pediatric physeal ankle fracture

Pediatric Physeal Ankle Fracture

Abstract

Ankle fracture is the second most common fracture type inchildren, and physeal injury is a particular concern. Growingchildren have open physes that are relatively weak compared withsurrounding bone and ligaments, and traumatic injuries can causephyseal damage and fracture. Tenderness to palpation over thephysis can aid in the clinical diagnosis of ankle fracture. Swelling,bruising, and deformity may be identified, as well. Plainradiographs are excellent for initial evaluation, but CT may berequired to determine displacement and to aid in surgical planning,particularly in the setting of intra-articular fractures. The Salter-Harris classification is the most widely used system to determineappropriate management and assess long-term prognosis.Complications of physeal injury include shortening and/or angulardeformity. Tillaux and triplane fractures occur in the 18-monthtransitional period preceding physeal closure, which typicallyoccurs at age 14 years in girls and age 16 years in boys.Management is determined by the amount of growth remaining,with the intent of maintaining optimum function while limiting therisk of physeal damage and joint incongruity.

In growing children, the physestend to be more susceptible to in-

jury than the surrounding tissues.This is especially true during the ad-olescent growth spurt, in which bothactivity and growth are accelerated.Ankle injuries are among the mostcommon injuries sustained by chil-dren.1 In children aged 10 to 15years, ankle injuries are second onlyto those of the wrist and hand.2-4 An-kle injuries account for approxi-mately 9% to 18% of physeal inju-ries.

The deltoid ligament provides me-dial ligamentous stability to the an-kle. The lateral ligamentous stabiliz-ers are the posterior talofibularligament, calcaneofibular ligament,and anterior talofibular ligament.The distal stabilizers of the tibia andfibula are the posterior tibiofibular

ligament and the anterior tibiofibu-lar ligament. These ligaments attachto the epiphysis of the tibia and fib-ula, respectively, and are generallystronger than the growing physis;thus, traumatic ankle injuries aremore likely to cause physeal and os-seous injury than ligamentous injury.

The distal tibial physis accountsfor 45% of overall tibial growth.5

Growth typically continues until age14 years in girls and age 16 years inboys.6 Prior to complete closure,there is an 18-month transitional pe-riod in which specific injuries can oc-cur (ie, Tillaux, triplane). During thisperiod, the physis begins closure cen-trally, followed by closure anterome-dially and posteromedially and, fi-nally, laterally. The unfused portionsof the physis are at risk of injury dur-ing this period.

Thomas H. Wuerz, MD, MSc

David P. Gurd, MD

From the Cleveland ClinicFoundation, Cleveland, OH.

Neither of the following authors norany immediate family member hasreceived anything of value from orhas stock or stock options held in acommercial company or institutionrelated directly or indirectly to thesubject of this article: Dr. Wuerz andDr. Gurd.

J Am Acad Orthop Surg 2013;21:234-244

http://dx.doi.org/10.5435/JAAOS-21-04-234

Copyright 2013 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

234 Journal of the American Academy of Orthopaedic Surgeons

History

Typically, pediatric ankle injury oc-curs with a twisting mechanism tothe lower leg during sport or play.Sports that involve lateral motionand jumping have the highest riskof inversion and eversion ankle inju-ries. Both of these common injurytypes cause pain and swelling, and itis difficult to differentiate betweensprain and fracture. Persistent inabil-ity to bear weight is indicative offracture.7

Physical Examination

A thorough examination should beperformed, focusing on skin defects,swelling, neurologic deficits, vascularinjury, and deformity. Sensationshould be checked on the plantarand dorsal aspects of the foot. Thesensory nerves for the dorsum of thefoot are the saphenous nerve (me-dial) and the sural nerve (lateral).The superficial peroneal nerve sup-plies the middle portion, with the ex-ception of the great toe web space,which is innervated by the deep per-oneal nerve. The lateral plantarnerve innervates the lateral onefourth of the plantar surface, and themedial plantar nerve innervates themedial three fourths.

Motor evaluation can be per-formed with toe flexion and exten-sion. In particular, the examinershould evaluate the function of theextensor hallucis longus muscle aswell as ankle dorsiflexion, plantarflexion, inversion, and eversion. Ifthe dorsalis pedis and posterior tibia-lis pulses are not evident on palpa-tion, a Doppler probe should be usedto assess for signals. Capillary refillto the toes is useful in checking fordistal perfusion. Abnormal findingswarrant further vascular assessmentwith a Doppler probe. Palpationabove and below the ankle can help

to rule out associated injuries such asMaisonneuve fracture, which is rarein adolescents, and fifth metatarsalfracture, which is commonly associ-ated with inversion or rotation inju-ries.

