This complication has been found to correlate positively with high-energy mechanisms of trauma (83), significant initial displacement, and multiple attempts at closed reduction (24). (a) Axial radiograph of the right calcaneus bone in a 16-year-old boy who jumped from a 1015-fthigh window shows an obliquely oriented linear fracture extending through the calcaneus bone (arrows). 6. Notice however, that there are many similarities between Weber B and C with only differences in the order of events. A nondisplaced Salter-Harris type I fracture may manifest with soft-tissue swelling centered over the growth plate and focal clinical tenderness (12). In a relatively recent study (67) of the MRI appearances of pediatric cuboid fractures, the fractures were found to occur in isolation, linear, and most commonly adjacent to the tarsometatarsal joint. (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). We, and third parties, use cookies on our website. (a) AP radiograph of the right foot in a 1-year-old girl who fell while being carried down the stairs shows a fracture (arrow) at the base of the first MT bone. Study these images. CT is the best imaging method for confirming the diagnosis and ruling out intra-articular fractures. Distal tibial physeal closure occurs in a unique eccentric pattern (Fig 1) over a period of 18 months, typically between 12 and 15 years of age in girls and between 14 and 18 years of age in boys. MT ossification occurs in the 2nd to 4th fetal month, talar and calcaneal ossification begins in the 3rd fetal month, and the cuboid bone ossifies in the 6th fetal month. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. If multiple MT bones were fractured, they always involved contiguous bones (75). It was determined that the occurrence of these mechanisms always follows a uniform order. Stage III: rupture of interosseous membrane + high fibular fracture. An avulsion of the fibular attachment is even more rare. stage 2 is injury to the anterior syndesmosis, which is usually not visible, unless there is a Tillaux fracture. The associated fracture of the distal fibular shaft (arrow) does not involve the fibular physis. Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. Figure 15b. Associated spinal fractures are less common in children than in adults (5.4%), but other extremity fractures are more common in pediatric patients (49). Using the Salter-Harris classification as a template, Dias and Tachdjian (35) classified ankle fractures in skeletally immature patients on the basis of the foots position at the time of trauma and the direction of the abnormal force. Findings at presentation include pain, swelling, inability to bear weight, and possibly medial plantar ecchymosis. Up to 22% of all MT fractures involve the base of the MT bone, and 90% of these injuries occur in children older than 10 years (33). With increasing maturity, the distal fibular physis becomes increasingly undulated, providing stability (1). Figure 19b. 24). Figure 5. Fracture mimics. Juvenile Tillaux fractures represent a transitional subset of Salter-Harris type III fractures of the anterolateral tibial epiphysis that occur in adolescents after physeal fusion is nearly complete and minimal residual anterolateral physeal patency remains (Fig 13). Knijnenberg et al (69) found that the distances between the first and second MT bases measured on AP radiographs obtained in skeletally healthy pediatric patients were consistently shorter than 3 mm. This is a normal developmental variant; there is no associated soft-tissue swelling. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. https://www.physio-pedia.com/Avulsion_Fractures_of_the_Ankle Revista Ciencias Biomdicas, Vol. Coronal reformatted CT image shows a distal tibial fracture (single-headed arrow). The adult criteria for loss of tibiofibular overlap in the mortise view and increased tibiofibular clear space to greater than or equal to 6 mm do not signify syndesmotic disruption in the skeletally immature patient (15). The talus will continue to exorotate and will no longer be checked by the medial ligaments, causing the talus to push away the fibula. Hawkins type II displaced talar neck fracture in a 15-year-old girl with left ankle deformity, ecchymosis, and swelling after she fell from an aerial cheerleading spin and landed on her left leg. L = left. Figure 11. Distinct biologic and mechanical attributes of the pediatric skeleton translate into fracture patterns, complications, and treatment dilemmas that differ from those of adults. CT may aid in preoperative planning (70), but it cannot be used to determine instability. Talar neck fractures are much more common than talar body fractures, which, in turn, are more common than lateral and posterior process fractures. And finally in stage 4 there will be a rupture of the posterior syndesmosis or tertius avulsion (stage 4). Distal tibial metaphyseal fractures in a 25-day-old male newborn who presented with multiple sites of skin bruising and lethargy. