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Pediatric Ankle & Foot Fractures Steven Rabin, MD Revised: March 2011 Original authors (2004): Laura Phieffer, MD & Steven Frick, MD Revised (2006): Steven.

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Presentation on theme: "Pediatric Ankle & Foot Fractures Steven Rabin, MD Revised: March 2011 Original authors (2004): Laura Phieffer, MD & Steven Frick, MD Revised (2006): Steven."— Presentation transcript:

1 Pediatric Ankle & Foot Fractures Steven Rabin, MD Revised: March 2011 Original authors (2004): Laura Phieffer, MD & Steven Frick, MD Revised (2006): Steven Frick, MD

2 Pediatric Ankle Fractures

3 Epidemiology 2nd most common site of physeal fractures in children Most occur between ages 8 - 15 y.o. Boys > girls Direct and indirect mechanisms of injury

4 Anatomy All ligamentous structures attach distal to the physis Ligaments are stronger than physis and bone Physeal injury more common than ligament injury Anterior Tibio-fibular ligament important in transitional fractures when the physis is closing

5 Ankle Anatomy Distal tibia ossification center appears between 6 - 24 months Distal fibula ossification center appears between 9 - 24 months Medial malleolar extension appears at about 7 years

6 Physeal Closure Distal tibia physis closes: –About age 12-15 yrs girls –About age 13-17 yrs boys Medial malleolus extension appears ~10 yrs Asymmetric closure over ~18 months –Tibia physis closes in center first then medially and posteriorly. –Anterolateral portion of physis is the last to close Closure of the distal fibula physis follows distal tibia physeal closure by ~12-24 months

7 Distal Tibial Physeal Closure

8 Age / Fracture Pattern Spiegel P, et al. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.

9 Classification Anatomic Salter-Harris –High interobserver correlation –Correlated with outcomes

10 Classification - Ankle Fractures Mechanism of injury: Dias L, Tachdjian M. Physeal injuries of the ankle in children: classification. Clin Orthop Relat Res. 1978;136:230- 3.

11 Diagnosis - Ankle Fractures Direct/indirect mechanisms Acute/subacute May have subtle exam findings Differentiate sprain from non-displaced fracture by location of tenderness –(Pain over the physis/bone = physeal injury) –(Pain over the soft tissues = sprain)

12 Imaging of Ankle Fractures Radiographs - AP, LAT, Mortise –know normal anatomic variants Stress radiographs CT scan – to assess articular involvement MRI – role not well defined Bone Scan – if in doubt about an accessory ossification center vs. an acute fracture

13 Accessory Ossification Centers – Smooth Borders Accessory ossification centers usually appear between ages of 7 to 10 yrs Fuse by skeletal maturity Medial (os subtibiale) in 20% of patients Lateral (os subfibulare) in 1% of patients

14 Treatment Considerations Location of fracture Mechanism of injury Degree of displacement Age of child (how much growth remains) –Distal tibia physis contributes: 3-4 mm growth per year 35-45% of overall tibial length

15 Salter-Harris Type I Fracture Typically occur in younger pts Seen with all mechanisms (SI, SPF, SER, PER) Often missed initially (dx sprain): –Physis weaker than ligaments so physeal injury is more common than a sprain Xrays –Acute – often normal except for soft tissue swelling over physis –Subacute - reveal widening of physis- healing

16 Salter I Distal Tibia Fractures: Treatment Less than 3 mm displacement –Cast –4-6 weeks depending on the patients age Greater than 3 mm displacement –Gentle closed reduction and casting –Usually require anesthesia –If interposed soft tissue, must be removed –If unstable, pin fixation may be needed. –More likely to be unstable if fibula also fractured Follow x-rays for 6-12 months to evaluate for premature physeal closure

17 Salter I Fracture Distal Tibia Salter I fracture of the distal tibia (with metaphyseal fibula fracture) Treated with closed reduction and pin fixation

18 Salter-Harris Type II Fractures Most common distal tibia Fx type Seen with all mechanisms (SI, SPF, SER, PER) Mechanism deduced by –Direction of displacement of the tibial epiphysis, –Type of associated fibula fx –Location of metaphyseal spike