Pain, swelling, and ecchymosis arecommon with both fracture andsprain. The integrity of the soft tissueaffects the timing of surgical inter-vention. Excessive swelling and frac-ture blisters warrant delayed surgicalintervention because of increasedrisk of wound healing problems andinfection. Immobilization and eleva-tion are warranted until the swellinghas largely resolved. Syndesmoticsprain presents with tenderness overthe anterior tibiofibular ligament orpain when the foot is dorsiflexed andexternally rotated. Signs of compart-ment syndrome include excruciatingpain, especially in association withpainful passive motion, significantswelling, and potential motor andsensory deficits.

Imaging

AP, mortise, and lateral radiographsshould be obtained of patients withpersistent ankle pain, especiallythose who cannot bear weight. Ac-cording to the Ottawa Ankle Rules,radiographs should be obtained ifthe patient cannot bear weight im-mediately after the injury and forfour steps at the time of evaluation,and in the presence of bone tender-ness at the posterior edge or tip of ei-ther malleolus.7

MRI has been shown to providesuperior anatomic detail and infor-mation regarding fracture lines.8

MRI can also aid in diagnosing carti-laginous, ligamentous, and tendinousinjury. CT can be invaluable in surgi-cal planning, particularly for intra-articular fractures, because it offersenhanced delineation of fracturealignment and displacement.9,10

Fracture Classifications

Salter-HarrisThe Salter-Harris classification ofphyseal fractures is the most com-monly used anatomic system11 (Fig-ure 1). It is simple, and each injurytype has prognostic significance.Type I fractures extend through thegrowth plate only and do not enterthe metaphysis or epiphysis. Type IIfractures extend through the physisand metaphysis. Type III fractures in-volve the physis and epiphysis. TypeIV fractures involve the epiphysis,physis, and metaphysis. Type V frac-tures are crush injuries to the physis.

The risk of physeal arrest is lowerwith type I and II injuries than withtypes III, IV, and V. Type III and IVinjuries often require open reductionand internal fixation (ORIF) to mini-mize articular incongruity and to re-duce the risk of physeal arrest by fa-cilitating reduction of the physis.12

The risk of growth arrest is higher intype IV injuries because they encom-pass the epiphysis, physis, and me-taphysis. Left displaced, metaphysealbone can heal to epiphyseal bone,creating a bony bridge across thephysis and compromising furthergrowth. Type V injuries are at in-creased risk of growth disturbancebecause of the local crush injury anddamage to the physis. Type V frac-tures are difficult to identify initially,which often delays management andfurther increases the risk of long-term sequelae of growth disturbance.These fractures are rare, however.Perichondrial ring injuries have beenproposed as a distinct sixth category.These result from direct open injuriesor from trauma caused by surgicaldissection.

Lauge-HansenThe Lauge-Hansen classification isthe most commonly used system fordefining mechanism of injury of an-

Thomas H. Wuerz, MD, MSc, and David P. Gurd, MD

April 2013, Vol 21, No 4 235

kle fractures.13 It is based on severalclinical and experimental studies andwas developed to classify ankle frac-tures in adults.

Dias and Tachdjian14 developedtheir own pediatric ankle fractureclassification based on the principlesof the Lauge-Hansen and Salter-Harris systems (Figure 2). The fourDias-Tachdjian types are supination-inversion, pronation/eversion–ex-ternal rotation, supination–plantar

flexion, and supination–external ro-tation. The first term in each pairingindicates the position of the foot atthe time of injury, and the second in-dicates the direction of the force ofinjury.

Two additional fracture patternshave since been added: juvenileTillaux and triplane. A vertical com-pression fracture was subsequentlyadded; it has the same implicationsas Salter-Harris type V injury.14

Management

Displaced physeal fractures must bereduced in a timely fashion. Thoseolder than 1 week are at increasedrisk of physeal damage during the re-duction maneuver. Some patients donot seek prompt medical attention.In grossly displaced fractures, thephysician must weigh the risk of per-sistent fracture displacement againstthe risk of iatrogenic physeal dam-

Illustration of the Salter-Harris classification of pediatric ankle fractures. A, Type I. B, Type II. C, Type III. D, Type IV.E, Type V. The arrow indicates a compressive force. (Copyright Cleveland Clinic Foundation, 2011, Cleveland, OH.)

Figure 1

Illustration of the Dias-Tachdjian classification of pediatric ankle fracture. A, Supination-inversion. B, Pronation/eversion–external rotation. C, Supination–plantar flexion. D, Supination–external rotation. (Copyright Cleveland ClinicFoundation, 2011, Cleveland, OH.)

Figure 2



age. The patient should be followeduntil near skeletal maturity to assessfor physeal damage and deformity.

