to assure no re-displacement in cast
– Follow-up x-rays obtained every 6-12 months for 2 to
3 yrs to assess for growth arrest

• Displaced (>2mm) Tillaux fxs
– Anatomic reduction required
– If closed reduction achieved
• Long leg cast with knee flexed 30 degrees and foot internally rotated if unstable
– If closed reduction unsuccessful
• Attempt closed reduction under anesthesia
• If still unsuccessful, may use k-wires to joystick Tillaux fragment (percutaneously or open)
• Fixation with small fragment or 4.0 cannulated screws
– Postop - SLC x 3-4 wks, then SLWC x 3 wks

• Child with ankle pain:
– Fracture difficult to see

• CT shows a Salter III
(“Tillaux”) fracture of the distal tibia
– Tillaux fractures occur near the end of growth as medial portion of distal tibial physis closes before the lateral side closes

Tillaux Fracture Example
• Post-operative and healed x-rays after hardware removal: no residual deformity

• Injury to accessory ossification centers
• Treatment SLWC 3-4 weeks
–
Ogden (1990)
• Good results 26/27 patients with injuries involving the medial side
• 5/11 pts with injuries involving the lateral side had persistent symptoms requiring excision
Ogden JA, Lee J. Accessory ossification patterns and injuries of the malleoli. J Pediatr Orthop . 1990;10(3):306-16.

• Typically Salter-Harris I or II fractures
– When isolated, usually minimally displaced
• Can treat with a SLWC for 3-4 wks
– Significant displacement occurs more often with Salter III and IV distal tibial fractures
• Usually reduces with tibial reduction
– If fracture is unstable
• Can usually fix with smooth intramedullary or oblique k-wires
• Sometimes plate fixation, especially if comminuted.

Salter I Distal Fibula typical “goose egg” swelling over distal fibula with tenderness over distal fibular physis

• Should be diagnosis of exclusion
• Tenderness should be over the ligaments
• If tenderness is over the physis, may be a
Salter I ankle fractures or non-displaced calcaneus fracture
• Treatment as with any sprain: rest, ice, elevation, and splint until comfortable.

• Depends on mechanism of injury
– Higher energy, worse prognosis
– Greater comminution, worse prognosis
• Depends on age of the patient
– Less chance for re-modeling if older
• Often poor outcome with
– Medial distal tibial physeal injuries
– Residual articular step off
• Presence of an associated fibular fracture– has no prognostic significance

• Growth arrest
– Can occur with any fracture pattern
– Most often with Salter
III and IV fractures
– Usually seen 6 to 18 months after injury
(but as late as 2 yrs after injury)

• Growth arrest
– Occur in fractures treated operatively and non-op
– Radiographic Harris growth lines
• Allow for earlier intervention
• Look for in x-rays 6-12 weeks
– LLD tolerated well
– Angular deformity less well tolerated

• Treatment:
– Observation if near end of growth
– Monitor and epiphysiodesis or bar resection depending on deformity
– Osteotomy if persistent deformity after growth has ceased.

Physeal Injury Simulating Bone
Tumor
• Arrow points to growth arrest line

• Arthritis
• Malunion
• Delayed/nonunion
• AVN distal tibial epiphysis (rare)

10 year old – 3 months after distal
Tibia fracture

• Heterogenous group of fractures
• Age dependent
• Important to have high index of suspicion to avoid missing diagnosis
• Correlate physical exam and x-ray findings
• Follow until skeletal maturity
• May develop late sequelae

• Often missed
• 5-8% of all pediatric fractures
• Reductions of fractures important
– Less remodeling potential
– Reach 50% of mature length of foot bones by
18 mo. (compared to femur/tibia - do not reach until 3 yrs)

• Types of foot injuries 1
– Metatarsal fractures 90%
– Phalangeal fractures 18%
– Navicular fractures 5%
– Talar fractures 3%
– Calcaneal fractures 3%
– Cuboid fractures 2%
• 1 Data from Cleveland Fracture Service, A.Crawford
(Skeletal Trauma)

• Hindfoot: talus, calcaneus
• Midfoot: navicular, cuboid,
3 cuneiforms
• Forefoot:
– 5 metatarsals (distal epiphyses except for 1 st MT - proximal epiphysis)
• Distal 1 st Metatarsal pseuodoepiphysis may occur
– 14 phalanges (proximal epiphyses)
• Variable number of sesamoids/accessory ossicles

• AP, lateral, oblique XR of foot
• AP, lateral, oblique XR of ankle as well
• Co-existent unrecognized fractures of distal tibia/fibula occur in up to 8% patients with foot fractures
• Comparison views of opposite foot may be helpful

• Less than 1% of all pediatric fractures:
– 56 % = Avulsion fractures
– 20% = Osteochondral lesions
– 19% = Talar neck fractures
– 6% = Talar body fractures
Jensen et al. Prognosis of fracture of the talus in children: 21 (7-34)year follow-up of 14 cases. Acta Orthop Scand 1994;65:398-400.

