PEDIATRIC ANKLE FRACTURE (PEDIATRIC MEDIAL MALLEOLUS FRACTURE)

PEDIATRIC ANKLE FRACTURE (PEDIATRIC MEDIAL MALLEOLUS FRACTURE)

 

Pediatric ankle fractures, also known as ankle fractures of children, are common childhood injuries. This fracture includes fractures of one or more of the bones that make up the ankle: the tibia (also known as the shin bone), fibula (outer to tibia and ankle), and talus (small bone behind the foot).

Ankle fractures in children range from very mild to complex. Simple fractures can often be successfully treated with simple walking shoes, but more complex injuries may require surgery. The orthopaedist will advise on treatment options for ankle fractures in children and long-term follow-up to monitor the outcome of treatment.

Pediatric ankle fractures pose a different fracture pattern and treatment course than adults. It has physical and mechanical properties.

Certain treatment goals, such as functional alignment to restore joint congruence and prevent early arthritis, are common to both groups, but protecting and maintaining the infant's physique is a priority.

In this article, we will be able to know about:

 

 

ANKLE ANATOMY OF CHILDREN

Ankle fractures in children and adolescents usually occur in the tibia or fibula and usually affect the growth plate. The growth plate is near the end of the long bone and is the area of ​​cartilage that hardens into the bone solid when the child is fully grown. Since the growth plate is the last hardened part of the bone, it is easy to fracture.

In adolescence, when the growth plate first closes and begins to harden, transient fractures of the mature growth plate can occur. The two common transition fractures of the ankle are the Tillaux fracture and the triplane fracture.

Among all the injuries of physis, highest complication rates are seen in fractures of the distal tibial physis, including premature arrest of physis, bar formation, angular deformity, and joint mismatch.

Physis contains four zones, from epiphysis to metaphysis, where mechanical strength decreases due to a decrease in the matrix cell ratio- reserve zone, hypertrophy zone, proliferative zone, and provisional calcification zone.

Fractures usually occur through the hypertrophied zone, which has the largest cells and less extracellular matrix than the other zones. This preserves the reserve zone for most fractures. It is located on the epiphyseal side of the fracture and contains progenitor cells for fracture growth. There is an increased risk of causing failure to thrive in the body as it can damage the reserve zone.

Distal tibial physis provides 40% of tibial growth and 17% of lower limb growth, showing 3-4 mm annual growth in childhood. The growth of the distal tibia is proportional to the proximal tibia of young patients, but in adolescents, the growth of the proximal tibia is faster and the growth of the distal tibia is tapered.

Injuring your physique at a young age can make a significant difference in leg length. The distal center of tibial ossification appears about 6 months after birth, and the distal fibula appears about 1 to 3 years after birth.

Distal tibial and physis of fibula obstruction occurs in females aged 12 to 17 years and males aged 15 to 20 years.

In contrast to other physis, tibial physis closure occurs slowly and eccentrically, starting around the hump of Poland, anterolateral ligament, posterolateral ligament, and finally the anterolateral ligament.

In the case of triplane and Tillaux fractures, physical arrest is generally not a concern as the physique is already closed with these fracture patterns. Avascular necrosis after trauma is extremely rare because the distal tibial plate is well supplied with blood.

The distal fibula is contained in the lateral distal tibial groove with significant ligament restriction from the ligaments of anterior tibiofibular and posterior tibiofibular and the calcaneofibular ligament. The ligament structure of a child is very sturdy, but the physique is biomechanically affected by shear and rotational forces.

Therefore, the same mechanism of injury that can lead to ankle sprains in adults can occur in children with physical or avulsion fractures. Physis of the distal fibula becomes wavy and more stable in childhood. The distal fibula often has a secondary ossification center that can be x-rayed to simulate a detached fracture.

Therefore, laboratory findings can be used to distinguish non-displaced avulsion fractures from ossification centers.

 In childhood, fibula growth is evenly distributed in the proximal and distal tibial physis, but in adolescence, proximal tibial growth predominates. An isolated physical stoppage of the fibula is rare, but it can result in ankle valgus.

 

CLASSIFICATION OF ANKLE FRACTURES

Salter-Harris classification:

The most common symptom of Salter-Harris fractures is local joint pain after traumatic events (collisions, crushes, falls, etc.). Patients may imagine that there is swelling around the joints in addition to local tenderness throughout the physique. If an upper limb is injured, the patient may complain of limited range of motion.