Salter-Harris Type I and IIFracturesSalter-Harris type I and II fractureshave a low incidence of physeal arrestand typically are managed similarly.Type I fractures represent approxi-mately 15% of distal tibial physealfractures.15 The physis is disruptedthrough the zone of hypertrophy.Type II fractures account for approx-imately 40% of distal tibial frac-tures. The fracture crosses throughthe zone of hypertrophy and exitsthrough the metaphysis, creating atriangular fragment (ie, Thurston-Holland fragment) (Figure 3). Dis-placed Salter-Harris type I and IIfractures should be reduced to mini-mize subsequent growth distur-bances. For physeal fractures in gen-eral, reduction is required in the

presence of either an intra-articulargap of ≥2 mm or a step-off of ≥2mm.16 In type I and II fractures inparticular, a residual physeal gap of≥3 mm has been found to be a signif-icant risk factor for premature phys-eal closure.17 The acceptable degreeof angulation has not been well es-tablished.18 However, angular defor-mity is associated with increasedcontact pressures in the ankle joint.19

Reduction should be attempted in asfew attempts as possible, preferablyonly once or twice, to prevent fur-ther physeal injury. Reduction mustbe done under sufficient sedation oranesthesia. For well-reduced frac-tures, cast treatment of 4 to 6 weeksleads to good results. If closed reduc-tion is not successful, open reductionshould be performed.

Failure of closed reduction is oftencaused by interposed soft tissue, suchas periosteum or tendon. Typically,the fracture site is approached fromthe tension side (ie, the side on whichthe fracture gap is located) to gainaccess to interposed soft tissue. Fol-

lowing removal of the soft tissue, thefracture is reduced. These fracturesusually are stable, and internal fixa-tion is rarely necessary. Unstablefractures are managed with eitherORIF or percutaneous fixation. TheThurston-Holland fragment providesan area of bone for screw placementand avoids fixation across the physis.Screws are inserted parallel to thephysis to achieve a stable configura-tion. Two screws are typically used.If the fragment is too small for screwfixation, smooth wires can be used;these wires should be removed fol-lowing fracture healing.

Salter-Harris Type IIIFractureThis fracture type accounts for ap-proximately 25% of distal tibialfractures.16-18,20 The fracture extendsthrough the physis and exits throughthe epiphysis (Figure 4). Such frac-tures are frequently associated withintra-articular incongruity and phys-eal damage. Type III injuries are typi-cally seen with medial malleolus

AP radiograph demonstrating aSalter-Harris type II fracture of thedistal tibia with associated fibularshaft fracture. Displacement iseasily visualized.

Figure 3

A, AP radiograph demonstrating a Salter-Harris type III fracture of the medialmalleolus. B, AP fluoroscopic image obtained following fracture reduction andscrew fixation.

Figure 4


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fractures and Tillaux fractures.Joint incongruity and growth dis-

turbance are long-term risks of typeIII fracture. Incongruence within thejoint can lead to abnormal articularcartilage forces and early cartilagedegeneration. Displacement <2 mmshould be managed nonsurgicallywith a long leg non–weight-bearingcast for 4 weeks, followed by a bootfor 4 weeks. The patient is allowedto remove the boot for range-of-motion exercises but must remainnon–weight-bearing for the first 2weeks.

ORIF is recommended for all frac-tures with >2 mm of residual displace-ment after closed reduction.21 Typically,a medial approach is used for medialmalleolar fractures and an anterolateralapproach for Tillaux fractures. Unlessthe physes are near complete closure,fixation across the physis should beavoided. Preferably, screw fixation isachieved parallel to the physis and ar-ticular surface while remaining withinthe epiphysis. It is acceptable forsmooth pins to cross the physis toachieve fracture fixation. However, thepins should be removed once the frac-

ture is stable and early healing has oc-curred. When using transepiphysealcannulated screw fixation, the surgeonshould consider removing the screwsonce the fracture is healed becausepeak contact pressures have beenshown to be significantly increasedwith epiphyseal screws.22 Alterna-tively, bioabsorbable screws can beused, with similar outcomes; screwremoval is not required.1

Salter-Harris Type IVFractureThese fractures, which traverse themetaphysis, physis, and epiphysis,represent approximately 25% of dis-tal tibial fractures16,17 (Figure 5).Type IV injury is seen with triplanefractures and shearing injuries to themedial malleolus. Patients with non-displaced fractures are treated innon–weight-bearing long leg castsfor 4 weeks, followed by non–weight-bearing in a boot for 2 weeksand commencement of range-of-motion exercises, followed by weightbearing in the boot for another 2weeks.20

A step-off or gap >2 mm must bemanaged with ORIF to minimize ar-ticular incongruity and physeal barformation. Medial malleolus frac-tures are managed with a mediallydirected approach using a J incision.A combination of metaphyseal andepiphyseal screw fixation can createa stable construct. The fibular frac-tures that typically present withSalter-Harris type IV distal tibialfractures are Salter-Harris type I andII injuries. These fractures usuallyare stable following reduction of thetibial fracture. Fractures fluoroscopi-cally deemed to be unstable shouldbe managed with internal fixation.