19 Salter-Harris Type II fractures: Treatment Non-displaced fractures –Short leg cast (SLC) for 3 weeks –Then walking SLC for 3 weeks Displaced fractures –Avoid repeated attempts at reduction –If unstable consider a long leg cast for 2-3 weeks, otherwise a short leg cast for 3-4 weeks then a short leg walking cast for 2-3 weeks (depending on age) –Open reduction infrequently indicated –Follow for growth arrest

20 Salter II Fracture of the Distal Tibia Salter II fracture of the distal tibia –treated with closed reduction and cannulated screw fixation

21 Salter-Harris Type I & II fxs If reduction is incomplete, how much residual displacement is acceptable? –Carothers and Crenshaw (1955) accurate reposition of the displaced epiphysis at the expense of forced or repeated manipulation or operative intervention is not indicated Carothers C, Crenshaw A. Clinical significance of a classification of epiphyseal injuries at the ankle. Am J Surg. 1955;89(4):879-89.

22 Salter-Harris Type I & II fxs If reduction is incomplete, how much residual displacement is acceptable? –Spiegel (1978) correlated Salter-Harris classification with risk of shortening, angular deformity and joint incongruity recommended precise anatomical reduction Spiegel P, et al. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.

23 Salter-Harris Type I & II fxs Differing opinions regarding indication for open reduction for interposition of periosteum => widening with minimal angulation –Kling (1984) –Phieffer (2000)- Animal model –Barmada (2005) believes interposed periosteum leads to growth disturbance -Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57. -Phieffer et al. Effect of interposed periosteum in an animal physeal fracture model. Clin Orthop Relat Res. 2000;376:15-25. -Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23(6):733-9.

24 Closed reduction with incomplete reduction because of interposed soft tissues – removed at ORIF

25 Salter-Harris Type I & II fxs Displaced subacute (>7-10 days out) fxs –Residual displacement may have to be accepted –If growth does not sufficiently correct malunion, corrective osteotomy performed

26 Salter II Fracture of the Distal Tibia

27 Salter-Harris Type III & IV fxs Mechanism of injury similar for both fx patterns (typically supination-inversion) Usually produced by medial corner of talus being driven into the junction of distal tibial articular surface and the medial malleolus Can see central and lateral fx patterns

28 Salter-Harris Type III & IV fxs Treatment and prognosis are similar Anatomic restoration of the articular surface is a high priority Medial pattern appears to be at higher risk for developing partial growth arrest and subsequent varus deformity -Spiegel P, Cooperman D, Laros G. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50. -Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57. -Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to the ankle. Foot Ankle. 1991;11(6):372-83.

29 Salter-Harris Type III & IV fxs Non-displaced fractures (<1 mm) –Cast for 3-4 wks => SLWC x 3 wks –May need CT after cast placement to assess displacement –Follow with x-rays in cast to assure no displacement –Percutaneous fixation is an option –Follow for growth arrest

30 Salter IV Minimally Displaced Distal Tibia Fracture *Fixation avoids physis

31 Salter-Harris Type III & IV fxs Displaced fractures (>2 mm) –Require Anatomic reduction –Closed reduction under general anesthesia – If continued > 2 mm displacement => open reduction –Open reduction with epiphyseal fixation parallel to growth plate if possible, especially if significant growth remaining –Postop: Cast (NWB) for 3-4 wks => SLWC x 3 wks –Follow for growth arrest: 15% incidence of growth arrest even with anatomic reduction

32 Salter III Injury- Closed reduction with percutaneous internal fixation

33 Salter IV Distal Tibia Fracture

34 Salter-Harris Type III & IV fxs Subacute displaced fxs –Accept up to 2 mm displacement –Greater than 2 mm displacement Goal to restore joint congruity Recommend reduction regardless of time from injury Debridement and interposition graft, if necessary

35 Delayed diagnosis Salter IV medial malleolus fracture in 6 yr multi-trauma patient Initial radiographs 15 days out from injury

36 ORIF 16 days after injury Anterior approach

37 Note Harris growth line parallels physis and increased distance between markers – normal growth Nine months post-operative

38 Salter-Harris Type V fxs Crush injury to physis No associated displacement Diagnosis made with follow-up xrays revealing premature physeal closure Treatment directed primarily at sequelae of growth arrest

39 High energy injuries to distal tibia Uncommon Severe injury to distal tibial articular surface – poor prognosis Restore articular surface, if possible Length and alignment – bridging external fixation can be helpful

