Transcript introduction - MoKazem.com

Ankle injuries in children
‫د موفق الرفاعي‬
introduction
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Second in frequency
25-38 of physial fractures
Males > females
10-15 years
Physial fractures are more common than
ligamentous injuries in children
Anatomy
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D.T.E appears at 6-12 m & contributes
45% of the tibial growth
Medial malleolous appears at 7y in
females – 8y in males
Physial closure begins at 15y in females –
17y in males and lasts at 18
D.F.E appears at 18-20 m and close at 12
24 m later than the distal tibia
Closure of distal tibial physis
Mechanism of injury & classification
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Anatomic .c
Salter Harris
Mechanism of injury .c
Lauge
Hansen .c
Dias Tachdjian .c
Salter Harris anatomic classification
Dias – Tachdjiac classification
Variations of grade 2 supination - inversion injuries
Severe supination – inversion injury
Stage 1 supination – external rotation
Stage 2 supination – external rotation injury
Pronation – dorsiflection injury
Axial compression - type injury
Diagnostic Features
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Twisting injury
Physical examination: lacerations
open .f
ecchymosis
swelling
Pulse evaluation & neurologic examination
Tenderness over the bony anatomy
especially over distal fibular physis
Radiographic examination:AP-lateralmortize views- stress x ray
Stress radiograph
Secondary ossification center
treatment
Closed reduction: gentle- early- conscious
sedation or general anesthesia
 ORIF : failure of closed reduction
displaced physial fractures
displaced articular fractures
open fractures
fractures with significant tissue
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Injury
 Campbell:
most of salter 3-4 triplane- tillaux
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require ORIF and surgery is
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recommended for 2-3 mm or
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more of displacement
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Salter 1-2 distal fibular .f
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The most common .f of the ankle
Often misdiagnosed as an ankle sprain
Inversion of the supinated foot
Salter 1 12 y
Salter 2 10 y
Treatment:
nondisplaced salter 1
short leg walking cast
4 weeks
displaced salter 1
short leg nonweight
bearing cast 4-6 weeks
salter 2
short leg nonweight bearing cast 46 weeks
Salter 1 tibial .f
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15% - 10 .y
All four mechanisms result in this injury
Fibular fracture in 25%
Gentle reduction & long leg cast 4 weeks
then short leg cast 2 weeks
Salter 2 tibial .f
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The most common 40% - 12.5 y
Supination – external rotation
Supination – planter flextion
Fibular f. in 20%
Reduction requires a reversal of the mechanism
Thurston holland fragment is helpful in
determining the mechanism of injury
posterior fragment
supination – planter
flexion
lateral fragment
pronation – external
rotation
posteromedial fragment
supination –
external rotation
treatment
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Nondisplaced:
long leg cast 4 w
short leg cast 3 w
Displaced:
gentle closed reduction knee flexion 90 + planter flexion
of foot
axial rotation [ with the deformity then opposite] long leg
cast 4 w then short leg cast 3 w
Supination – external r:
the foot in internal rotation
Supination – planterflexion :
the foot in dorsiflexion
the patient should be relaxed during reduction
Balance between repeat closed reductions & acceptance
of the reduction
Salter 3 distal tibial f.
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20%
11-12
Supination – inversion injury
the epiphyseal f. is always medial to the medline
Fibular f. in 25%
Nondisplaced
long leg cast 4 weeks then
short leg cast for 4 weeks with the foot in 5-10
degrees of inversion
Displaced > 2 mm
closed reduction
O.R.I.F [ SCREW ] &
SHORT LEG CAST 6
WEEKS
Results are good ,15% premature physial
closure
Salter 4 distal tibial f.
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Rare injuries [1%]
Supination – inversion injury
The most are displaced
O.R.I.F
The approach is curvilinear
Fixation with screw parallel to the physis
Long leg cast 4 weeks – short leg cast 3 weeks
Radiographic monitoring every 6 monthes
Bioabsorbable pins
Salter 5 distal tibial f.
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Extremely rare
Axial compression
force
Noted after physial
arrest
Compression of the
germinal layer or
vascular or both
complications
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2.
3.
Premature closure of the physis [the
most common 7,7 % ]
Delayed or nonunion
Valgus deformity secondary to malunion
Premature closure of the physis
Injury to the germinal layer
asymmetric
or symmetric growth arrest
 Displaced salter 3 &salter 4
16
12
17m
20m
1,6cm
1,1cm
with varus deformity 15 degree
 Most of them treated with closed reduction [
importance of ORIF
 Follow these patients during first 2 years until
near skeletal maturity
 Osseous bar within the physis
 Park harris growth arrest lines
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Treatment depends on location – size – amount
of growth remaining
Growth remaining >2 years + physial arrest <
50% width of the physis
resect the
osseous bar &replace with cranioplast or adipose
tissue
Metal markers
If the patient is closer to skeletal maturity [
female> 11 y - male> 13 y ]
epiphysiodysis of the lateral aspect of the tibial
physis [ with contralateral epiphysiodysis ]
Varus deformity
opening wedge osteotomy
of the tibia with osteotomy of the fibula
Varus deformity
Valgus deformity secondary to malunion
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Inadequate reduction of pronation –
eversion –external rotation injury
Valgus tilt > 15-20 degree will not correct
by remodeling
distal medial
epiphysiodesis [screw across the medial
physis]
Valgus deformity
Nonunion & delayed union
The Tillaux fracture
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Fracture of the lateral portion of the distal tibial
end
2,9% - asymmetric closure of the physis [
centrally
medially
laterally ]
External rotation stretches the inferior
tibiofibular ligament
salter 3 fracture
Treatment
closed reduction or ORIF
ORIF : displacement> 2mm following closed
reduction or the fracture is seen more than 2 -3
days following injury with > 2mm displacement
Fixation with 4mm screw anterolateral to
potseromedial
The Triplane fracture
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6-8%
10-16 y [13,5 ]
Supination – external rotatoin
Fibular fracture 50%
Coronal – sagittal – transverse
Three parts t.f.
Two parts t.f.
Four parts t.f.
Extra articular triplane f.
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2.
Intramalleolar intraarticular
f. within the weight bearing
zone
Intramalleolar intraarticular
f.outside weightbearing zone
3. Extraarticular fracture .
Treatment of triplane f.
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The goal is anatomic reduction of articular
surface
Nondisplaced or minimal displacement
axial
traction + casting with internal rotation of the
foot if the fracture is lateral or eversion if it is
medial [ 4 weeks then short leg cast 3 weeks ]
Fibular fracture should be reduced first
ORIF indications: failure to achieve adequate
reduction [ within 2mm ]
displaced f. > 3mm at time of initial evaluation
Campbell : two parts fracture –closed reduction
[ salter 4 ] & 3 part fracture needs ORIF [
salter3 first then salter2 ]
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• This lecture is one of a series of lectures were prepared and
presented by residents in the department of orthopedics in
Damascus hospital, under the supervision of Dr. Bashar Mirali.
• This site is not responsible of any mistake may exist in this
lecture.
Dr. Muayad Kadhim
‫ مؤيد كاظم‬.‫د‬