Salter-Harris Type VFractureThese rare fractures are caused bycompressive forces across thephysis.16-18 Type V fractures are diffi-cult to diagnose on initial radio-graphs. Physical examination elicitsdiscomfort over the physis, but ini-tial radiographs may not show defin-itive fracture. Growth arrest is a ma-jor concern. If recognized early after

Sagittal (A), coronal (B), and axial (C) CT scans of a displaced Salter-Harris type IV triplane fracture involving themetaphysis, physis, and epiphysis.

Figure 5



injury, excision of the damaged por-tion of the physis and placement of afat graft may prevent deformity.These fractures, however, are fre-quently diagnosed months or yearsafter injury and after the develop-ment of limb-length discrepancy orangular deformity. Late managementis performed to correct limb-lengthdiscrepancy or angular deformity.

Salter-Harris Type VIFractureThis rare physeal injury represents aperichondrial ring injury; it is typi-cally caused by a lawnmower scalp-ing the medial ankle, but it can occurthrough indirect forces from athleticinjuries or traffic injuries resulting inclosed fractures.23 Closed fractureswith minimal displacement (<2 mm)can be managed nonsurgically withimmobilization. Displacement >2mm must be managed with eitherclosed reduction and percutaneouspinning or ORIF. Open scalping inju-ries require débridement of the areaof the perichondrial ring or plasticsurgery with skin grafting and/ormusculocutaneous grafting. Such in-juries are difficult to manage and fre-quently result in physeal closure.

Isolated Distal FibularFractureMost isolated distal fibular fracturesare Salter-Harris type I or II injuries.Often, they are the result of low-energy trauma. Typically, these iso-lated fractures heal well when man-aged with a short leg walking cast.Salter-Harris type III and IV injuriesare rare. The treating physician musttake care to distinguish fracture froman accessory ossification center (osfibulare). This anatomic variant is lo-cated at the distal tip of the fibulaand should not be misinterpreted asan avulsion fracture. Immobilizationin a short leg walking cast has beenrecommended for this specific in-

jury.24 Alternatively, in our experi-ence, a pneumatic walking boot canbe used.

Transitional Fracture

The distal tibial physis closes at ap-proximately age 14 years in girls andage 16 years in boys.6 Prior to com-plete physeal closure, there is a tran-sitional period lasting approximately18 months in which the physis be-gins to close in a consistent fashion.Closure begins centrally, followed byanteromedial, posteromedial, andlateral closure. Transitional fracturesoccur in this period. While the physisremains open, the lateral aspect ofthe distal tibial physis is weaker,which makes this area more suscepti-ble to injury when it is stressed. Ex-ternal rotation of a supinated foot, acommon sports-related injury, canlead to separation of the anterolat-eral from the anteromedial quadrantof the epiphysis.25

Approximately 7% to 15% of allphyseal fractures in adolescents aretransitional fractures.20 Such frac-tures that involve the epiphysis onlyare juvenile Tillaux fractures. Tri-plane fractures extend into the me-taphysis of the distal tibia.

Tillaux Fracture

The juvenile Tillaux fracture involvesthe anterolateral aspect of the distaltibia in adolescents.26 These Salter-Harris type III fractures extendthrough the physis and epiphysis andexit intra-articularly; they accountfor 3% to 5% of pediatric anklefractures.16,18 The fracture can beproduced experimentally by evertinga supinated foot. The anterior tibio-fibular ligament attaches to the an-terolateral distal tibial epiphysis;when an external rotation force isapplied, the ligament causes avulsionfracture at the level of the open

growth plate. The fracture line ex-tends horizontally through the physisand vertically through the epiphysis,creating an intra-articular fracture.Typically, the patient is too sore tobear weight on examination. Swell-ing and ecchymosis can be identifiedanterior to the ankle. There may bediffuse tenderness throughout the an-kle, and point tenderness is elicitedon the anterolateral aspect of the dis-tal tibia. The fracture line is best seenon a mortise view. However, true de-lineation of the amount of displace-ment is difficult because of osseousoverlap. CT is warranted in cases inwhich displacement >2 mm is sus-pected (Figure 6). CT better definesfracture displacement and can aid insurgical planning.