40 High energy distal tibia fracture/subluxation 11 year old female in MVC

41 CT scan demonstrates significantly comminuted articular surface and anterior subluxation of talus

42 Intraop views – bridging external fixation and ORIF with pin fixation

43 One Year Follow Up

44 12 Year Old – High Velocity GSW – loss of tibial epiphysis/anterior soft tissues/tendons - bridging external fixator - latissimus free flap -ankle fusion

45 Transitional Fractures Fractures occurring during asymmetric closure of distal tibial physis –Triplane fx Fracture appears to be in multiple planes May be 2, 3 or 4 part fractures –Tillaux fx Fracture of the anterolateral epiphysis

46 Transitional Fractures Triplane fx –Tend to be seen in younger pts than those with Tillaux fx –More displacement/swelling –Appear as Salter III on AP view and Salter II on lateral view –Treatment decisions usually based on articular displacement –CT scan often helpful

47 Triplane Fractures Combination of Salter II and III fractures: usually near end of growth (Complex type IV fracture) Anterior epiphseal fracture with large posteriomedial metaphyseal fragment…fibula may also be fractured

48 Triplane Fractures Results Overall results are good following adequate reduction –Von Laer (1985) –Clement and Warlock (1987) - Good early results –Erlt (1988) - Decline in results over time -von Laer L. Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia. J Bone Joint Surg Am. 1985;67(5):687-98. -Clement D, Worlock P. Triplane fracture of the distal tibia. A variant in cases with an open growth plate. J Bone Joint Surg Br. 1987;69(3):412-5. -Ertl J, Barrack R, Alexander A, VanBuecken K. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg Am. 1988;70(7):967-76.

49 Triplane Fractures Non-displaced –Cast (NWB) 3-4 wks, then SLWC x 3-4 wks –Monitor in cast to assure no displacement –FU x-rays every 6-12 months for 2 to 3 yrs to assess for growth arrest

50 Triplane Fractures Displaced Triplane Fractures (>2 mm) –Anatomic reduction required –If closed reduction successful Cast: consider a long leg cast with 30 of knee flexion and foot internally rotated, if unstable –If closed reduction unsuccessful => ORIF Reduction/internal fixation done in step-wise fashion with small fragment or 4.0 cannulated screws –Postop - SLC x 3-4 wks, then SLWC x 3 wks

51 Adequate Imaging Helps CT gives 3D visualization of fracture patterns Essential for planning

52 Triplane Fracture Surgical Correction

53 Transitional Fractures Juvenile Tillaux fractures –Patients tend to be older than those with triplane fx –Fibula prevents marked displacement: may be subtle –Local tenderness at anteriolateral joint line –Mortise view essential –May need CT scan –Although literature based on small series, excellent results with anatomic reduction noted

54 Tillaux Fractures Treatment Non-displaced –Cast (NWB) x 3 wks, then SLWC x 3-4 wks –CT scan after cast placement may be needed to assure no displacement –Radiographs in cast to assure no re-displacement in cast –Follow-up x-rays obtained every 6-12 months for 2 to 3 yrs to assess for growth arrest

55 Displaced (>2mm) Tillaux fxs –Anatomic reduction required –If closed reduction achieved Long leg cast with knee flexed 30 degrees and foot internally rotated if unstable –If closed reduction unsuccessful Attempt closed reduction under anesthesia If still unsuccessful, may use k-wires to joystick Tillaux fragment (percutaneously or open) Fixation with small fragment or 4.0 cannulated screws –Postop - SLC x 3-4 wks, then SLWC x 3 wks Tillaux Fractures Treatment

56 Tillaux Fracture Example Child with ankle pain: –Fracture difficult to see

57 Tillaux Fracture Example CT shows a Salter III (Tillaux) fracture of the distal tibia –Tillaux fractures occur near the end of growth as medial portion of distal tibial physis closes before the lateral side closes

58 Tillaux Fracture Example Post-operative and healed x-rays after hardware removal: no residual deformity

59 Other Distal Tibial Fractures Injury to accessory ossification centers Treatment SLWC 3-4 weeks – Ogden (1990) Good results 26/27 patients with injuries involving the medial side 5/11 pts with injuries involving the lateral side had persistent symptoms requiring excision Ogden JA, Lee J. Accessory ossification patterns and injuries of the malleoli. J Pediatr Orthop. 1990;10(3):306-16.