• Usually require only symptomatic treatment
• Splint, cast or brace for comfort
• Usually healed in 2-3 weeks
Kay R, Tang C. Pediatric foot fractures: evaluation and treatment . J Am Acad Orthop Surg . 2001;9(5):308-19.

• Lateral/medial process fractures
– Rarely displace
– Symptomatic treatment only
– Non-unions rare
• Usually asymptomatic, if they occur

• Example: 14 year old girl.
• Treatment: similar to an adult.

• Fixation

• Rare injuries
• Neck fractures most common with apex plantar angulation
• Monitor for 1 year for possible AVN (rare)

• Hawkins’ Classification (same as in adults)
– Type I = nondisplaced
– Type II = displaced talar neck involving subtalar joint
– Type III = displaced talar neck fractures involving both ankle and subtalar joints
– Type IV = displaced talar neck fractures involving ankle, subtalar and talo-navicular joints
Hawkins LG: Fractures of the neck of the talus. J Bone Joint Surg
52A:991–1002, 1970.
Canale ST, Kelly FB: Fractures of the neck of the talus, long term evaluation of seventy one cases. J Bone Joint Surg 60A:143–156, 1978.

• If nondisplaced
– Treatment is non-weightbearing in a above-knee cast for 6-8 weeks.
• If displaced
– Treatment may include ORIF
– Angulation < 5 degrees acceptable
– > 5 degrees angulation requires reduction under general anesthesia
– Displaced (>2mm) fractures at the articular surface require ORIF
Kay R, Tang C. Pediatric foot fractures: evaluation and treatment . J Am Acad Orthop Surg . 2001;9(5):308-19.

Hawkins 2 Talar Neck Fracture with
Distal Fibula Avulsion
• Example: Talar neck fracture
• Distal fibula avulsion with ankle instability.

Talar Neck Fracture with Distal
Fibula Avulsion
• ORIF of both fractures
– To restore stability

Displaced talar neck fracture with medial and lateral malleolar fractures
• Initial x-rays
• Postop x-rays - Anatomic reduction required
(same as in adults)

Talar Neck Fracture
(with bi-malleolar fractures)
• Complication:
– Avascular Necrosis
– Less common than in adults but can still occur
– Long term follow-up necessary

• Extremely rare injury (case reports only)
• Represent dislocation of subtalar and talonavicular joints
• Four types based on direction of foot
– Medial most common
– Also lateral, anterior, posterior
• Adults – usually have an associated displaced talar neck fracture
– But in children, isolated dislocations more common

• Often associated foot fracture
• Attempt closed reduction
– Open reductions associated with ultimate decreased
ROM
• Associated intra-articular fracture of talonavicular joint adversely affects outcome
• No reported cases of associated AVN

• Osteochondral fractures
– Inversion/plantar flexion injury
• Posteromedial lesion (more common)
– Eversion/dorsiflexion injury
• Anterolateral lesion
• Often require MRI for diagnosis
• Non-displaced lesion => NWB in cast
• Displaced lesion => excision/currettage

• Classification
– Type I lesions are nondisplaced.
– Type II lesions are partially detached.
– Type III lesions are detached but not displaced.
– Type IV lesions are detached and displaced or rotated.
Berndt AL, Harty M: Transcondylar fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg 41A:988–1020, 1959.

• Splint/non-weightbearing for 1-2 months
– The initial treatment for all but type IV for 1 to
2 months. No contact sports for another 2-3 months
• If no symptomatic and/or radiographic improvement by 3 to 4 months,
– Drilling, debridement, or arthroscopic fixation may be indicated.
Higuera, et al. Osteochondritis dissecans of the talus during childhood and adolescence. J Pediatr Orthop 1998;18:328-332.

Ankle sprain that didn’t heal-
Anterolateral Talar
Osteochondral Lesion

• Rare – 2% of all pediatric foot fractures
• Result of significant falls
• 5% associated with lumbar spine injuries
• Often missed diagnosis
– Difficult to diagnosis if non-displaced
• Extra-articular fractures are more frequent
– Approximately 65% of calc fxs in children
• Bone scan can confirm diagnosis
Kay R, Tang C. Pediatric foot fractures: evaluation and treatment . J Am Acad Orthop Surg . 2001;9(5):308-19.