If the injury affects the lower extremities, the patient may not be able to support the affected weight. It is important to note that the symptoms may mimic ligament injuries and may give a positive result on a ligamentous laxity test.

Therefore, care must be taken not to misdiagnose symptoms that are related only to joint tissue.

 

Salter-Harris classification divides the fractures in five types:

Salter I or slipped:

This is when the line of fracture passes through physis or within the growth plate. Type I fractures result from the longitudinal force exerted by physis that separates the epiphysis from the metaphysis. It should be kept in mind that normal x-rays do not rule out physeal injury in symptomatic pediatric patients. X-rays are normal with no bone involvement and may show mild to moderate soft tissue swelling.

Look for enlargement or epiphyseal displacement that may indicate a fracture. Diagnosis is based on clinical findings such as localized tenderness and swelling around the growth plate.

Salter II or above:

This is the case when the fracture extends to both physis and the metaphysis. These are the most common and occur outside the joint space.

If you see a small protruding area at the end of the metaphysis, it is called a Thurston Dutch fragment or sign of corner.

Care should be taken when describing extension using the terms proximal and distal, as the position of the body is not fixed, but relative to the metaphysis. If the proximal end of the bone is affected, the physis is proximal to the metaphysis.

That is, it extends distally from physis toward the metaphysis. If it is the distal end of the bone, the physis is distal to the metaphysis. That is, it extends proximally from physis to the metaphysis.

Salter III or lower:

This is a fracture of intra-articular nature, and extends from physis to the epiphysis. If the fracture extends to the full length of physis, this type of fracture can form two epiphyseal segments. Due to the involvement of the epiphysis, articular cartilage can be damaged. An example of this is the Tillaux fracture, which is a fracture of the anterolateral and epiphyseal of the growth plate.

Salter IV or transverse:

This is also an intra-articular fracture, where the fracture itself passes through the epiphysis, physis, and metaphysis. Because this fracture gets epiphysis involved, it can damage the articular cartilage. An example of this is a triplane fracture of the ankle, which has three components:

  • Vertical element through the epiphysis.
  • Horizontal component passing through the growth plate.
  • Diagonal component through the metaphysis.

Type III and IV fractures carry a risk of growth retardation, altered joint mechanics, and dysfunction, respectively. Therefore, both require urgent orthopedic examination.

Salter V or ruined:

This type of fracture happens due to crushing or compression damage to the growth plate. In Type V, force is spread via the epiphysis and physis, which might lead to disruption in the areas of hypertrophic, germinal matrix, and the vascular supply. Fractures of Harris-Salter V are very rare but can be seen with electric shock, frostbite, and radiation. Because this pattern of fracture tends to result because of serious injuries, and they usually have a poor prognosis and stop bone growth.

Note that on radiographs, it can be latent and therefore x-rays can look normal. This can be diagnosed retrospectively as soon as growth arrest occurs. For symptomatic children taking normal radiographs with proper settings, the possibility of type V should be considered. Nevertheless, there may be signs of enlargement of the body, which may be a possible sign of the presence of displacement. Anterior-posterior and lateral views may be required to properly depict the type of fracture, and of course, contralateral unaffected limb imaging may be required for comparison.

Salter VI:

It is very rare, and results because of an open injury (e.g., because of a lawnmower sort of thing) or might occur because of surgeries performed on you. Injury of perichondrial ring is seen.

 

DIAS AND TACHDIJIAN CLASSIFICATION

There are five different classifications:

Supination-inversion:

  • Grade I: Avulsion of distal fibular epiphysis because of inversion force of adduction. It, occasionally, may be transepiphyseal. It doesn’t usually occur with lateral ligament failure.
  • Grade II: Because of more and more inversion, fracture of distal tibia is seen. It may, however, occasionally cause a fracture which goes through the medial malleolus (just below the physis).

Supination-plantarflexion:

There is a posterior displacement of tibial epiphysis because of forceful plantarflexion. Because the fragment of Thurston-Holland is made up of the tibial metaphysis (posterior), it is displaced posteriorly. It is usually seen in absence of a fracture of fibula. On antero-posterior (or AP) radiographs, supination-pronation type may be difficult to be seen.

Supination-external rotation:

  • Grade I: Fracture of distal tibia is seen because of a forceful external rotation. There is a posterior displacement of distal fragment. In this type, the fragment of Thurston-Holland fragment is seen posteromedially displaced.  Because the line of fractures extends medially and proximally, it can easily be seen on anteroposterior radiographs.
  • Grade II: anteroinferior extending to posterosuperior fracture (low spiral) of fibula is seen because of severe external rotation.