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails They are connected by 3 ligaments (the medial/lateral collateral ligaments and the interosseous ligament). These fractures represent 5%10% of pediatric intra-articular ankle injuries (37). Radiographics. The deforming mechanism is often supinationexternal rotation, although other mechanisms have been reported (38). Although the distal fibula is a common location of suspected Salter-Harris type I physeal fractures of the distal fibula (SH1DF), these fractures may be clinically and radiographically indistinguishable from sprain. Three standard (AP, oblique, and lateral) radiographic views are usually adequate for the detection of fifth MT fractures. Ossification of the anterolateral distal tibial metaphysis leads to the creation of two separate lines in this radiographic projection; the more lateral line (not shown) corresponds to the anterior tibia, and the more medial line is the incisura fibularis (white line), which articulates posteriorly with the fibula. The distal talar fragment (arrow) is slightly superiorly displaced, while the tibiotalar and talonavicular articulations are congruent. Ischemia can involve only part of the talar dome, usually the medial aspect, and result in a partial Hawkins sign, usually of the lateral talar dome. Calcaneal fractures. (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). For example, lack of a tibiofibular overlap on the mortise view can be a normal variant in skeletally immature patients and should not be mistaken for syndesmotic disruption. Figure 2b. -. Revista Brasileira de Ortopedia, Vol. Drawing illustrates the Salter-Harris classification of growth plate fractures at the distal tibia. (a) Lateral radiograph of the ankle of a 14-year-old boy after a twisting injury to the right ankle shows a subtly widened anterior physis at the distal tibia with a posteriorly based Thurston-Holland fragment (arrow). 1, The Journal of Foot and Ankle Surgery, Vol. Lateral. In that case the ankle is unstable and may dislocate. This is always stage 2 and unstable. These lines normally are horizontal; tenting or angulation into the fracture site is suspicious for bony bridge formation (33). It involves less than one-third of the mediolateral distance across the epiphysis (33). Step 1The first question you should ask yourself is:Is it a Weber type A fracture? Joint depression can be assessed at comparisons with the contralateral foot. Forefoot fractures account for 6%10% of fractures in children and involve the toes and MT bones. They have a bimodal However, 2 weeks later, calcaneal tuberosity sclerosis is visible radiographically, with subsequent spontaneous recovery (4). Intra-articular displacement (double-headed arrow) of 3 mm is seen. 16). 1985;(199):28-38. Tibiotalar dislocation in a 14-year-old girl that occurred after a trampoline injury. 15). A Salter-Harris type I physeal fracture passes along the width of the physis and may be visible at radiography if the growth plate is widened or the epiphyseal and metaphyseal components are malaligned. When the broken bones break through the skin, the injury is called an open or compound fracture. CT is useful for assessment of comminuted fractures and small fractures of the anterior process, and for surgical planning. Variable ossification of the navicular bone may be mistaken for Khler disease (33). High fibular fracture and a tertius fracture. On examination: mild swelling, hotness, and tenderness over the References Ng J, Rosenberg Z, In addition, lateral fibular translation increases and fibular external rotation decreases (14). The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops (stage I). The ankle is a ring structure consisting of the tibia, fibula and the talus. On AP radiographs obtained in adults, measurements of the distance between the first and second MT bases and the distance between the medial cuneiform bone and second MT base are considered to be abnormal if they are greater than 2 mm. 2, Radiologic Clinics of North America, Vol. 4, International Journal of Emergency Medicine, Vol. In addition, the role of imaging in ensuring appropriate treatment, follow-up, and patient and parent counseling is highlighted. The midfoot is a complex anatomic association of five tarsal bones (navicular bone, cuboid bone, and three cuneiform bones) and their corresponding articulations. 2, Radiologic Clinics of North America, Vol. Salter-Harris type III fracture of the distal tibia in a 13-year-old boy. AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. Several systems for classifying calcaneal fractures exist (Fig 16). 1998;69(1):43-7. Figure 10a. Below is an example of a supination-adduction fracture (fig. Since the fibula fracture in a Weber C is most commonly not visible on the x-rays of the ankle, this can be a tough question to answer.We will have to look for additional findings that lead us to the right answer and that will help us to make the decision to do additional images. (c) AP radiograph obtained after reduction and internal fixation shows restored ankle alignment and placement of a pin to repair the distal fibular physeal fracture. Midfoot and hindfoot fractures generally involve greater force, such as that from a fall from a height or from a higher-speed mechanismfor example, a bicycle or motor vehicle accident. This is a stage 1 stable Weber A fracture. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. 53, No. The ankle is stabilized by its bone and ligamentous anatomy. The supination-inversion (SI), supinationexternal rotation (SER), pronationexternal rotation (PER), and supinationplantar flexion (SPF) mechanisms of injury are depicted. The fracture line of the distal fibula continues to the level of the horizontal tibiotalar joint (stage II). The navicular bone articulates with the three cuneiform bones and occasionally the cuboid bone. Nondisplaced fracture of the proximal aspect of the right (R) fifth MT bone in an 11-year-old girl who injured her ankle while playing basketball. Stage I supination-adduction fracture. The distal tibial ossification center appears when an infant is around 6 months of age, whereas the distal fibular ossification center appears when a child is around 13 years of age. Open physes protect against ligamentous and syndesmotic injuries (18). Intra-articular injuries increase the risk of subsequent arthritis sevenfold (84). 