Tillaux fractures are intra-articular,and those that are displaced cancause altered joint stresses and earlydegenerative changes.27 Patients withnondisplaced fractures are treatedwith 4 weeks in non–weight-bearinglong leg casts applied in internal ro-tation, followed by non–weight-bearing in a boot for 2 weeks whilerange-of-motion exercises out of theboot are started, after which weightbearing in the boot for another 2weeks is allowed.28 Patients must befollowed closely initially, with radio-logic imaging performed to verify ad-equate alignment during cast treat-ment. Displaced fractures must bereduced. Manderson and Ollivierre29

described a technique for closed re-duction using dorsiflexion and inter-nal rotation. For fractures with milddisplacement, it may be possible toimprove alignment using a cast ap-plied in internal rotation.

Reduction and screw fixation is in-dicated for fractures with either dis-placement >2 mm or translation >1mm30-32 (Figure 7). Typically, an an-terolateral approach is used. Linte-cum and Blasier33 described amethod focusing on direct visualiza-tion for ORIF. Schlesinger and


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Wedge34 reported on six patients inwhom closed reduction failed. How-ever, they successfully manipulatedthe fracture fragments with the useof 2-mm smooth Steinmann pins,which were stabilized with 1.6-mmKirschner wires. These wires were re-moved 6 weeks postoperatively. Allpatients were able to return to ath-letic activity.

Long-term results of treatment ofTillaux fractures have been verygood.35 Because there is minimal tono growth remaining, fixation thatcrosses the physis is unlikely to causecomplications. Bioabsorbable im-plants also can be used.1 These pa-tients are near the end of growth andphyseal function, and thus, the riskof physeal damage with resultant de-formity is low.17

Triplane Fracture

Triplane fractures are a subgroup ofSalter-Harris type IV injuries. Typi-cally, the fracture line is in sagittalorientation within the epiphysis, ax-ial through the physis, and coronalwithin the metaphysis (Figures 5 and8). Many variants of this fracturehave been described.36-40 Triplane

fractures account for 5% to 15% ofpediatric ankle fractures.18 Averagepatient age is 13 years (range, 10 to17 years). This fracture typically oc-curs when a supinated foot is sub-jected to external rotation forces.30

AP, lateral, and mortise radio-graphs are essential for initial diag-nosis (Figure 8). CT is valuable for

assessing the fracture configurationand for surgical planning (Figure 5).Jones et al31 reported that all sur-geons questioned changed surgicalplanning for screw position after re-viewing the CT scan.

Management of triplane fracturesdepends mostly on the amount ofdisplacement visualized on CT. Cast

Axial (A) and coronal (B) CT scans of a Tillaux fracture. Note the Salter-Harris type III fracture with displacement.

Figure 6

AP (A), mortise (B), and lateral (C) radiographs demonstrating metallic screw fixation of a Tillaux fracture.

Figure 7



immobilization is used for minimallydisplaced (<2 mm) and nondisplacedfractures. A long leg cast is used ini-tially to help control rotation. Plac-ing the foot in internal rotation mayhelp reduce the displaced fracture

and maintain alignment. Postreduc-tion CT can be used to confirm satis-factory alignment. Long-term studieshave shown reduction to be benefi-cial for fractures with >2 mm dis-placement.17,30,36,39 Rapariz et al41 re-

ported that fractures with <2 mm ofdisplacement did well followingclosed reduction, but fractures with>2 mm displacement developed de-generative changes and discomfort.ORIF is the traditional surgical op-tion for triplane fractures42 (Figure9). Lintecum and Blasier33 reportedgood results with an anterior surgicalapproach and percutaneous screwfixation to achieve anatomic align-ment.

Some surgeons have performedclosed reduction and percutaneousfixation in an attempt to minimizelength of the incision and scar irrita-tion. Castellani et al43 devised amethod using Kirschner wires as joy-sticks to manipulate fractures thatwere difficult to reduce. This ap-proach enabled the use of small inci-sions. They reported good results,with a complication rate of 8.3%, in-cluding transient neuropathy andhardware irritation. Retained trans-epiphyseal metallic screws have beenshown to significantly increase peakcontact pressures over baseline; thus,removal is recommended.22 Po-dezswa et al1 compared bioabsorb-able screw fixation with metallicscrew fixation and reported similarresults with each type. Each grouphad some loss of fixation requiringfurther surgery.

Physeal damage and partial phys-eal closure occur in approximately7% to 21% of cases.20,21,25,32 Long-term studies have not shown difficul-ties caused by physeal closure.32 Thisis likely because growth stops shortlyafter treatment. Patients in whom >2years of growth is expected shouldbe followed more closely.

Growth Disturbance AfterPhyseal Injury

In growing children, physeal anklefractures have the potential to causegrowth disturbance. The incidence of

AP (A) and lateral (B) radiographs of an ankle with a triplane fracture anddistal fibular fracture.

Figure 8

AP (A) and lateral (B) fluoroscopic images obtained following surgical fixationof a triplane fracture.