Pronation-external rotation:

Because of the force of external rotation, fracture of distal tibia or of transverse fibula is seen. It may, occasionally, be seen with medial malleolus fracture that is transepiphyseal in nature. There is a lateral displacement of fragment of distal tibia. In this type, the fragment of Thurston-Holland is seen displaced laterally. Pronation(eversion)-external rotation type may be related to ankle joint diastasis.

Axial compression:

This results in Salter-Harris V fracture with injury to distal tibial physis. It is be impossible or at least difficult to be diagnosed on first presentation. It is diagnosed usually when the growth arrest is seen on radiographs on follow-ups.

Other fracture types:

  1. Displaced fractures.
  2. Distal fractures of fibula: If only the fibula of the ankle is damaged, it is primarily a Type I or II Salter-Harris fracture. These isolated fractures are primarily due to low energy trauma such as falling from a standing height. Isolated distal fibula fractures generally heal well when treated with walking shoes or short leg casts.
  3. Triplane fractures: Triple surface fractures are a complex pattern of injury found in more physically mature adolescents as the growth plate begins to close. Triplane fractures are Salter-Harris type IV fractures, including three different levels of fractures. These fractures spread through the metaphysis (the enlarged part of the bone shaft), the physis (plate of growth), and the epiphysis (the bone end). Triplane fracture treatment depends on how much the bone fragments have been displaced from each other. Minimal displacement and non-displacement triplane fractures can be treated with a long leg cast. However, these fractures are often displaced and require open reduction and internal fixation, making it easier to maintain reduction.
  4. Tillaux fractures: These fractures are named after a surgeon who was French. These are SH III fractures. Tillaux fractures account for 3-5% of ankle fractures in children and usually occur in late adolescence when the growth plate begins to close. Fracture fragments tend to loosen/become unstable and are treated with open reduction and screwing.
  5. Medial Malleolus Fractures.

 

PEDIATRIC MEDIAL MALLEOLUS FRACTURE

Isolated fractures of the medial malleolus of ankle generally occur when the foot is forcibly rolled in or out. When the foot rolls inward, the medial malleolus ankle is compressed inside the ankle. Stretching your legs can cause tension on the inner part of your ankles, which can lead to fractures. Fractures on the inside or medial side of the ankle can also occur in a stress fracture pattern. In these cases, there are no severe injuries and repeated stress on the activity can weaken the bones. Ankle stress fractures are most common in endurance athletes and military recruits.

Medial malleolus fractures cause the following symptoms:

  • Pain on the inner aspect of the ankle.
  • Swelling and bruising on the feet and ankles.
  • Difficult to walk.

If you experience any of these symptoms, you should see a doctor to determine the cause of the pain. There are well-established criteria for determining if X-rays are needed. Most fractures are clearly visible on x-ray without further testing.

As mentioned earlier, every time an ankle fracture occurs, there is concern about other bone and ligament damage that may occur as part of a typical injury pattern. Patients with medial malleolus fracture of ankle should be carefully examined to make sure there are no other fractures or ligament damage around the joint.

There are options for treating medial malleolus ankle fractures, both non-surgical and surgical.

Several studies have shown good healing of medial malleolus ankle fractures treated without surgery. In most cases, these fractures are not completely out of their positions. Non-surgical treatment is often preferred even if the bone fragments are too small to adversely affect the overall stability of the joint alignment. In general, most doctors recommend surgery for fractures that can affect joint stability and alignment.

If the fracture is not properly positioned, surgical intervention to align and stabilize the bone is often recommended.

Bone is usually secured with metal screws, but there are several other options that can be considered depending on the fracture pattern.

When surgery is performed, infection and healing issues are of utmost concern. The ankle joint is treated with special care after surgery because the bones are poorly protected and only the layer of skin covers the surgical repair.

Proper wound healing and avoidance of infection at the surgical site are important concerns. For this reason, most doctors perform surgery immediately (before swelling occurs) or wait days or weeks for the swelling to subside to minimize swelling during surgery and keep the soft tissue healthy.

Another major concern about ankle fracture injuries is that bones generally tend to heal well, but ankle cartilage injuries can result from the injury itself. This cartilage damage can lead to early ankle osteoarthritis.

Depending on the type of fracture, the surgeon may be able to visually inspect the cartilage. Also, some surgeons may choose to have an ankle arthroscopy during repair to get a better view of the cartilage. Even after surgery to restore proper joint alignment and stability, there is an increased risk of developing osteoarthritis of the ankle later in life after an ankle fracture.

