I. The systems used to classify clinically important fractures, including the Salter-Harris, Dias-Tachdjian, Rapariz, and Hawkins systems, are described, with illustrations that reinforce key concepts. Figure 22b. Toe Fractures.Phalangeal fractures account for up to 18% of all foot fractures and are most commonly Salter-Harris type I or type II injuries. 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). Arch Surg. (b) Sagittal reformatted CT image of the right foot of an 11-year-old boy who fell from a roof shows a posterior extra-articular nondisplaced calcaneal fracture (arrow). The forefoot includes the MT and phalangeal bones and their articulations. In addition, lateral fibular translation increases and fibular external rotation decreases (14). Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. In their classification system, type I fractures are characterized by a narrow fracture line and no intramedullary sclerosis, type II fractures have a wider fracture line with evidence of intramedullary sclerosis, and type III fractures are characterized by complete obliteration of the medullary cavity by sclerotic bone. 5, 2022 Radiological Society of North America, https://doi.org/10.1148/radiology.138.1.7455097. Figure 20. Initial foot radiograph findings (not shown) were unremarkable. There also could be a stage 4 injury to the posterior syndesmosis. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-48969. For example, necrotizing fasciitis can be seen with calcaneal fractures that are related to lawn mower injuries (48). Developing apophysesfor example, those developing at the fifth MT basecan be mistaken for avulsion fractures. (c) Mortise radiograph of the ankle in a 17-year-old boy shows a further decreased medial clear space (black arrow), developing tibiofibular overlap (single-headed white arrow), and a further increased fibular width (double-headed arrow). Certain fracture types have been identified as being associated with an overall higher risk of complications (Table 5). They are connected by 3 ligaments (the medial/lateral collateral ligaments and the interosseous ligament). Normal developmental appearances of the ankle with age in three boys. (b) Lateral hindfoot radiograph shows the multipartite, fragmented, sclerotic appearance of a developing calcaneal apophysis. Transverse ligaments connect the bases of the lateral four MT bones but not the bases of the first and second MT bones. An x-ray does not exclude ligament damage. ATFL = anterior tibiofibular ligament. 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). Thickening of the anterior talofibular ligament and calcaneofibular ligament without loss of continuity. An associated complete fracture through the distal fibula (*), with medial displacement of the detached distal fibular epiphysis, also is present. Tiny bone avulsed fracture from the distal fibula and an anatomical variant, os subfibulare. Posteroanterior, lateral, and axial radiographic views are obtained routinely, with an oblique view recommended to visualize anterior process fractures (51). Fractures of the lateral process of the talus in children, The snowboarders foot and ankle, Talar Fractures and Dislocations: A Radiologists Guide to Timely Diagnosis and Classification, Fractures of the neck of the talus: long-term evaluation of seventy-one cases, Avascular necrosis of the talus: a pictorial essay, Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer, Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment, The toddlers cuboid fracture, MR imaging features of cuboid fractures in children, Making sense of lisfranc injuries, Radiographic Anatomy of the Pediatric Lisfranc Joint, Lisfranc injury in adolescents, The diagnosis and treatment of injuries to the Lisfranc joint complex, Lisfranc injuries in children and adolescents, Pediatric Forefoot Fractures: Assessment of Fracture Patterns and Predictors of Complicated Outcome, A study of metatarsal fractures in children, A study of metatarsal fractures in children, Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection, Jones fractures and related fractures of the proximal fifth metatarsal, Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management, Obesity in Pediatric Trauma, Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor, Outcome of physeal and epiphyseal injuries of the distal tibia with intra-articular involvement. Comparison of the modified Brostrom procedure for chronic lateral ankle instability with and without subfibular ossicle. Distal tibial metaphyseal fractures in a 25-day-old male newborn who presented with multiple sites of skin bruising and lethargy. Fractures of the body tend to occur in the sagittal and horizontal planes after major trauma such as a motor vehicle collision. 