Figure 9


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partial or complete premature phys-eal closure varies by fracture type,with closure in 2% to 40% of Salter-Harris type I and II fractures and in8% to 50% of type III and IVfractures.44-47 Physeal closure alsowas more likely in the setting of dis-placement >3 mm or periosteumtrapped in the fracture site of Salter-Harris type II fractures.44-48 Learyet al49 found that high-energy trauma(eg, motor vehicle accident) wasmore likely to cause growth arrestthan either low-energy trauma orsports-related injuries. Every 1 mmof displacement increased the risk ofphyseal damage by 15%.

Children with physeal ankle frac-ture should be followed and evalu-ated for signs of growth arrest or de-formity for 2 years following theinitial injury. Sclerotic lines are oftenseen radiographically within the me-taphysis once the fractured bone re-sumes normal longitudinal growth.Figure 10 illustrates the appearanceof physeal closure with resultinggrowth arrest lines. Lines that arenot parallel to the physis are indica-tive of partial growth arrest. Partialarrest affects only part of the physis,which can result in increasing angu-lar deformity in addition to limb-length discrepancy. Surgical interven-tion may be indicated in patientswith substantial growth remaining.Medial-sided growth arrest results invarus angulation, limb-length dis-crepancy, and relative fibular over-growth, often with lateral impinge-ment. Complete growth arrest affectsmost of the physis, resulting in limb-length discrepancy. This is a concernin young children with significantgrowth remaining. In patients whoare close to skeletal maturity at thetime of injury, limb-length discrep-ancy is minimal, and intervention isnot required. Complete distal tibialgrowth arrest results in relative fibu-lar overgrowth and, potentially, lat-eral impingement.

In the patient with substantial an-gular deformity, osteotomy can rees-tablish the mechanical axis. The de-gree of acceptable angular deformityhas not been well established. In chil-dren who are close to skeletal matu-rity, the expected limb-length dis-crepancy is small, so in the absenceof angular deformity, no correctivemeasure is required. Epiphysiodesisof the distal fibula should be consid-ered to limit fibular overgrowth andresulting lateral impingement andconcomitant lateral overload of theankle.

In younger children, physeal barresection may be considered if <50%of the physis is compromised and >2years of growth remain48,50 (Figure11). The extent of physeal involve-ment is determined with CT or MRI.CT is typically best for delineatingthe extent of growth arrest in plan-ning for a bar resection.

Typically, peripheral physeal bars

are approached directly. Excision ofthe overlying periosteum and re-moval of abnormal bone is extendeduntil normal physeal cartilage is un-covered. This resection may be per-formed instead of osteotomy in pa-tients with angular deformity <20°.50

Central bars can be reached by drill-ing through a metaphyseal windowor through an osteotomy in casesthat require concomitant correctionof an angular deformity.51,52 Follow-ing excision of the bar, the resultingdefect is filled with adipose tissue orcement (Figure 12). Contralateralepiphysiodesis can be performed aswell to prevent limb-length discrep-ancy following bar formation.

Summary

Physeal ankle fractures in childrenwarrant special consideration withregard to the amount of displace-ment, the possibility of growth plateinjury, management, and the amountof physeal growth remaining. Chil-dren are susceptible to such fractures

AP radiograph demonstratinggrowth arrest lines (arrows)following ankle fracture in apediatric patient. These lines lieparallel to the adjacent physes andthus do not represent asymmetricgrowth.

Figure 10

CT scan demonstrating evidence ofbony bridging across the physis ina pediatric patient who sustained aSalter-Harris type IV fracture of themedial malleolus.

Figure 11



because of the relative weakness ofthe physis compared with the sur-rounding structures. The type ofphyseal fracture is one factor used todetermine the likelihood of growtharrest. Transitional fractures occurwithin the 18-month period leadingup to physeal maturation. CT can behelpful in determining displacementand in surgical planning.

The goals of management are tomaintain optimum function whilelimiting the risk of physeal damageand joint incongruity. The literatureis lacking in level I clinical studiescomparing different treatment mo-dalities and long-term outcomes.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, references 1and 49 are level III studies.

References printed in bold type arethose published within the past 5years.

1. Podeszwa DA, Wilson PL, Holland AR,

Copley LA: Comparison ofbioabsorbable versus metallic implantfixation for physeal and epiphysealfractures of the distal tibia. J PediatrOrthop 2008;28(8):859-863.

2. King J, Diefendorf D, Apthorp J, NegreteVF, Carlson M: Analysis of 429 fracturesin 189 battered children. J PediatrOrthop 1988;8(5):585-589.

3. Peterson HA, Madhok R, Benson JT,Ilstrup DM, Melton LJ III: Physealfractures: Part 1. Epidemiology inOlmsted County, Minnesota, 1979-1988.J Pediatr Orthop 1994;14(4):423-430.