 

SIGNS AND SYMPTOMS

It is often difficult to distinguish between an ankle sprain from a more serious fracture of ankle. At first, both sprains and fractures cause swelling, inflammation, and pain.

Other symptoms and symptoms of ankle fractures are:

  • Pain, which can be severe.
  • Not being able to put weight on legs.
  • Bruises.
  • Pain when someone touches the area.
  • Deformed ankle.

 

PHYSICAL EXAMINATION

Children and adolescents with ankle fractures will visit you with spontaneous swelling after trauma, pain begins immediately, and pain worsens during exercise. There may be swelling or bruising on the skin. This is usually equal to the amount of energy transmitted during an injury and therefore correlates with the severity of the injury. The skin should be carefully examined to rule out open fractures.

Severe bruises and subsequent bruised areas that can occur with excessive swelling can affect the placement of subsequent surgical incisions and should be considered. Significant changes can cause visible deformities and impair the vascular supply of the foot. The main vascular pulses to the feet of both the dorsalis pedis and tibialis posterior should be palpated in the presentation to assess capillary filling.

A complete neurological examination of the lower extremities distal to the injury includes superficial sensations on the dorsal and sole sides of the foot. The point of greatest tenderness is the key to understanding an injury.

Palpation is important in distinguishing ankle sprains from fractures and diagnosing associated fractures.

Tenderness to pressure on bone protrusions indicates damage or fractures in the physis of the body, while tenderness to ligaments is more common in sprains. Palpation should thoroughly be done up from the ankle to the knee to rule out high fractures of fibula (Maisonneuve fractures) and downwards in the case of fractures of the 5th or metatarsal bones.

Compartment syndrome is rare but can occur after an ankle fracture. Clinicians need to pay attention to the clinical manifestations of compartment syndrome. A syndrome known as the syndrome of extensor retinaculum can occur in a subset of patients where translation that is excessive of the fragment causes compression of the anterior ankle, especially the structure of the deep peroneal nerve.

Findings include pain unrelated to injury, first space of web hypoesthesia or paresthesia, and weakness of the toe extensor muscles. Syndrome of extensor retinaculum needs to be effectively treated with surgical remedies.

Your doctor should always check for atypical symptoms such as lack or inadequate trauma history, previous pain or constitutional symptoms. Infants are particularly at risk of misdiagnosis because they have no associated risk factors that can mimic fractures and may not be able to associate traumatic episodes to develop hematogenous osteomyelitis. The less common causes of atypical fractures are extra-accidental trauma or leukemia.

Radiographs should always be examined for lesions that are lytic or periosteal reactions next to the fracture site. In addition, medical histories that do not match the injury pattern should warn doctors of a possible child abuse. Almost half of cases of child abuse occur with only one fracture.

 

DIAGNOSIS

A 3-view radiograph of the ankle should be used to selectively examine fractures in patients with ankle injuries. The Ottawa Rule (bone tenderness along the ankle, unable to carry weight) was designed to determine when adults need x-rays and has been validated for children, but has a false negative rate for adults.

The low-risk ankle rules are specially designed for children to help determine when X-rays are needed to save patients from undergoing unnecessary radiographs, and thereby for cost reduction purposes. Salter-Harris 1 and 2 fractures and distal fibula detachment fractures are sprains or low risk ankle damage. X-rays are not needed if only the distal fibula or adjacent lateral ligaments are tender.

An x-ray should be used to examine the enlargement of Physis, which may indicate a fracture of Salter-Harris type 1. Mortise should be carefully examined for evidence of intra-articular fracture patterns such as triplane fractures or tillaux fracture. These findings can be very subtle. The Salter-Harris 2 fracture of the fibula is only visible in the lateral view and may be overlaid on the image of the lateral tibia. If there is a shift, this can lead to a halt in growth.

If radiographs suggest an intra-articular fracture pattern, CT scans can be performed to assess joint congruence, assess the need for surgical treatment, and assist in preoperative planning. This is most commonly shown for Triplane fractures or Tillaux fractures, as most Salter-Harris fractures can be evaluated and managed without axial images.

MRI can provide similar information, but it is as expensive, also CT is present in most centers whereas MRI is not readily available. Several reports show that magnetic resonance imaging (MRI) does not change, especially, the treatment regimen for acute pediatric ankle fractures. However, it can provide information for surgical planning, characterize suspicious osteochondroma damage, and rule out underlying tumors and infections.