3, 2022 Radiological Society of North America, Pediatric Ankle Fractures: Concepts and Treatment Principles, Analysis of the incidence of injuries to the epiphyseal growth plate, Physeal fractures. Unable to process the form. Open calcaneal fracture, for which placement of antibiotic calcaneal beads was required, in a 19-year-old patient. Dias-Tachdjian supinationplantar flexion ankle fractures. Osteonecrosis appears radiographically as talar dome sclerosis, and it usually develops a few weeks to 6 months after the fracture manifests (33). The incidence of these fractures is increased in older children (4). Physeal widening was noted at the anterior distal tibia on the accompanying lateral radiograph (not shown). In a prospective cohort study (27) involving 18 children with SH1DF that was diagnosed presumptively by using clinical findings, no Salter-Harris type I fractures were seen at MRI; rather, the majority of the injuries were ligamentous sprains or osseous contusions. (c) Mortise radiograph of the ankle in a 17-year-old boy shows a further decreased medial clear space (black arrow), developing tibiofibular overlap (single-headed white arrow), and a further increased fibular width (double-headed arrow). We use cookies to keep statistics (Google Analytics cookies are completely anonymised), to store preferences, but also for marketing purposes. As in each The syndesmosis consists of the anterior/posterior tibiofibular ligament and the interosseous ligament, The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops, an isolated tertius fracture is very rare. Figure 23b. Unable to process the form. Clin Orthop Relat Res. We have to assume that there also is a rupture of the anterior syndesmosis (stage 2). The treatment of ankle fractures can be surgical or nonsurgical and is focused on restoring articular congruency and functional alignment and the additional, pediatric-specific goal of protecting the physis (86). For instance a tertius fracture is either stage 3 in a Weber B or a stage 4 in Weber C fracture. These stages in Weber B and C always follow a strict order.This means that when you find a stage 3 fracture, there already must be a stage 1 and 2 even if you can't see them.We will discuss these stages in the next chapter. Lisfranc injury in a 17-year-old high school football player, which occurred after another player fell on the back of his heel, causing hyperflexion of his midfoot. Figure 28. Weber B is the most common ankle fracture accounting for 60-70% of all ankle fractures. Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. L = left. AP (a) and lateral (b) ankle image. Anterolateral ankle pain and swelling. According to Bozic et al (15), the medial clear space on anteroposterior (AP) and mortise radiographic views significantly decreases with age (Fig 2) to less than 4 mm in adults. Local soft tissue was swollen. Another important thing to realize is that traction on a ligament results in either a rupture or an avulsion. If multiple MT bones were fractured, they always involved contiguous bones (75). In young children, growth at the distal tibia and fibula is proportionate to that at the knee; however, in adolescents, growth of the proximal tibia and fibula accelerates while ankle growth tapers (1). The two differences between Weber B and C are: Sometimes we are lucky, because the fibula fracture is visible on the x-rays of the ankle.Then we know we are looking at an unstable stage 3 weber C fracture. (b) AP radiograph of the right foot in an 8-year-old girl shows contiguous MT fractures: a nondisplaced second MT bone fracture (arrow) and displaced slightly comminuted third and fourth MT bone fractures (arrowheads). There may be extremely subtle sclerosis or no visible abnormality at radiography, and, thus, MRI may be required (Fig 19). Figure 21. The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops (stage I). (b) Accompanying lateral radiograph shows the dislocation at the tibiotalar joint to be posterior. 2013;33(7):2047-64. It was originally described by Christian Lauge-Hansen, a Danish pathologist in 1950 and later copied by Bernhard Georg Weber in 1972, a member of the AO-group. 2, Radiologic Clinics of North America, Vol. ADVERTISEMENT: Supporters see fewer/no ads. A conservative approach involves appropriate immobilization and protected weight bearing, with serial follow-up radiographs obtained to exclude late displacement in the cast. Analytical cookies are used to understand how visitors interact with the website. 2015;205(5):1061-7. Several systems for classifying calcaneal fractures exist (Fig 16). Among these rare injuries, fractures to the talar neck, as classified by Hawkins (Table 4) (57,58), are the most common. Figure 10a. If the address matches an existing account you will receive an email with instructions to reset your password. Findings on standard nonweight-bearing radiographs of the foot (not shown) were unremarkable. Fracture immobilization can also cause hyperemia and disuse subchondral lucency. The supinationplantar flexion mechanism (Fig 10) is the least common of the Dias-Tachdjian ankle fracture patterns and involves a displaced physeal fracture of the distal tibia without any associated fibular fracture. Intra-articular injuries increase the risk of subsequent arthritis sevenfold (84). A displaced ankle fracture is where the broken bone fragments are separated. A group of distal tibial metaphyseal fractures in very young children are pathognomonic for nonaccidental trauma. These classification systems aid in diagnosis and treatment