4. Mann DC, Rajmaira S: Distribution ofphyseal and nonphyseal fractures in2,650 long-bone fractures in childrenaged 0-16 years. J Pediatr Orthop 1990;10(6):713-716.

5. Birch JG: Growth and development, inHerring J, Tachdjian MO, eds:Tachdjian’s Pediatric Orthopaedics, ed 4.Philadelphia, PA, Saunders, 2008, pp3-22.

6. Johnson EW Jr, Fahl JC: Fracturesinvolving the distal epiphysis of the tibiaand fibula in children. Am J Surg 1957;93(5):778-781.

7. Stiell IG, Greenberg GH, McKnight RD,Nair RC, McDowell I, Worthington JR:A study to develop clinical decision rulesfor the use of radiography in acute ankleinjuries. Ann Emerg Med 1992;21(4):384-390.

8. Seifert J, Matthes G, Hinz P, et al: Roleof magnetic resonance imaging in the

diagnosis of distal tibia fractures inadolescents. J Pediatr Orthop 2003;23(6):727-732.

9. Kärrholm J, Hansson LI, Laurin S:Computed tomography of intraarticularsupination - eversion fractures of theankle in adolescents. J Pediatr Orthop1981;1(2):181-187.

10. Seitz WH Jr, LaPorte J: Medial triplanefracture delineated by computerizedaxial tomography. J Pediatr Orthop1988;8(1):65-66.

11. Salter RB, Harris WR: Injuries involvingthe epiphyseal plate. J Bone Joint SurgAm 1963;45(3):587-622.

12. Kay RM, Matthys GA: Pediatric anklefractures: Evaluation and treatment.J Am Acad Orthop Surg 2001;9(4):268-278.

13. Lauge-Hansen N: Fractures of the ankle:II. Combined experimental-surgical andexperimental-roentgenologicinvestigations. Arch Surg 1950;60(5):957-985.

14. Dias LS, Tachdjian MO: Physeal injuriesof the ankle in children: Classification.Clin Orthop Relat Res 1978;(136):230-233.

15. Mizuta T, Benson WM, Foster BK,Paterson DC, Morris LL: Statisticalanalysis of the incidence of physealinjuries. J Pediatr Orthop 1987;7(5):518-523.

16. Caterini R, Farsetti P, Ippolito E: Long-term followup of physeal injury to theankle. Foot Ankle 1991;11(6):372-383.

17. Barmada A, Gaynor T, Mubarak SJ:Premature physeal closure followingdistal tibia physeal fractures: A newradiographic predictor. J Pediatr Orthop2003;23(6):733-739.

18. Bible JE, Smith BG: Ankle fractures inchildren and adolescents. Techniques inOrthopaedics 2009;24(3):211-219.

19. Ting AJ, Tarr RR, Sarmiento A, WagnerK, Resnick C: The role of subtalarmotion and ankle contact pressurechanges from angular deformities of thetibia. Foot Ankle 1987;7(5):290-299.

20. Kärrholm J: The triplane fracture: Fouryears of follow-up of 21 cases andreview of the literature. J Pediatr OrthopB 1997;6(2):91-102.

21. Kling TF Jr, Bright RW, Hensinger RN:Distal tibial physeal fractures in childrenthat may require open reduction. J BoneJoint Surg Am 1984;66(5):647-657.

22. Charlton M, Costello R, Mooney JF III,Podeszwa DA: Ankle joint biomechanicsfollowing transepiphyseal screw fixationof the distal tibia. J Pediatr Orthop2005;25(5):635-640.

23. Havranek P, Pesl T: Salter (Rang) type 6

Illustration demonstrating management of a physeal bar. A, Drilling to theaffected physis and excision of the bar. B, Placement of adipose tissue toprevent further bar formation. (Copyright Cleveland Clinic Foundation, 2011,Cleveland, OH.)

Figure 12


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physeal injury. Eur J Pediatr Surg 2010;20(3):174-177.

24. Ogden JA, Lee J: Accessory ossificationpatterns and injuries of the malleoli.J Pediatr Orthop 1990;10(3):306-316.

25. El-Karef E, Sadek HI, Nairn DS, AldamCH, Allen PW: Triplane fracture of thedistal tibia. Injury 2000;31(9):729-736.

26. Tillaux P: Traite d’anatomicTopographique Avec Applications a laChirurgie. Paris, France, Asselin yHouzeau, 1892.

27. Nenopoulos SP, Papavasiliou VA,Papavasiliou AV: Outcome of physealand epiphyseal injuries of the distal tibiawith intra-articular involvement.J Pediatr Orthop 2005;25(4):518-522.