60 Distal Fibula Fractures Typically Salter-Harris I or II fractures –When isolated, usually minimally displaced Can treat with a SLWC for 3-4 wks –Significant displacement occurs more often with Salter III and IV distal tibial fractures Usually reduces with tibial reduction –If fracture is unstable Can usually fix with smooth intramedullary or oblique k-wires Sometimes plate fixation, especially if comminuted.

61 Salter I Distal Fibula typical goose egg swelling over distal fibula with tenderness over distal fibular physis

62 Pediatric Ankle Sprains Should be diagnosis of exclusion Tenderness should be over the ligaments If tenderness is over the physis, may be a Salter I ankle fractures or non-displaced calcaneus fracture Treatment as with any sprain: rest, ice, elevation, and splint until comfortable.

63 Ankle Fractures Prognosis Depends on mechanism of injury –Higher energy, worse prognosis –Greater comminution, worse prognosis Depends on age of the patient –Less chance for re-modeling if older Often poor outcome with –Medial distal tibial physeal injuries –Residual articular step off Presence of an associated fibular fracture– has no prognostic significance

64 Ankle Fractures Complications Growth arrest –Can occur with any fracture pattern –Most often with Salter III and IV fractures –Usually seen 6 to 18 months after injury (but as late as 2 yrs after injury)

65 Ankle Fractures Complications Growth arrest –Occur in fractures treated operatively and non-op –Radiographic Harris growth lines Allow for earlier intervention Look for in x-rays 6-12 weeks –LLD tolerated well –Angular deformity less well tolerated

66 Growth Arrest Treatment: –Observation if near end of growth –Monitor and epiphysiodesis or bar resection depending on deformity –Osteotomy if persistent deformity after growth has ceased.

67 Physeal Injury Simulating Bone Tumor Arrow points to growth arrest line

68 Other Complications of Ankle Fractures Arthritis Malunion Delayed/nonunion AVN distal tibial epiphysis (rare)

69 10 year old – 3 months after distal Tibia fracture

70 CT shows anterior central bar

71 Ankle Fractures Summary Heterogenous group of fractures Age dependent Important to have high index of suspicion to avoid missing diagnosis Correlate physical exam and x-ray findings Follow until skeletal maturity May develop late sequelae

72 Pediatric Foot Fractures

73 Epidemiology Often missed 5-8% of all pediatric fractures Reductions of fractures important –Less remodeling potential –Reach 50% of mature length of foot bones by 18 mo. (compared to femur/tibia - do not reach until 3 yrs)

74 Pediatric Foot Fractures Types of foot injuries 1 –Metatarsal fractures 90% –Phalangeal fractures 18% –Navicular fractures 5% –Talar fractures 3% –Calcaneal fractures 3% –Cuboid fractures 2% 1 Data from Cleveland Fracture Service, A.Crawford (Skeletal Trauma)

75 Pediatric Foot Anatomy Hindfoot: talus, calcaneus Midfoot: navicular, cuboid, 3 cuneiforms Forefoot: –5 metatarsals (distal epiphyses except for 1 st MT - proximal epiphysis) Distal 1 st Metatarsal pseuodoepiphysis may occur –14 phalanges (proximal epiphyses) Variable number of sesamoids/accessory ossicles

76 Foot Accessory Ossicles

77 Radiographs AP, lateral, oblique XR of foot AP, lateral, oblique XR of ankle as well Co-existent unrecognized fractures of distal tibia/fibula occur in up to 8% patients with foot fractures Comparison views of opposite foot may be helpful

78 Talus Fractures Less than 1% of all pediatric fractures: –56 % = Avulsion fractures –20% = Osteochondral lesions –19% = Talar neck fractures –6% = Talar body fractures Jensen et al. Prognosis of fracture of the talus in children: 21 (7-34)- year follow-up of 14 cases. Acta Orthop Scand 1994;65:398-400.

79 Talus Avulsion fractures Usually require only symptomatic treatment Splint, cast or brace for comfort Usually healed in 2-3 weeks Kay R, Tang C. Pediatric foot fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9(5):308-19.