planning, facilitate communication, and help standardize documentation and research. Open fractures have an overall higher propensity for the development of infection (Fig 24). We, and third parties, use cookies on our website. It involves less than one-third of the mediolateral distance across the epiphysis (33). Primary tibial and fibular ossification is present at birth (11). This is a stage IV pronation-exorotation fracture. Step 1The first question you should ask yourself is:Is it a Weber type A fracture? The case shows superior extensor retinaculum injury, grade I injuries of lateral ankle ligaments, and avulsion fracture of the anterior calcaneal process. Figure 15. They are connected by 3 ligaments (the medial/lateral collateral ligaments and the interosseous ligament). Both the tibiofibular overlap on AP and mortise views and the relative fibular width on AP views increase with age. 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. They may have two, three, or four parts, as shown. In the Hill et al (72) study, 52% of skeletally immature patients had Myerson type B1 injuries, in contrast to 56% of patients with closed physes, who had Myerson type B2 injuries. 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 A Salter-Harris type II fracture involves at least part of the physis width and a contiguous portion of the metaphysis, which create a so-called wedge-shaped Thurston-Holland fragment, which represents a triangular portion of the metaphysis attached to the epiphysis (25). Figure 17b. Most ankle fractures with dislocations require surgical treatment. Open fractures are rare, accounting for just 2% of all ankle fractures. Unlike non-operative treatment of a lateral ligament rupture, non-operative treatment of avulsion fractures do not yield satisfactory results. Symptoms of an ankle avulsion fracture are very similar to an ankle sprain and it is very difficult to diiferentiate without an X-ray or an MRI scan. (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. In view of the widened medial clear space, this is a rupture of the medial collateral ligaments (stage IV). Step 3If it is not type A or type B, then the last question is:Can this be a Weber type C fracture?These fractures are usually not visible on x-rays of the ankle, because the fibula fracture is too high, but the algoritm provides clues for the detection of these fractures. Swelling. A stage II is considered an unstable ankle fracture. However when there is also a vertical or push-off fracture of the medial malleolus, then it is stage 2 and the ankle is unstable, as the ring of stability is broken in two places. 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. Figure 2a. (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). Fracture mimics. 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. Transitional Fractures.A subgroup of pediatric ankle fractures called transitional fractures occur during the 18-month developmental window (in girls aged 1215 years and boys aged 1418 years) that marks the progressive closure of the distal tibial physis, which starts centrally and ends laterally (25). A popping or cracking sound. The abundant blood supply to the tibial plafond makes posttraumatic avascular necrosis of the plafond very rare. In a retrospective review (26) of 725 tibial fractures in children, 31.0% of the cases involved the distal tibial physis, and the majority (56.9%) of these were cases of Salter-Harris type II fracture, 21.7% were cases of Salter-Harris type III fracture, and 20% were cases of Salter-Harris type IV fracture. The ring of stability is broken in two places (scroll). Impaction injuries can give rise to radiographically occult osteochondral fractures of the talar dome (61). Revisiting Radiograph-Negative Ankle Injuries in Children: Is It a Fracture or a Sprain? Tertius avulsion fracture or rupture of posterior syndesmosis, Avulsion fracture of medial malleolus or rupture of medial collateral bands. Figure 13b. Meinberg E, Agel J, Roberts C, Karam M, Kellam J. Fracture and Dislocation Classification Compendium2018. Then continue for a discussion of this case. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Babu V, Feger J, Feger J, et al. Salter-Harris Classification of Physeal Fractures.The most simple and commonly used anatomic classification system for pediatric physeal fractures (12,23,24) is the Salter-Harris system (Table 2, Fig 4) (25). Closed reduction should be attempted for displaced fractures. AP radiograph of both legs obtained as part of a skeletal survey for possible nonaccidental trauma shows bilateral bucket-handle fractures (arrows) at the distal tibiae. (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. Cartilaginous precursors of the immature skeleton can cause normal developmental phenomena to be mistaken for injury and injuries to go unrecognized if they involve the cartilage only. stage 2 is injury to the anterior syndesmosis, which is usually not visible, unless there is a Tillaux fracture. The postoperative ankle fork is once again symmetrical. Bernhard Georg Weber. With this classification, each injury type is assigned a prognostic significance. Associated