28. Podeszwa DA, Mubarak SJ: Physealfractures of the distal tibia and fibula(Salter-Harris type I, II, III, and IVfractures). J Pediatr Orthop 2012;32(suppl 1):S62-S68.

29. Manderson EL, Ollivierre CO: Closedanatomic reduction of a juvenile tillauxfracture by dorsiflexion of the ankle: Acase report. Clin Orthop Relat Res 1992;(276):262-266.

30. Feldman DS, Otsuka NY, Hedden DM:Extra-articular triplane fracture of thedistal tibial epiphysis. J Pediatr Orthop1995;15(4):479-481.

31. Jones S, Phillips N, Ali F, Fernandes JA,Flowers MJ, Smith TW: Triplanefractures of the distal tibia requiringopen reduction and internal fixation:Pre-operative planning using computedtomography. Injury 2003;34(4):293-298.

32. Ertl JP, Barrack RL, Alexander AH,VanBuecken K: Triplane fracture of thedistal tibial epiphysis: Long-term follow-up. J Bone Joint Surg Am 1988;70(7):967-976.

33. Lintecum N, Blasier RD: Directreduction with indirect fixation of distal

tibial physeal fractures: A report of atechnique. J Pediatr Orthop 1996;16(1):107-112.

34. Schlesinger I, Wedge JH: Percutaneousreduction and fixation of displacedjuvenile Tillaux fractures: A new surgicaltechnique. J Pediatr Orthop 1993;13(3):389-391.

35. Beaty JH, Linton RC: Medial malleolarfracture in a child: A case report. J BoneJoint Surg Am 1988;70(8):1254-1255.

36. Cooperman DR, Spiegel PG, Laros GS:Tibial fractures involving the ankle inchildren: The so-called triplaneepiphyseal fracture. J Bone Joint SurgAm 1978;60(8):1040-1046.

37. Jarvis JG, Miyanji F: The complextriplane fracture: Ipsilateral tibial shaftand distal triplane fracture. J Trauma2001;51(4):714-716.

38. Smekal V, Kadletz R, Rangger C, GföllerP: A new type of triplane fracture in a19-year-old snowboarder. J Trauma2001;50(1):155-157.

39. Shin AY, Moran ME, Wenger DR:Intramalleolar triplane fractures of thedistal tibial epiphysis. J Pediatr Orthop1997;17(3):352-355.

40. Healy WA III, Starkweather KD, MeyerJ, Teplitz GA: Triplane fractureassociated with a proximal third fibulafracture. Am J Orthop (Belle Mead NJ)1996;25(6):449-451.

41. Rapariz JM, Ocete G, González-HerranzP, et al: Distal tibial triplane fractures:Long-term follow-up. J Pediatr Orthop1996;16(1):113-118.

42. McGillion S, Jackson M, Lahoti O:Arthroscopically assisted percutaneousfixation of triplane fracture of the distaltibia. J Pediatr Orthop B 2007;16(5):313-316.

43. Castellani C, Riedl G, Eberl R,Grechenig S, Weinberg AM: Transitional

fractures of the distal tibia: A minimalaccess approach for osteosynthesis.J Trauma 2009;67(6):1371-1375.

44. Horn BD, Crisci K, Krug M, PizzutilloPD, MacEwen GD: Radiologicevaluation of juvenile tillaux fractures ofthe distal tibia. J Pediatr Orthop 2001;21(2):162-164.

45. Langenskiöld A: Traumatic prematureclosure of the distal tibial epiphysealplate. Acta Orthop Scand 1967;38(4):520-531.

46. Rohmiller MT, Gaynor TP, Pawelek J,Mubarak SJ: Salter-Harris I and IIfractures of the distal tibia: Doesmechanism of injury relate to prematurephyseal closure? J Pediatr Orthop 2006;26(3):322-328.

47. Cass JR, Peterson HA: Salter-Harristype-IV injuries of the distal tibialepiphyseal growth plate, with emphasison those involving the medial malleolus.J Bone Joint Surg Am 1983;65(8):1059-1070.

48. Birch JG: Surgical technique of physealbar resection. Instr Course Lect 1992;41:445-450.

49. Leary JT, Handling M, Talerico M, YongL, Bowe JA: Physeal fractures of thedistal tibia: Predictive factors ofpremature physeal closure and growtharrest. J Pediatr Orthop 2009;29(4):356-361.

50. Kasser JR: Physeal bar resections aftergrowth arrest about the knee. ClinOrthop Relat Res 1990;(255):68-74.

51. Peterson HA: Partial growth plate arrestand its treatment. J Pediatr Orthop1984;4(2):246-258.

52. Williamson RV, Staheli LT: Partialphyseal growth arrest: Treatment bybridge resection and fat interposition.J Pediatr Orthop 1990;10(6):769-776.



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