• Treat soft tissues first with elevation
• Non-displaced injuries
– NWB with Jones’ dressing then cast when soft tissue swelling subsides
– Weightbearing in 3-6 weeks
• Displaced injuries
– ORIF when soft tissues amenable
• Acceptable displacement not well-defined
• Adolescents - same indications as adults
Brunet JA: Calcaneal fractures in children. Long-term results of treatment. J Bone Joint Surg 82B:211–216, 2000.
Inokuchi S, Usami N, Hiraishi E, Hashimoto T: Calcaneal fractures in children. J Pediatr Orthop 18:469–474, 1998.

• Fractures of the navicular, cuboid and cuneiforms
– 2-7% of pediatric foot fractures
– Usually avulsion injuries
• Immobilize 2-3weeks
– If high energy trauma, may have associated
LisFranc and other fractures
• Watch closely for compartment syndrome
• May need ORIF
Kay R, Tang C. Pediatric foot fractures: evaluation and treatment . J Am Acad Orthop Surg . 2001;9(5):308-19.

(Tarsal-metatarsal fractures/dislocations)
• Direct/indirect mechanisms of injury
• Represent significant force
– Fracture of base of 2nd MT - implies more severe injury
– Associated cuboid fx - implies dislocation
• Treatment - requires anatomic reduction
– Treat soft tissues first with elevation
– Closed reduction/pinning vs. ORIF
– Beware of compartment syndrome

• Same treatment classification and options as in adults.
• Residual pain reported in up to 22% of pediatric patients.
Johnson GF. Pediatric Lisfranc injury: “Bunk bed” fracture. AJR Am J Roentgenol. 1981;137:1041-1044.
Wiley JJ: Tarso-metatarsal joint injuries in children. J
Pediatr Orthop. 1981; 1:255-260.

• Most common pediatric foot fracture (60%)
– 5 th metatarsal base is most frequent
• Usually caused by direct trauma
– Except base of 5 th more often avulsion
• Metatarsal shaft fractures most common
– Lateral displacement – acceptable (if Lisfranc joint intact)
– Significant dorsal/plantar angulation not acceptable, requires closed reduction/pinning
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

• 1st metatarsal fractures
– Can see buckle fracture just distal to proximal physis (treatment – SLWC x 3 wks)
– Do not confuse pseudoepiphysis at distal end with fracture
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

• 5th metatarsal fractures
– Proximal metaphyseal transverse fractures most common
– Treatment SLWC x 6 wks
– Distinguish from “Jones” fractures
• Occur in proximal diaphysis
• Occur in older children (15 - 20 y.o.)
– Do not confuse os vesalianum (os peronei) with fracture (oblique orientation proximally)
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

• Metatarsal base fractures
– Require significant force
– Consider early fasciotomy if significant swelling/venous congestion in toes
• No reported compartment pressures to guide
• Use clinical judgment
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

Metatarsal Fractures and Growth
Deformity
• Physeal fractures of the base of the first metatarsal may cause abnormal growth with shortening of the first ray.
• Overgrowth may also occur after metatarsal fractures.
– Overgrowth is more common than growth inhibition
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

• Treatment of Physeal
Injuries
– Non-displaced
• SLWC x 4-6 wks
– Displaced
• Finger-trap traction until swelling subsides then percutaneous pinning
• Open reduction if unable to obtain adequate alignment
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

• 18% of children’s foot fractures
– 2/3 involve proximal phalanges
– 1/3 middle phalanges
– Rarely distal phalanges
• Treatment
– Traction, closed reduction, buddy taping, hard sole shoe
• Open injures require I&D/IV antibiotic
– Osteomyelitis can occur

• Great toe distal phalangeal fractures
– Beware of crush injuries
– May represent open fractures
– If suspect open injury, treat with I&D and antibiotics to avoid complication of osteomyelitis
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

• Common cause of pediatric open fractures
• 70% are bystanders
• Occur with all types of mowers but majority are riding mowers.
• Distribution of injuries
– Head/eye 24%
– Upper extremity 36%
– Lower extremity 39%
Alonso JE, Sanchez FL. Lawn mower injuries in children: A preventable impairment. J Pediatr Orthop. 1995;15:83-89.

• Highly contaminated injuries
– Initial irrigation & debridment/antibiotic coverage
– Repeat debridements until wound is clean

• May require internal or external fixation of fractures
• Attempt coverage by
7-14 days, if possible
• >50% require skin grafting or flap coverage
Dormans JP, Azzoni M, Davidson RS, Drummond DS.
Major lower extremity lawn mower injuries in children.
J Pediatr Orthop. 1995;15:78-82.