injury to the peroneus longus tendon may be present. The ankle is a synovial hinge joint that comprises the tibia and fibula, which articulate around the central talus; this complex is referred to as the ankle mortise (8). Necessary cookies are absolutely necessary for the website to function properly. Figure 2c. You may have to click on them to get a larger view. Injury mechanisms include stubbing or kicking injuries, dropped objects falling on the toe(s), and falls from a height. Figure 25. Premature physeal arrest at the distal tibia is one of the most feared complications; rates of up to 66.7% have been reported in the literature (8082). Accessing this course requires a login. Potential Pathologies Associated with Adolescent Ankle Injuries: Triplane fracture in a 13-year-old girl who had left ankle pain and swelling and was unable to bear weight after a roller skating injury. (b) AP radiograph obtained after open reduction and internal fixation with cancellous screw placement across the distal tibia shows a reduced intra-articular gap (arrow). By clicking 'Accept and continue' you agree to the use of all cookies as described in our. 28). Limping or an inability to walk, if the broken bone is It allows the website owner to implement or change the website's content in real-time. By clicking on 'set it yourself', you can read more about our cookies and adjust your preferences. The presence of the Hawkins sign (talar dome subchondral lucency due to resorption) on AP foot radiographs at 68 weeks indicates an intact blood supply. Midtarsal or Transverse Tarsal Joint (Chopart) Injuries.Midtarsal joint injuries occur at the junction between the hindfoot and the midfoot. McFarland (31) described Salter-Harris types III and IV medial malleolar fractures as a distinct category of injuries associated with traumatic arrest of the distal tibia. Is there an avulsion of the lateral malleolus. Joint depression can be assessed at comparisons with the contralateral foot. At first sight it just looks like only a tertius fracture. Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure? This manifestation is followed by a transverse, higher-grade fracture of the fibular diaphysis. Oblique radiograph of the right foot shows a subtle transversely oriented fracture lucency (black arrows) at the base of the right fifth MT bone, signifying a nondisplaced fracture. Weber A is the result of a pull-off or avulsion on the lateral side due to extreme supination of the foot with adduction. (a) AP radiograph of the left ankle shows asymmetric closure (arrows) of the left distal tibial physis. Premature physeal fusion at the distal tibia as a complication of remote Salter-Harris type IV fracture of the distal tibia in a 13-year-old boy. Cuboid fractures represent 5% of all tarsal fractures, and they may be radiographically subtle without a visible lucent line. Figure 23. Loss of syndesmotic integrity has important treatment ramifications: In one study (18), the frequency of surgical intervention for pediatric syndesmotic injuries was increased 44-fold in patients who also sustained an ankle fracture, eightfold in those with a medial clear space more than 5-mm wide, and fivefold in those whose physes were fused. MT fractures. And finally in stage 4 there will be a rupture of the posterior syndesmosis or tertius avulsion (stage 4). There is also a tertius fracture (stage III). 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. (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). 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. Population-based studies suggest that the incidence of ankle fractures has increased dramatically since the early 1960s. Figure 14c. 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. Accessory centers of ossification adjacent to the ankle and foot bones can mimic avulsion fractures on radiographs. After completing this journal-based SA-CME activity, participants will be able to: Characterize fracture patterns that affect the skeletally immature ankle and foot, and the associated imaging findings that may prompt surgical intervention. These injuries represent approximately 13% of all pediatric osseous injuries. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. II. Figure 10b. A subgroup of pediatric ankle fractures called transitional fractures occur during the 18-month developmental window (in girls aged 1215 years and boys aged 1418 years) Lawrence and Botte (77) described three anatomic subgroups, or zones, of proximal fifth MT fractures: zone 1 (tuberosity avulsion fractures), zone 2 (metaphyseal-diaphyseal junction and Jones fractures), and zone 3 (proximal diaphyseal stress fractures). When the broken bones break through the skin, the injury is called an open or compound fracture. Ankle extensor retinaculum and lateral ligaments injuries - ultrasound, avulsion fracture of the anterior calcaneal process. Although the mean age at which the tibiofibular overlap appeared on the AP view was 5 years in both boys and girls, this overlap appeared on the mortise view in girls at a mean age of 10 years and in boys at a mean age of 16 years (15). You have sustained an avulsion fracture to your ankle, which is treated like a soft tissue injury (sprain) to your ankle. 