20): In practice, the mechanism is often referred to with the term inversion trauma.Note: this trauma mechanism is also seen in Weber A fractures. Schmidt and Weiner (49) modified the Essex-Lopresti (52) classification of calcaneal fractures for use in children and included compound fractures secondary to lawn mower injuries (4,33). Figure 24. Ng J, Rosenberg Z, Bencardino J, Restrepo-Velez Z, Ciavarra G, Adler R. US and MR Imaging of the Extensor Compartment of the Ankle. (a) AP radiograph of the left ankle shows asymmetric closure (arrows) of the left distal tibial physis. (c) AP radiograph obtained after reduction and internal fixation shows restored ankle alignment and placement of a pin to repair the distal fibular physeal fracture. There is no associated syndesmotic widening. (b) Accompanying lateral radiograph shows the dislocation at the tibiotalar joint to be posterior. The midfoot consists of five tarsal bones and their articulations. Provides insight into the trauma mechanism. The forefoot includes the MT and phalangeal bones and their articulations. These fractures result from forced dorsiflexion with an axial load after high-energy trauma. (b) Mortise radiograph of the ankle in an 11-year-old boy shows a slight decrease in the medial clear space (black arrow), a narrowed tibiofibular interval (single-headed white arrow) with no overlap yet seen, and a slightly widened distal fibula (double-headed arrow). This leaflet explains the ongoing management of your injury. The Lisfranc joint is the articulation of the tarsus with the MT bases. stage 1 which is the medial injury, where it all starts. Trauma mechanism of supination-exorotation according to Lauge-Hansen. Fracture immobilization can also cause hyperemia and disuse subchondral lucency. Extensor retinaculum syndrome usually involves the anterior metaphyseal spike of a triplane fracture compressing the extensor hallucis and peroneus tertius muscle bellies and the deep peroneal nerve against the rigid superior extensor retinaculum. In many cases however, the fibula fracture is higher up and we need additional x-rays to find the fracture. The patients skeletal maturity must be considered in treatment decisions. The force then rotates anteriorly around the ankle to lateral (stage II) and continues behind the ankle (stage III), ending at the medial side of the ankle. Salter-Harris type V injuries are rare or at least tend not to be diagnosed acutely. The exorotation movement produces a direction of force at the front of the ankle (stage I). (b) Volume-rendered CT image in a different patient with a similar injury pattern more clearly depicts a posterior fracture fragment. Figure 14a. The epiphysis is fractured, with a distraction of 3 mm measured at the epiphysis (double-headed arrow). Figure 14c. When the x-rays of the ankle show no obvious fracture like a Weber A or B, then the question is: could this be a Weber C fracture? 4. Foot radiograph findings were unremarkable. MT fractures. Figure 23b. Since repeated attempts at closed reduction can result in physeal damage, they should be performed with caution. There may be an accompanying fibular fracture that does not involve the physis (33). The normal anatomy of the distal tibia (A), as well as type I (B), type II (C), type III (D), type IV (E), and type V (F) Salter-Harris fractures, are depicted. Primary tibial and fibular ossification is present at birth (11). A popping or cracking sound. The rarity of foot fractures among infants and toddlers can be explained by the proportionately larger number of cartilaginous components in their skeleton, which causes the pediatric foot to have high elastic resilience. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Skin tenting signifies soft-tissue injury. Figure 13b. Treatment for this complication is determined on the basis of the size of the physeal bar and the residual growth potential. At first sight it just looks like only a tertius fracture. This is an overview of the stages of ankle fractures. Exorotation of the foot in Weber B results in a oblique push-off fracture because the fibula is held against the talus due to the supination, while in Weber C the fibula is quite loose resulting in a twist-like high fibula fracture. A displaced ankle fracture is where the broken bone fragments are separated. The midfoot locks the hindfoot to the forefoot, enabling flexibility and stiffness. MT fractures. The anteromedial portion of this physis (Kump bump) fuses first, and the anterolateral portion (Chaput tubercle) fuses last. stage 4 is injury to the posterior syndesmosis, which sometimes can not be seen, but will be suspected if there is a widening of the ankle fork or when there is an avulsion of the malleolus tertius like we see in the illustration. Due to the pronation there is enormous stress on the medial collateral bands and thats where the injury will start with either a band rupture or an avulsion of the medial malleolus (stage 1). 