80 Lateral or Medial Process Talus Fractures Lateral/medial process fractures –Rarely displace –Symptomatic treatment only –Non-unions rare Usually asymptomatic, if they occur

81 Talar Dome Fracture Example: 14 year old girl. Treatment: similar to an adult.

82 Talar Dome Fracture Fixation

83 Talar Neck & Body Fractures Rare injuries Neck fractures most common with apex plantar angulation Monitor for 1 year for possible AVN (rare)

84 Pediatric Talus Neck Fractures Hawkins Classification (same as in adults) –Type I = nondisplaced –Type II = displaced talar neck involving subtalar joint –Type III = displaced talar neck fractures involving both ankle and subtalar joints –Type IV = displaced talar neck fractures involving ankle, subtalar and talo-navicular joints Hawkins LG: Fractures of the neck of the talus. J Bone Joint Surg 52A:991–1002, 1970. Canale ST, Kelly FB: Fractures of the neck of the talus, long term evaluation of seventy one cases. J Bone Joint Surg 60A:143–156, 1978.

85 Talar Neck Fractures If nondisplaced –Treatment is non-weightbearing in a above-knee cast for 6-8 weeks. If displaced –Treatment may include ORIF –Angulation < 5 degrees acceptable –> 5 degrees angulation requires reduction under general anesthesia –Displaced (>2mm) fractures at the articular surface require ORIF Kay R, Tang C. Pediatric foot fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9(5):308-19.

86 Hawkins 2 Talar Neck Fracture with Distal Fibula Avulsion Example: Talar neck fracture Distal fibula avulsion with ankle instability.

87 Talar Neck Fracture with Distal Fibula Avulsion ORIF of both fractures –To restore stability

88 Displaced talar neck fracture with medial and lateral malleolar fractures Initial x-rays Postop x-rays - Anatomic reduction required (same as in adults)

89 Talar Neck Fracture (with bi-malleolar fractures) Complication: – Avascular Necrosis –Less common than in adults but can still occur –Long term follow-up necessary

90 Peritalar Dislocations in Children Extremely rare injury (case reports only) Represent dislocation of subtalar and talonavicular joints Four types based on direction of foot –Medial most common –Also lateral, anterior, posterior Adults – usually have an associated displaced talar neck fracture –But in children, isolated dislocations more common

91 Peritalar Dislocations in Children Often associated foot fracture Attempt closed reduction –Open reductions associated with ultimate decreased ROM Associated intra-articular fracture of talonavicular joint adversely affects outcome No reported cases of associated AVN

92 Osteochondral Talus Fractures Osteochondral fractures –Inversion/plantar flexion injury Posteromedial lesion (more common) –Eversion/dorsiflexion injury Anterolateral lesion Often require MRI for diagnosis Non-displaced lesion => NWB in cast Displaced lesion => excision/currettage

93 Osteochondral Lesions (Osteochondritis dissecans) Classification –Type I lesions are nondisplaced. –Type II lesions are partially detached. –Type III lesions are detached but not displaced. –Type IV lesions are detached and displaced or rotated. Berndt AL, Harty M: Transcondylar fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg 41A:988–1020, 1959.

94 Osteochondral Lesions Treatment Splint/non-weightbearing for 1-2 months – The initial treatment for all but type IV for 1 to 2 months. No contact sports for another 2-3 months If no symptomatic and/or radiographic improvement by 3 to 4 months, –Drilling, debridement, or arthroscopic fixation may be indicated. Higuera, et al. Osteochondritis dissecans of the talus during childhood and adolescence. J Pediatr Orthop 1998;18:328-332.

95 Ankle sprain that didnt heal- Anterolateral Talar Osteochondral Lesion

96 Calcaneal Fractures Rare – 2% of all pediatric foot fractures Result of significant falls 5% associated with lumbar spine injuries Often missed diagnosis –Difficult to diagnosis if non-displaced Extra-articular fractures are more frequent –Approximately 65% of calc fxs in children Bone scan can confirm diagnosis Kay R, Tang C. Pediatric foot fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9(5):308-19.

97 Treatment Calcaneal Fractures Treat soft tissues first with elevation Non-displaced injuries –NWB with Jones dressing then cast when soft tissue swelling subsides –Weightbearing in 3-6 weeks Displaced injuries –ORIF when soft tissues amenable Acceptable displacement not well-defined Adolescents - same indications as adults Brunet JA: Calcaneal fractures in children. Long-term results of treatment. J Bone Joint Surg 82B:211–216, 2000. Inokuchi S, Usami N, Hiraishi E, Hashimoto T: Calcaneal fractures in children. J Pediatr Orthop 18:469–474, 1998.

