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Current clinical concepts are reviewed regarding the epidemiology, anatomy, evaluation and treatment of pediatric ankle fractures. Correct diagnosis and management relies on appropriate exam, imaging, and knowledge of fracture patterns specific to children. Treatment is guided by patient history, physical examination, plain film radiographs and, in some instances, CT.

Treatment goals are to restore acceptable limb alignment, physeal anatomy, and joint congruency. For high risk physeal fractures, patients should be monitored for growth disturbance as needed until skeletal maturity.

The present review discusses pediatric ankle fractures, defined as tibia and fibula fractures distal to the metaphysis in patients with open physes. The majority of these fractures are caused by sports injuries or low-energy trauma 1. The pediatric ankle with open physes and incomplete ossification presents distinct mechanical and biological properties compared to skeletally mature patients.

Thus, children have unique ankle fracture Screwing mature wife holding ankle in air and require specific treatment to preserve and monitor the physis. There is a higher incidence of ankle fractures in children with increased BMI. Of all physeal injuries, fractures of the distal tibial physis have among the highest rates of complications, including premature physeal arrest, bar formation, angular deformity, and articular incongruity 12 The physis contains four zones, from the epiphysis to the metaphysis with decreasing mechanical strength due to decreasing matrix-cell ratio: Screwing mature wife holding ankle in air typically occurs through the hypertrophic zone, which has the largest cells and less extracellular matrix than the other zones.

For most fractures, this in turns preserves the reserve zone, which is located on the epiphyseal side of the fracture and contains the progenitor cells for physeal growth 14 Fractures which cross the physis into the epiphysis Salter Harris III and IV typeshowever, may damage the reserve zone and thus are at higher risk of causing physeal growth disturbance.

Distal tibial growth occurs proportionately to the proximal tibia in young patients, but in adolescents the proximal tibia growth becomes Screwing mature wife holding ankle in air rapid and distal tibial growth tapers off Thus, injury to the physis at a young age can result in significant leg length discrepancy. The distal tibial ossification center appears around 6 months of age and the distal fibula around 1 to 3 years of age.

Distal tibial and fibular physeal closure occurs around 12 to 17 years in females and 15 to 20 in males 17 This pattern of closure explains the specific tibial physeal fracture patterns seen in adolescent triplane and Tillaux fractures.

Physeal arrest is generally not a concern for triplane and Tillaux fractures, since the physis is already closing in these fracture patterns.

Abundant blood supply is provided to the distal tibial physis, so post-traumatic avascular necrosis of the plafond is very rare.

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The distal fibula is contained in a groove on the lateral distal tibia with significant ligamentous constraint with the anterior and posterior tibiofibular and calcaneofibular ligaments. Ligamentous structures in children are quite robust, whereas the physis is biomechanically vulnerable to shear and rotational forces.

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Thus, the same injury mechanism which may result in an ankle sprain in adults can present with physeal or avulsion fractures in children. The distal fibula physis becomes undulating during childhood, which does provide it with additional stability The distal fibula frequently has a secondary center of ossification which can mimic an avulsion fracture on radiograph. The medial os subtibiale is more prevalent than the lateral os subfibulare.

Growth of the fibula is evenly distributed between the proximal and distal tibia physis in childhood, although the proximal tibia growth becomes predominant in adolescents.

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Patients frequently present following a twisting injury to the ankle. It is important to distinguish an ankle fracture from an ankle sprain. Hallmark findings include inability to bear weight, bony tenderness, swelling, or deformity.

The skin should be evaluated for open wounds, ecchymoses, or abrasions.

Edema and discoloration may develop over the first 24—48 hours after injury. Neurovascular status should be assessed, including a sensory exam, palpation of pulses, and testing of capillary refill.

Then a focused exam should evaluate the site of maximal tenderness, specifically examining the distal tibial and fibular physes, medial and lateral malleoli, tibial and fibula shafts, the base of the 5 th metatarsal and the peroneal tendons.

A 5 th metatarsal fracture or peroneal tendon subluxation may present as an ankle fracture.

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Ligamentous structures should be evaluated as well, including anterior and posterior talofibular ligaments, calcaneofibular ligaments, and anterior tibiofibular ligament. Maximal tenderness over the ligaments distal to the malleoli may indicate sprain rather than fracture. The treating physician should always assess for atypical presentations, such as absent or inadequate trauma history, antecedent pain, or constitutional symptoms.

Small children are particularly at risk for misdiagnosis, as they may not be able to recount an episode of trauma and can develop hematogenous osteomyelitis with no associated risk factors which can mimic a fracture. Less common causes of atypical fractures include nonaccidental trauma or leukemia.

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Radiographs should always be evaluated for a lytic lesion or periosteal reaction adjacent to the fracture site. In addition, a history that does not match the presenting injury pattern should alert the physician of possible child abuse. Nearly half of the child abuse cases present with solitary fracture alone. Ankle radiographs with three views should be used to selectively evaluate for fracture in patients with ankle injuries. The Ottawa Rules bony tenderness along the malleoli, inability to bear weight were developed for adults to Screwing mature wife holding ankle in air determine when radiographs are necessary 23 and have been validated for children 2425but have been criticized for having a high false negative rate in adults.

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Low risk ankle injuries are defined as sprains, nondisplaced Salter-Harris 1 and 2 fractures, and avulsion fractures of the distal fibula. X-rays are not required if there is only tenderness of the distal fibula or adjacent lateral ligaments Radiographic images should be evaluated for physeal widening, which may indicate a Salter Harris 1 fracture. The plafond and mortise should be carefully examined for evidence of an intra-articular fracture pattern, such as a Tillaux or triplane fracture, as these findings can be quite subtle.

A Salter Harris 2 fracture of the fibula may only be visible on the lateral view and will be superimposed on the image of the lateral tibia. If displaced, this may result in a growth arrest.

Scope of Review

If radiographs are suspicious for an intra-articular fracture pattern, a CT may be obtained to evaluate articular congruity, assess the need for surgical Screwing mature wife holding ankle in air, and assist in preoperative planning. This is most commonly indicated for Tillaux and triplane fractures, as most Salter Harris fractures can be assessed and treated without axial imaging.

After viewing CT imaging, surgeons more frequently recommend surgical treatment for Tillaux and triplane fractures due to significant intra-articular step-offs that are difficult to appreciate on plain films An MRI may provide similar information but has increased costs and at most centers is not as readily obtained as CT. Several reports show magnetic resonance imaging MRI specifically does not change in the treatment plan for acute pediatric ankle fractures.


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