• High complication rate
– Infection
– Growth arrest
– Amputation rates
• 16-78%
• > 50% unsatisfactory results
Dormans JP, Azzoni M, Davidson RS, Drummond DS.
Major lower extremity lawn mower injuries in children.
J Pediatr Orthop. 1995;15:78-82.

• Late deformity may occur
– Muscle imbalances from loss of soft tissue attachments
– Due to growth arrest and asymmetric growth.

Needs Long Term
Follow-up
• Varus Deformity of the first ray
– This deformity likely to progress due to muscle imbalances and medial over-growth (intact 1 st
MT,PP,DP and 2 nd MT physes) without lateral growth (loss of 3 rd , 4 th , and
5 th MT physes)

• Difficult area to obtain adequate durable soft tissue coverage
• May require revisions of flaps or skin grafts
– Insensate
– Potential for graft breakdown
– May need special shoes/orthotics/fillers
– Orthotics & fillers may need yearly replacement.
Dormans JP, Azzoni M, Davidson RS, Drummond DS.
Major lower extremity lawn mower injuries in children.
J Pediatr Orthop. 1995;15:78-82.

• Education/ Prevention key
• Children
– < 14 years old shouldn’t operate a lawnmower
– And no riders other than mower operator
– Small children should not be present in yard while mower is being operated
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Return to
Pediatrics
Index

• Review Articles
• Kay R, Tang C. Pediatric foot fractures: evaluation and treatment
. J Am Acad
Orthop Surg . 2001;9(5):308-19.
• Ribbans WJ, Natarajan R, Alavala S. Pediatric foot fractures.
Clin Orthop Relat
Res . 2005 Mar;(432):107-15.
• Original Articles
• Alonso JE, Sanchez FL. Lawn mower injuries in children: A preventable impairment. J Pediatr Orthop. 1995;15:83-89.
• Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop .
2003;23(6):733-9.
• Berndt AL, Harty M: Transcondylar fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg. 41A:988–1020, 1959.
• Brunet JA: Calcaneal fractures in children. Long-term results of treatment . J
Bone Joint Surg. 82B:211–216, 2000.

• Canale ST, Kelly FB: Fractures of the neck of the talus, long term evaluation of seventy one cases. J Bone Joint Surg. 60A:143–156, 1978.
• Carothers C, Crenshaw A. Clinical significance of a classification of epiphyseal injuries at the ankle. Am J Surg . 1955;89(4):879-89.
• Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to the ankle. Foot Ankle . 1991;11(6):372-83.
• Clement D, Worlock P. Triplane fracture of the distal tibia. A variant in cases with an open growth plate. J Bone Joint Surg Br . 1987;69(3):412-5.
• Dias L, Tachdjian M. Physeal injuries of the ankle in children: classification. Clin
Orthop Relat Res . 1978;136:230-3.
• Dormans JP, Azzoni M, Davidson RS, Drummond DS. Major lower extremity lawn mower injuries in children. J Pediatr Orthop. 1995;15:78-82.
• Ertl J, Barrack R, Alexander A, VanBuecken K. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg Am . 1988;70(7):967-76.
• Hawkins LG: Fractures of the neck of the talus . J Bone Joint Surg. 52A:991–
1002, 1970.

• Higuera J, Laguna R, Peral M, Aranda E, Soleto J: Osteochondritis dissecans of the talus during childhood and adolescence. J Pediatr Orthop. 1998;18:328-332.
• Inokuchi S, Usami N, Hiraishi E, Hashimoto T: Calcaneal fractures in children. J
Pediatr Orthop . 18:469–474, 1998.
• Jensen et al. Prognosis of fracture of the talus in children: 21 (7-34)-year followup of 14 cases. Acta Orthop Scand. 1994;65:398-400.
• Johnson GF. Pediatric Lisfranc injury: “Bunk bed” fracture. AJR Am J
Roentgenol. 1981;137:1041-1044.
• Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57.
• Ogden JA, Lee J. Accessory ossification patterns and injuries of the malleoli. J
Pediatr Orthop . 1990;10(3):306-16.
• Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children.
Injury. 1995;26:537-538.
• Phieffer et al. Effect of interposed periosteum in an animal physeal fracture model. Clin Orthop Relat Res . 2000;376:15-25.

• Spiegel P, Cooperman D, Laros G. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.
• von Laer L. Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia. J Bone Joint Surg Am. 1985;67(5):687-98.
• Wiley JJ: Tarso-metatarsal joint injuries in children. J Pediatr Orthop.
1981; 1:255-260.
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