Normal ankle stress view is not recommended for most ankle fractures in children. However, for the equivalent of an adult ankle fracture (supination of external rotation, SER pattern), the gravity stress view assesses whether surgical treatment is needed and whether weight loading can be started immediately. It is a useful tool. Gravity stress views are more tolerable and less painful than normal routine radiographs (manual; stress).

 

TREATMENT

Treatment of ankle fractures in children is based on several factors, including:

  • Fracture Location.
  • Degree of damage to the growth plate.
  • Position of the foot when injured.
  • Direction of force when injured.
  • Degree of displacement (displacement of bone fragments).

Fractures of the growth plate require careful treatment, as long-term consequences can result in bent ankles and uneven length of legs.

Salter-Harris system is the most widely used classification system for growth plate fractures. The Salter-Harris classification shows how badly the growth plate is damaged and how likely it is to develop failure to thrive.

The purpose of treating ankle fractures in children is to restore joint congruence and ankle, lower limb alignment, and body anatomy, and thus maintain pain-free ankle function until adulthood.

When treating a child's ankle fracture, several considerations go into the equation, each of which needs to take into account the presence of physique. Children with ankle fractures and still growing for more than 3 years should be monitored for growth arrest on semi-annual or yearly radiographs until symmetrical growth is seen. Most treatment decisions are based on the condition of the distal tibial component and the syndesmosis.

Isolated fibula fractures are rarely indicated for surgical treatment at medical facilities.

Regardless of classification, non-displaced fractures are conservatively treated with proper fixation and protected loads. To rule out shifts in the cast, you should consider continuous radiographs every 1-2 weeks for the first 3 weeks. Depending on the patient's age and type of fracture, plaster treatment is usually completed in 4-6 weeks, after which the fracture boots can be recommended for initial weight bearing.

Fractures that are not displaced can be treated with a plaster cast. The load condition and fixation period depend on the type and stability of the fracture. Low-risk ankle fractures such as distal fibula detachment fractures, non-displaced fibula SHI fractures, or lateral talus detachment fractures can be treated with air sprints or walking shoes. SHI distal fibula fractures may be much less common than previously thought.

Fractures involving the weight-bearing surface of the long bone-tibia with displacement are also initially managed with casting and closed reduction. extremely distal fractures like Tillaux fractures are usually put in a short leg cast, on the other hand intra-articular fractures that involve the metaphysis and that are supposed to have a rotational component are put in a long leg cast. A routine CT is ordered post-reduction and inspection of the joint surface is done. Displacement greater than that of 2 mm at the surface of weight-bearing of the long bone- tibia is considered as an indication for surgery.

For fractures of SH-III and SH-IV type (of the medial malleolus fracture) that have 1 mm or a displacement greater than that, it is usually recommended to have ad surgical fixation one because of the risk of non-union and arrest of growth. Dislocated distal fibula fractures are often associated with distal tibial fractures, but can also occur alone. In contrast to isolated distal tibial fractures, the risk of physical arrest of isolated fibula growth is very low. For fibula fractures that are displaced in connection with a tibial fracture, tibial fracture reduction usually also leads to fibula fracture reduction. Occasionally, a displaced fibula fracture or a greenstick fracture may interfere with the reduction of a distal tibial fracture.

In that case, fibula closure or open reduction may be required. Fibula fixation usually provides proper fixation when additional stability is required.

Closed reduction is attempted for for Tillaux fractures with inversion, plantarflexion, and pressure that is manual on the fragment. A short leg cast is thought best for the patient. CT scan is obtained.

Conservational treatment may be done in case the displacement is less than 2mm. Surgical treatment is indicated in case the displacement is greater than 2mm. It is not known whether open reductions work best for Tillaux fractures or the surgical closed reduction.

CT scans are done on all patients to plan preoperative course. Attempting intraoperative fluoroscopy at various angles should be attempted, usually in an external rotation view, to find a projection showing the maximum extension of the fracture gap.

If there is a distraction of 2-4mm, formal reduction that is open might not be needed. If there is a dislocation and/or rotation component larger than 4 mm, a periarticular reduction clamp can be placed over the fragment percutaneously and on medial ankle through puncture and reduction attempts. Fractures that cannot be reduced with these techniques are usually treated with an open approach. As mentioned above, pre-operative CT scans and fluoroscopy methods are used to make a limited incision beyond the maximum displacement of the fracture.