2006;37(8):691-7. There was no associated fibular fracture. The bar can be resected if more than 2 years of growth remain and less than 50% of the physeal width is involved. For this reason, diagnosing one ankle fracture should always prompt an active search for a second fracture. (a) AP weight-bearing radiograph of the foot shows a very subtle step-off (arrow) between the intermediate cuneiform bone and second MT bone, which was not visible on the nonweight-bearing views. Vallier et al (58) divided Hawkins type II fractures into two subtypes (IIa and IIb) (Fig 17), which are used to predict the development of osteonecrosis. Step 2If it is not a type A. Mortise radiograph of the ankle shows a Salter-Harris type III fracture of the medial malleolus (arrow) and open growth plates. Better predictor of damage to the syndesmosis. Physis patency is used to explain differences in the injuries sustained by immature versus adult skeletons. At presentation, the patient usually has plantar ecchymosis. Figure 20b. Among these rare injuries, fractures to the talar neck, as classified by Hawkins (Table 4) (57,58), are the most common. The navicular bone ossifies between the ages of 2 and 4 years and may have multiple ossification centers. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Ogden (53) modified the Rowe et al (54) calcaneal fracture classification system, and Sanders et al (55) classified calcaneal fractures on the basis of their CT appearances. A Salter-Harris type IV fracture extends from the metaphysis to the epiphysis. Tibiofibular syndesmotic integrity is usually maintained (46). The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. As in each ring structure, one break will cause another break somewhere in the ring. The distal talar fragment (arrow) is slightly superiorly displaced, while the tibiotalar and talonavicular articulations are congruent. Injury mechanisms include both low-impact injuries and high-impact trauma such as a motor vehicle crash or fall from a significant height. Figure 22. Compartment syndrome is a rare complication of high-energy and complex injuries. A sagittally oriented apophysis (white arrow) at the base of the fifth MT bone also is seen. Table 2: Salter-Harris Classification of Physeal Fractures. The case shows superior extensor retinaculum injury, grade I injuries of lateral ankle ligaments, and avulsion fracture of the anterior calcaneal process. (b) AP postoperative radiograph shows first and second tarsometatarsal arthrodesis and an oblique screw transfixing the Lisfranc joint from the medial cuneiform bone to the base of the second MT bone. There also could be a stage 4 injury to the posterior syndesmosis. Understanding the role of supplemental radiographic projections and cross-sectional imaging, where applicable, can be additionally valuable, ensuring appropriate treatment, imaging follow-up, and patient and parent counseling. The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. It can occur at numerous sites in the body, but some areas are more sensitive to these types of fractures than others, such as at the ankle which mostly occurs at the lateral aspect of the medial malleolus or in the foot where avulsion fractures are common at the base of the fifth metatarsal, but also at the talus and calcaneus. This information is intended to supplement radiologists understanding of developmental phenomena, anatomic variants, fracture patterns, and associated complications that affect the pediatric foot and ankle. ImagesOn the AP-view and the coronal CT-reconstruction we see a Tillaux fracture as stage 1. Records the default button state of the corresponding category & the status of CCPA. Here a typical avulsion or pull-off fracture of the lateral malleolus.The avulsion fragment is quite large. The Ottawa ankle and foot rules (OAFR) (Table 1) represent a clinical decision algorithm for medical imaging in patients suspected of having ankle and midfoot fractures (5). Epidemiology in Olmsted County, Minnesota, 1979-1988, Pediatric foot fractures: evaluation and treatment, A study to develop clinical decision rules for the use of radiography in acute ankle injuries, Complications of Pediatric Foot and Ankle Fractures, Acute fractures of the pediatric foot and ankle, Chopart fractures and dislocations, Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries, The pediatric foot and ankle, Pediatric physeal ankle fracture, Ankle and Foot Injuries in the Young Athlete, Variation of Syndesmosis Anatomy With Growth, Radiographic appearance of the normal distal tibiofibular syndesmosis in children, Syndesmotic ankle sprains in athletes, Ankle syndesmotic injury, Syndesmosis injuries in the pediatric and adolescent athlete: an analysis of risk factors related to operative intervention, Syndesmotic ankle sprains, ACR appropriateness criteria acute trauma to the ankle, Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review, The metaphyseal lesion in abused infants: a radiologic-histopathologic study, Classifications In Brief: Salter-Harris Classification of Pediatric Physeal Fractures, Physeal fractures of the distal tibia and fibula (Salter-Harris Type I, II, III, and IV fractures), Injuries Involving the Epiphyseal Plate, Outcome of distal tibial physeal injuries, Magnetic resonance imaging of clinically suspected Salter-Harris I fracture of the distal fibula. Spinal and extremity radiographs should be obtained if there is clinical suspicion for injury to these areas. (b) Findings on the sagittal CT image of the left ankle confirm partial physeal fusion at the distal tibia (arrows). There is no associated syndesmotic widening. Compared with adults who have calcaneal fractures, children with these injuries have a higher proportion of extra-articular fractures and a better prognosis. Stage III: rupture of posterior tibiofibular ligament, Stage IV: rupture of medial collateral ligament and/or fracture of medial malleolus. Gill and Klassen (30) suggested that the findings in the Boutis et al studies (27,28) should help reduce uncertainty among clinicians, and, by extension, reduce overtreatment.. 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