98 Other Tarsal Fractures Fractures of the navicular, cuboid and cuneiforms –2-7% of pediatric foot fractures –Usually avulsion injuries Immobilize 2-3weeks –If high energy trauma, may have associated LisFranc and other fractures Watch closely for compartment syndrome May need ORIF Kay R, Tang C. Pediatric foot fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9(5):308-19.

99 Lisfranc Injuries (Tarsal-metatarsal fractures/dislocations) Direct/indirect mechanisms of injury Represent significant force –Fracture of base of 2nd MT - implies more severe injury –Associated cuboid fx - implies dislocation Treatment - requires anatomic reduction –Treat soft tissues first with elevation –Closed reduction/pinning vs. ORIF –Beware of compartment syndrome

100 Lisfranc Injuries Same treatment classification and options as in adults. Residual pain reported in up to 22% of pediatric patients. Johnson GF. Pediatric Lisfranc injury: Bunk bed fracture. AJR Am J Roentgenol. 1981;137:1041-1044. Wiley JJ: Tarso-metatarsal joint injuries in children. J Pediatr Orthop. 1981;1:255-260.

101 Metatarsal Fractures Most common pediatric foot fracture (60%) –5 th metatarsal base is most frequent Usually caused by direct trauma –Except base of 5 th more often avulsion Metatarsal shaft fractures most common –Lateral displacement – acceptable (if Lisfranc joint intact) –Significant dorsal/plantar angulation not acceptable, requires closed reduction/pinning Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

102 Metatarsal Fractures 1st metatarsal fractures –Can see buckle fracture just distal to proximal physis (treatment – SLWC x 3 wks) –Do not confuse pseudoepiphysis at distal end with fracture Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

103 Metatarsal Fractures 5th metatarsal fractures –Proximal metaphyseal transverse fractures most common –Treatment SLWC x 6 wks –Distinguish from Jones fractures Occur in proximal diaphysis Occur in older children (15 - 20 y.o.) –Do not confuse os vesalianum (os peronei) with fracture (oblique orientation proximally) Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

104 Metatarsal Fractures Metatarsal base fractures –Require significant force –Consider early fasciotomy if significant swelling/venous congestion in toes No reported compartment pressures to guide Use clinical judgment Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

105 Metatarsal Fractures and Growth Deformity Physeal fractures of the base of the first metatarsal may cause abnormal growth with shortening of the first ray. Overgrowth may also occur after metatarsal fractures. –Overgrowth is more common than growth inhibition Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

106 Growth Plate Injuries Treatment of Physeal Injuries –Non-displaced SLWC x 4-6 wks –Displaced Finger-trap traction until swelling subsides then percutaneous pinning Open reduction if unable to obtain adequate alignment Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

107 Pediatric Phalangeal Fractures 18% of childrens foot fractures –2/3 involve proximal phalanges –1/3 middle phalanges –Rarely distal phalanges Treatment –Traction, closed reduction, buddy taping, hard sole shoe Open injures require I&D/IV antibiotic –Osteomyelitis can occur

108 Pediatric Phalangeal Fractures Great toe distal phalangeal fractures –Beware of crush injuries –May represent open fractures –If suspect open injury, treat with I&D and antibiotics to avoid complication of osteomyelitis Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury 1995;26:537-538.

109 Lawnmower Injuries Common cause of pediatric open fractures 70% are bystanders Occur with all types of mowers but majority are riding mowers. Distribution of injuries –Head/eye 24% –Upper extremity 36% –Lower extremity 39% Alonso JE, Sanchez FL. Lawn mower injuries in children: A preventable impairment. J Pediatr Orthop. 1995;15:83-89.

110 Lawnmower Injuries Highly contaminated injuries –Initial irrigation & debridment/antibiotic coverage –Repeat debridements until wound is clean

111 Lawn Mower Injuries May require internal or external fixation of fractures Attempt coverage by 7-14 days, if possible >50% require skin grafting or flap coverage Dormans JP, Azzoni M, Davidson RS, Drummond DS. Major lower extremity lawn mower injuries in children. J Pediatr Orthop. 1995;15:78-82.

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113 Lawn Mower Injuries High complication rate –Infection –Growth arrest –Amputation rates 16-78% > 50% unsatisfactory results Dormans JP, Azzoni M, Davidson RS, Drummond DS. Major lower extremity lawn mower injuries in children. J Pediatr Orthop. 1995;15:78-82.

