1. Ankle injuries in children د موفق الرفاعي

2. introduction Second in frequency Second in frequency 25-38 of physial fractures 25-38 of physial fractures Males > females 10-15 years Males > females 10-15 years Physial fractures are more common than ligamentous injuries in children Physial fractures are more common than ligamentous injuries in children

3. Anatomy D.T.E appears at 6-12 m & contributes 45% of the tibial growth D.T.E appears at 6-12 m & contributes 45% of the tibial growth Medial malleolous appears at 7y in females – 8y in males Medial malleolous appears at 7y in females – 8y in males Physial closure begins at 15y in females – 17y in males and lasts at 18 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 D.F.E appears at 18-20 m and close at 12 24 m later than the distal tibia

4. Closure of distal tibial physis

5. Mechanism of injury & classification Anatomic.c Salter Harris Anatomic.c Salter Harris Mechanism of injury.c Lauge Hansen.c Mechanism of injury.c Lauge Hansen.c Dias Tachdjian.c Dias Tachdjian.c

6. Salter Harris anatomic classification

7. Dias – Tachdjiac classification

8. Variations of grade 2 supination - inversion injuries

9. Severe supination – inversion injury

10. Stage 1 supination – external rotation

11. Stage 2 supination – external rotation injury

12. Pronation – dorsiflection injury

13. Axial compression - type injury

14. Diagnostic Features Twisting injury Twisting injury Physical examination: lacerations Physical examination: lacerations open.f open.f ecchymosis ecchymosis swelling swelling Pulse evaluation & neurologic examination Pulse evaluation & neurologic examination Tenderness over the bony anatomy especially over distal fibular physis Tenderness over the bony anatomy especially over distal fibular physis Radiographic examination:AP-lateral- mortize views- stress x ray Radiographic examination:AP-lateral- mortize views- stress x ray

15. Stress radiograph

16. Secondary ossification center

17. treatment Closed reduction: gentle- early- conscious sedation or general anesthesia Closed reduction: gentle- early- conscious sedation or general anesthesia ORIF : failure of closed reduction ORIF : failure of closed reduction displaced physial fractures displaced physial fractures displaced articular fractures displaced articular fractures open fractures open fractures fractures with significant tissue fractures with significant tissue. Injury Campbell: most of salter 3-4 triplane- tillaux. require ORIF and surgery is. recommended for 2-3 mm or. more of displacement Campbell: most of salter 3-4 triplane- tillaux. require ORIF and surgery is. recommended for 2-3 mm or. more of displacement

18. Salter 1-2 distal fibular.f The most common.f of the ankle The most common.f of the ankle Often misdiagnosed as an ankle sprain Often misdiagnosed as an ankle sprain Inversion of the supinated foot Inversion of the supinated foot Salter 1 12 y Salter 1 12 y Salter 2 10 y Salter 2 10 y Treatment: Treatment: nondisplaced salter 1 short leg walking cast 4 weeks nondisplaced salter 1 short leg walking cast 4 weeks displaced salter 1 short leg nonweight bearing cast 4-6 weeks displaced salter 1 short leg nonweight bearing cast 4-6 weeks salter 2 short leg nonweight bearing cast 4- 6 weeks salter 2 short leg nonweight bearing cast 4- 6 weeks

19. Salter 1 tibial.f 15% - 10.y 15% - 10.y All four mechanisms result in this injury All four mechanisms result in this injury Fibular fracture in 25% Fibular fracture in 25% Gentle reduction & long leg cast 4 weeks then short leg cast 2 weeks Gentle reduction & long leg cast 4 weeks then short leg cast 2 weeks

20. Salter 2 tibial.f The most common 40% - 12.5 y The most common 40% - 12.5 y Supination – external rotation Supination – external rotation Supination – planter flextion Supination – planter flextion Fibular f. in 20% Fibular f. in 20% Reduction requires a reversal of the mechanism Reduction requires a reversal of the mechanism Thurston holland fragment is helpful in determining the mechanism of injury Thurston holland fragment is helpful in determining the mechanism of injury posterior fragment supination – planter flexion posterior fragment supination – planter flexion lateral fragment pronation – external rotation lateral fragment pronation – external rotation posteromedial fragment supination – external rotation posteromedial fragment supination – external rotation

21. treatment Nondisplaced: Nondisplaced: long leg cast 4 w long leg cast 4 w short leg cast 3 w short leg cast 3 w Displaced: Displaced: gentle closed reduction knee flexion 90 + planter flexion of foot 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 axial rotation [ with the deformity then opposite] long leg cast 4 w then short leg cast 3 w Supination – external r: Supination – external r: the foot in internal rotation the foot in internal rotation Supination – planterflexion : Supination – planterflexion : the foot in dorsiflexion the foot in dorsiflexion the patient should be relaxed during reduction the patient should be relaxed during reduction Balance between repeat closed reductions & acceptance of the reduction Balance between repeat closed reductions & acceptance of the reduction

