Rang’s Children’s Fractures
Wenger and Pring
2005

Articular Fractures

Salter-Harris Type VI Injuries of the Distal
Tibia

Ablation of the Perichondral Ring

Lawn mower injuries

Degloving injuries

Callus bridge forms between the epiphysis and metaphysis

Varus deformity and failure of growth

May be missed on initial x-rays

Articular Fractures

The Tillaux Fracture


In an adolescent within a year of complete closure of the distal tibial physis
Central and medial aspect of the physis has closed

Anterolateral aspect of physis

Open and vulnerable to avulsion injury by external rotation force

Bound down to fibular by anterior tibiofibular ligament

Fracture fragment is rectangular or pie shaped

Articular Fractures
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The Triplane Fracture
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Complex fracture with sagittal, transverse and coronal components

Crosses in part along and in part through the physis and enters the ankle joint

Usually external rotation force

Type III injury in AP x-ray view

Type II injury in lateral x-ray view
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CT scan defines the fracture configuration

Articular Fractures

The Triplane Fracture

Lateral triplane more common

Medial triplane less common

May have associated fibular fracture

May have associated tibial shaft fracture

Rare neurovascular compromise

Articular Fractures

The Triplane Fracture

Attempt closed reduction under sedation or anesthesia

Maximum acceptable displacement is 2mm at articular surface

ORIF

Anterolateral approach for lateral fracture

Posterior medial or lateral incisions

Interfragmentary screws or plate for fibula fracture



Attempt closed reduction with analgesia or sedation

Majority of fractures can be treated with casting

ORIF if closed reduction fails

Malleolar Fractures
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ORIF indications

Failed closed reduction

Closed reduction requires forced abnormal positioning of the foot

Medial ankle mortise widening 1-2 mm

Displaced fractures of articular surface

Open fracture

Malleolar Fractures

ORIF timing

Perform immediately before swelling on day of injury or wait 7-10 days until swelling resolves
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Splint while awaiting swelling to resolve

Perform immediately before swelling on day of injury or wait 7-10 days until swelling resolves

Splint while awaiting swelling to resolve

Wrinkle test to determine if swelling is likely to prevent skin closure

Malleolar Fractures

Lateral Malleolus

Ligament avulsion injury

Patients 4-10 years old

Ligament avulsion with a fragment of cartilage of epiphysis

ATF and CF ligaments

Treat with short leg cast 4-6 weeks

Forms bone ossicle when healed

May require excision if painful

Malleolar Fractures

Lateral Malleolus

Displaced fractures

Attempt closed reduction and casting

ORIF

Severe injuries

Inadequate reduction

K-wires, screws, 1/3 tubular plate

Syndesmotic screw when indicated

Malleolar Fractures

Medial Malleolus
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Uncommon injury

Evaluate for Maisonneuve proximal fibula fracture

Closed treatment if:

Undisplaced
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Distal portion medial malleolus

Anatomical reduction by manipulation

Obtain CT scan to prove joint surface not disrupted

Malleolar Fractures

Medial Malleolus

Displaced fractures require ORIF

K-wires should not cross physis if possible

2 transepiphyseal cannulated or cancellous screws

May need transmetaphyseal screw if metaphyseal portion of fracture is large

Malleolar Fractures

Medial Malleolus

If transepiphyseal fixation not possible use smooth
K-wires or tension band

Reduction may be hindered by trapped loose fragments

In skeletally mature patients may be stabilized by 2 transepiphyseal cannulated or cancellous screws perpendicular to the fracture similar to adults

Pitfalls

Physeal fractures of the distal tibia

Premature physeal arrest

More common if involvement of medial malleolus

Leg length inequality

Angular deformity of ankle

Follow patients with x-rays at 6 months and 1 year post-injury

Compare to x-rays of uninvolved ankle

Welsh Anatomist

Harris growth arrest lines are dense trabecular transversely oriented lines with the metaphysis, commonly seen in children of all ages. These lines, also called recovery lines, follow a period of illness or immobilization. These lines relate to a temporary slowdown of a longitudinal growth.

Pitfalls

Physeal fractures of the distal tibia

Asymmetry of Harris growth line of is an indicator of early premature physeal closure

A Harris growth arrest line pertains to children/teens in whom the bone lines show retarded growth, usually due to trauma to a bone

Obtain hand x-ray for bone age

MRI or CT for the extent and location of physeal arrest

Pitfalls

Physeal arrest of the distal tibia

Close observation with serial x-rays

Excision of physeal bar with interposition material
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Epiphysiodesis of the remaining open tibial physis, ipsilateral distal physis

Epiphysiodesis of contralateral open distal tibial physis & ipsilateral distal physis

Corrective osteotomy

Syndesmosis Injuries

Syndesmotic disruption

Usually pronation-abduction/ external rotation

Usually unstable

Require intraoperative assessment of stability

Use bone hook around fibula at syndesmosis to apply lateral stress

Usually require operative stabilization

Syndesmosis Injuries

Indications for syndesmotic fixation

Medial ligamentous injury, syndesmotic disruption & talar shift without fracture of fibula-tibiofibular diastasis

Maisonneuve fracture

Syndesmotic instability after fixation of fibula and avulsion of fractures of the tubercles or medial malleolus

Syndesmosis Injuries

Fixation techniques

1or 2 3.5-4.5 cortical screws

Hold but do not compress syndesmosis

Insert screws just above the level of the tibiofibular ligaments
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Place ankle in dorsiflexion to bring widest portion of the talus in the mortise when you tighten screws

Syndesmosis Injuries

Fixation techniques

Both cortices of the fibula and tibia are drilled, tapped and engaged by each screw

Keep non-weight bearing for 6-8 weeks

Remove syndesmotic screws prior to weight bearing

Ankle Sprains

Very common injuries

Usually inversion stress to ankle

Most commonly injured

Anterior talofibular ligament

Calcaneo-fibular ligament

Anterolateral swelling, tenderness, ecchymosis

Differentiate from Salter-Harris I & II injury of distal fibula by location of tenderness

Ankle Sprains

Grades according to severity

Grade I  ligaments in continuity

Grade II  partial tear of ligaments

Grade III  complete tear of ligaments with gross instability-5 locations

Midsubstance rupture

Rupture at bone attachment

Avulsion of bone at ligament attachment

Ankle Sprains

Treatment

“Ace, Ice and Adios”

Elastic support, ankle brace, posterior mold, short leg cast

Grade I-II sprain  allow weight bearing as tolerated with or without crutches depending on immobilization

Obtain stress x-ray views

Ankle Sprains

Recurrent ankle sprains

Residual ankle loss of motion, strength and balance sense

Ligamentous instability

Tarsal coalition

Talar dome injury

Obtain CT or MRI to better evaluate

Treat with physical therapy, external support, prolotherapy and surgery

Questions?