 

RECOVERY

Pediatric ankle fractures usually heal within 4-6 weeks. The stabilizing effect of a sprint, plaster model, or surgery relieves pain. As the healing process progresses, the pain improves and all pain disappears within 2 weeks of the injury. Your child's doctor or the pediatrician may prescribe painkillers to relieve the pain.

Children with mild fractures can walk quickly. However, usually no load can be applied until the fracture has healed. The pediatrician or your child's doctor will guide you through this process.

Fractures often heal in 4 to 6 weeks, but it takes longer to fully recover. Your doctor may recommend home therapy or physiotherapy to improve joint flexibility and leg strength. Only when this power returns will your child be normal again.

 

COMPLICATIONS

These fractures often cause stunting, which can lead to bending of the ankles and short legs. Therefore, growth -plate fractures must be carefully monitored by a physician to ensure correct long-term results.

Regular follow-up visits by the child's doctor should continue for at least one year after the injury. Complex fractures may require follow-up until the child reaches skeletal maturity.

Maintaining bone alignment, joint cavity congruence, and restoration of physical anatomy are major concerns in the early stages of follow-up. During medium- to long-term follow-up, patients with remaining growth may need to monitor growth arrest followed by angular deformities or leg length discrepancies.

 In patients at high risk of growth arrest, baseline scanograms and hand bone age confirm arrest and predict differences in expected growth remaining and expected leg length during skeletal maturation.

Some of the complications of Pediatric ankle fractures are:

  1. Closure of premature physis: PPC or premature physeal closure is a major problem in relation to pediatric ankle fractures. Complete arrest of physis of the tibia can lead to differences in leg length, and partial arrest of it can lead to angular deformation. The physical properties of the tibia and fibula are often equally unaffected, causing ankle sockets to grow asymmetrically and cause angular deformities. Premature closure of the fibula leads to overgrowth of the tibia, often leading to valgus deformity. Since the fibula can move proximally, overgrowth of the fibula is more tolerable. However, the exact range of permissible overgrowth is unknown and impingement of fibula may occur. Even with symmetric cessation of growth, ankle overgrowth and impingement of ankle can occur because the length of the fibula in the proximal direction grows faster than in the proximal tibia.
  2. Wound complications and deep infections: Superficial wound necrosis can be avoided by carefully treating the soft tissue and avoiding flap ridges, especially on the outside of the ankle. Infections at the surgical site are relatively rare and are treated according to standard principles.
  3. Abnormal union or malunion: abnormal unions or malunions are rare. Misalignments that do not affect the joints are treated with benign neglect if appropriate modifications are possible or if standard deformity corrections are in place. Osteotomy and fixation may be appropriate if the joint lines are involved in the abnormal union.
  4. Problems related to ankle joint: Patient is at risk of post-traumatic arthritis, pain, stiffness, and pain that doesn’t go away. Highest risk of getting post-traumatic arthritis is in distal tibial fracture of SH III and SH IV types. Anatomical reduction decreased the risk of arthritis of ankle. Physical therapy and programs of rehabilitation are helpful in stiffness. In case of mechanical symptoms that do not go away might specify lesions of osteochondroma, and MRI is indicated in this case. RSD or reflex sympathetic dystrophy is a rare complication which is also known as complex regional pain syndrome (CRPS); this complication is more seen in girls than boys. The treatment of such issues is limited to physical therapies and to physical therapies.
  5. Non-union (body not being able to heal the fracture on its own): this complication is rare as well, but can be a cause of problem in SH III and SH IV fractures of pediatric medial malleolus fractures. To reduce the risk of this complication, surgery is indicated for fractures where the displacement is greater than 1mm.
  6. Other complications: tibial metaphyseal osteonecrosis (that follows a SH I fracture), compartment syndrome or syndrome of extensor retinaculum, RSD or reflex sympathetic dystrophy (also known as CRPS or complex regional pain syndrome).

 

TAKEAWAY

Ankle fractures in children account for about 5% of childhood fractures and 15% of tibial injuries. The biomechanical differences between mature and immature bones, and the various forces exerted on these bones, help explain the differences between adult and child fractures. Potential complications associated with ankle fractures in children include complications of adult fractures (post-traumatic arthritis, rigidity, reflex sympathetic dystrophy, etc.) and limb injuries (discrepancy, angular deformities, or combinations of all).

The goal of treatment is to achieve and maintain a satisfactory reduction and avoid arrest. Knowledge of common ankle fracture patterns in children and the pitfalls associated with their assessment and treatment will help clinicians manage these injuries effectively.

 

 

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All Rights Reserved © By MarsoClinic

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