23. Salter 3 distal tibial f. 20% 11-12 20% 11-12 Supination – inversion injury Supination – inversion injury the epiphyseal f. is always medial to the medline the epiphyseal f. is always medial to the medline Fibular f. in 25% 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 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 Displaced > 2 mm closed reduction O.R.I.F [ SCREW ] & O.R.I.F [ SCREW ] & SHORT LEG CAST 6 SHORT LEG CAST 6 WEEKS WEEKS Results are good,15% premature physial closure Results are good,15% premature physial closure

25. Salter 4 distal tibial f. Rare injuries [1%] Rare injuries [1%] Supination – inversion injury Supination – inversion injury The most are displaced O.R.I.F The most are displaced O.R.I.F The approach is curvilinear The approach is curvilinear Fixation with screw parallel to the physis Fixation with screw parallel to the physis Long leg cast 4 weeks – short leg cast 3 weeks Long leg cast 4 weeks – short leg cast 3 weeks Radiographic monitoring every 6 monthes Radiographic monitoring every 6 monthes Bioabsorbable pins Bioabsorbable pins

27. Salter 5 distal tibial f. Extremely rare Extremely rare Axial compression force Axial compression force Noted after physial arrest Noted after physial arrest Compression of the germinal layer or vascular or both Compression of the germinal layer or vascular or both

28. complications 1. Premature closure of the physis [the most common 7,7 % ] 2. Delayed or nonunion 3. Valgus deformity secondary to malunion

29. Premature closure of the physis Injury to the germinal layer asymmetric or symmetric growth arrest Injury to the germinal layer asymmetric or symmetric growth arrest Displaced salter 3 &salter 4 Displaced salter 3 &salter 4 16 12 16 12 17m 20m 17m 20m 1,6cm 1,1cm 1,6cm 1,1cm with varus deformity 15 degree with varus deformity 15 degree Most of them treated with closed reduction [ importance of ORIF Most of them treated with closed reduction [ importance of ORIF Follow these patients during first 2 years until near skeletal maturity Follow these patients during first 2 years until near skeletal maturity Osseous bar within the physis Osseous bar within the physis Park harris growth arrest lines Park harris growth arrest lines

31. Treatment depends on location – size – amount of growth remaining Treatment depends on location – size – amount of growth remaining Growth remaining >2 years + physial arrest 2 years + physial arrest < 50% width of the physis resect the osseous bar &replace with cranioplast or adipose tissue Metal markers 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 ] 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 opening wedge osteotomy of the tibia with osteotomy of the fibula

32. Varus deformity

33. Valgus deformity secondary to malunion Inadequate reduction of pronation – eversion – external rotation injury 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 tilt > 15-20 degree will not correct by remodeling distal medial epiphysiodesis [screw across the medial physis]

34. Valgus deformity

35. Nonunion & delayed union

37. The Tillaux fracture Fracture of the lateral portion of the distal tibial end Fracture of the lateral portion of the distal tibial end 2,9% - asymmetric closure of the physis [ centrally medially laterally ] 2,9% - asymmetric closure of the physis [ centrally medially laterally ] External rotation stretches the inferior tibiofibular ligament salter 3 fracture External rotation stretches the inferior tibiofibular ligament salter 3 fracture Treatment closed reduction or ORIF 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 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 Fixation with 4mm screw anterolateral to potseromedial

41. The Triplane fracture 6-8% 10-16 y [13,5 ] 6-8% 10-16 y [13,5 ] Supination – external rotatoin Supination – external rotatoin Fibular fracture 50% Fibular fracture 50% Coronal – sagittal – transverse Coronal – sagittal – transverse

42. Three parts t.f.

43. Two parts t.f.

44. Four parts t.f.

45. Extra articular triplane f. 1. Intramalleolar intraarticular f. within the weight bearing zone 2. Intramalleolar intraarticular f.outside weightbearing zone 3. Extraarticular fracture.

46. Treatment of triplane f. The goal is anatomic reduction of articular surface 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 ] 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 Fibular fracture should be reduced first ORIF indications: failure to achieve adequate reduction [ within 2mm ] ORIF indications: failure to achieve adequate reduction [ within 2mm ] displaced f. > 3mm at time of initial evaluation 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 ] Campbell : two parts fracture – closed reduction [ salter 4 ] & 3 part fracture needs ORIF [ salter3 first then salter2 ]

49. MoKazem.com هذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل الأطباء المقيمين في شعبة الجراحة العظمية في مشفى دمشق, تحت إشراف د. بشار ميرعلي. الموقع غير مسؤول عن الأخطاء الواردة في هذه المحاضرة. 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. د. مؤيد كاظمDr. Muayad Kadhim