114 Lawnmower Injuries Long-term follow-up Late deformity may occur –Muscle imbalances from loss of soft tissue attachments –Due to growth arrest and asymmetric growth.

115 Needs Long Term Follow-up Varus Deformity of the first ray –This deformity likely to progress due to muscle imbalances and medial over-growth (intact 1 st MT,PP,DP and 2 nd MT physes) without lateral growth (loss of 3 rd, 4 th, and 5 th MT physes)

116 Lawn Mower Injuries Difficult area to obtain adequate durable soft tissue coverage May require revisions of flaps or skin grafts –Insensate –Potential for graft breakdown –May need special shoes/orthotics/fillers –Orthotics & fillers may need yearly replacement. Dormans JP, Azzoni M, Davidson RS, Drummond DS. Major lower extremity lawn mower injuries in children. J Pediatr Orthop. 1995;15:78-82.

117 Lawnmower Injuries Education/ Prevention key Children –< 14 years old shouldnt operate a lawnmower –And no riders other than mower operator –Small children should not be present in yard while mower is being operated Return to Pediatrics Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.orgota@aaos.org

118 Bibliography Review Articles Kay R, Tang C. Pediatric foot fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9(5):308-19. Ribbans WJ, Natarajan R, Alavala S. Pediatric foot fractures. Clin Orthop Relat Res. 2005 Mar;(432):107-15. Original Articles Alonso JE, Sanchez FL. Lawn mower injuries in children: A preventable impairment. J Pediatr Orthop. 1995;15:83-89. Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23(6):733-9. Berndt AL, Harty M: Transcondylar fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg. 41A:988–1020, 1959. Brunet JA: Calcaneal fractures in children. Long-term results of treatment. J Bone Joint Surg. 82B:211–216, 2000.

119 Bibliography Canale ST, Kelly FB: Fractures of the neck of the talus, long term evaluation of seventy one cases. J Bone Joint Surg. 60A:143–156, 1978. Carothers C, Crenshaw A. Clinical significance of a classification of epiphyseal injuries at the ankle. Am J Surg. 1955;89(4):879-89. Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to the ankle. Foot Ankle. 1991;11(6):372-83. Clement D, Worlock P. Triplane fracture of the distal tibia. A variant in cases with an open growth plate. J Bone Joint Surg Br. 1987;69(3):412-5. Dias L, Tachdjian M. Physeal injuries of the ankle in children: classification. Clin Orthop Relat Res. 1978;136:230-3. Dormans JP, Azzoni M, Davidson RS, Drummond DS. Major lower extremity lawn mower injuries in children. J Pediatr Orthop. 1995;15:78-82. Ertl J, Barrack R, Alexander A, VanBuecken K. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg Am. 1988;70(7):967-76. Hawkins LG: Fractures of the neck of the talus. J Bone Joint Surg. 52A:991– 1002, 1970.

120 Bibliography Higuera J, Laguna R, Peral M, Aranda E, Soleto J: Osteochondritis dissecans of the talus during childhood and adolescence. J Pediatr Orthop. 1998;18:328-332. Inokuchi S, Usami N, Hiraishi E, Hashimoto T: Calcaneal fractures in children. J Pediatr Orthop. 18:469–474, 1998. Jensen et al. Prognosis of fracture of the talus in children: 21 (7-34)-year follow- up of 14 cases. Acta Orthop Scand. 1994;65:398-400. Johnson GF. Pediatric Lisfranc injury: Bunk bed fracture. AJR Am J Roentgenol. 1981;137:1041-1044. Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57. Ogden JA, Lee J. Accessory ossification patterns and injuries of the malleoli. J Pediatr Orthop. 1990;10(3):306-16. Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children. Injury. 1995;26:537-538. Phieffer et al. Effect of interposed periosteum in an animal physeal fracture model. Clin Orthop Relat Res. 2000;376:15-25.

121 Bibliography Spiegel P, Cooperman D, Laros G. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50. von Laer L. Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia. J Bone Joint Surg Am. 1985;67(5):687-98. Wiley JJ: Tarso-metatarsal joint injuries in children. J Pediatr Orthop. 1981;1:255-260. Return to Pediatrics Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.orgota@aaos.org


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