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. Describes the mechanism of the ankle fracture and is subdivided into 3 groups (supination-adduction, supination-exorotation and pronation-exorotation). This fracture configuration is characteristic of nonaccidental trauma. Figure 14a. In patients who have more than 3 years of growth remaining, premature physeal arrest at the distal tibia should be serially monitored with biannual or annual radiography. Please enter your credentials below! Figure 20a. A Salter-Harris type III (Fig 5) fracture passes along at least part of the physeal width and extends through the contiguous portion of the epiphysis, often reaching the articular surface. Toddlers with calcaneal stress fractures who are just learning to walk refuse to bear weight. Because the midtarsal talonavicular and calcaneocuboid joints act in unison, they are often injured together (10). Weber B starts anterolateral due to the supination of the foot, while Weber C starts on the medial side due to the pronation of the foot. Os sub fibulare is noted (anatomical variant). It works only in coordination with the primary cookie. An approach to reading an ankle radiograph can be read here. Ossification of the hindfoot and midfoot bones proceeds eccentrically in a predictable pattern. Things become very easy once you remember the fixed order of the injuries: The injury mechanism that causes a Weber B fracture can stop at any stage. This is stage 1 and is stable.Lauge-Hansen calls this supination-adduction (SA). 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). Table 2: Salter-Harris Classification of Physeal Fractures. (a) AP radiograph of the ankle shows a medially displaced talar neck fracture (arrow). Weber B and Weber C fractures are very different in the type of fibula fracture. Injuries of the midfoot include fractures of individual bones and fracture dislocations involving the midtarsal (ie, talonavicular and calcaneocuboid) or tarsometatarsal articulations. The authors acknowledge the work of Nadezhda Kiriyak and Jane Lichorowic, Department of Imaging Sciences, University of Rochester, who contributed original artwork to this submission, and Sarah Klingenberger, Department of Imaging Sciences, University of Rochester, for help with the radiologic images. Pediatric ankle and foot fractures, second in incidence to hand and wrist injuries only, account for 13% of all pediatric osseous injuries. 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. Figure 3. Acta Orthop Scand. References Ng J, Rosenberg Z, Calcaneal fractures observed on CT images have been divided into intra- and extra-articular fractures on the basis of the involvement of the posterior facet of the subtalar joint (Fig 15) (48). Better predictor of damage to the syndesmosis. Lindsj U. Operative Treatment of Ankle Fracture-Dislocations. This is always stage 2 and unstable. The ankle is a ring structure consisting of the tibia, fibula and the talus. Injury. (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). CT is the best imaging method for confirming the diagnosis and ruling out intra-articular fractures. (b) Accompanying lateral radiograph also depicts the talar neck fracture. In addition, distal phalangeal fractures that extend through the nail matrix (ie, Pinckney fractures) are considered to be open fractures with a high risk of osteomyelitis if they are not treated adequately. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Fahey and Murphy (47) classified tibiotalar dislocations according to the direction of the dislocation. High twist-like fibula fracture above the level of the syndesmosis. MT fractures alone account for approximately 61% of all foot fractures (5). Combined experimental-surgical and experimental-roentgenologic investigations, Physeal injuries of the ankle in children: classification, Surgically Relevant Patterns in Triplane Fractures: A Mapping Study, The pediatric triplane ankle fracture, The triplane fracture: four years of follow-up of 21 cases and review of the literature, Distal tibial triplane fractures: long-term follow-up, Tibial fractures involving the ankle in children: the so-called triplane epiphyseal fracture, Epiphyseal fractures of the distal ends of the tibia and fibula: a retrospective study of two hundred and thirty-seven cases in children, Pediatric Triplane Ankle Fractures: Impact of Radiographs and Computed Tomography on Fracture Classification and Treatment Planning, Fracture Pattern and Periosteal Entrapment in Adolescent Displaced Distal Tibial Physeal Fractures: A Magnetic Resonance Imaging Study, Long-term result of a pure tibiotalar dislocation in a child, Appendicular joint dislocations, Upward tibiotalar dislocation without fracture: a case report, Dislocations and fractures of the talus, Multidetector CT evaluation of calcaneal fractures, Calcaneal fractures in children: an evaluation of the nature of the injury in 56 children, Fractures of the os calcis in children, Calcaneus fracture in the child, The mechanism, reduction technique, and results in fractures of the os calcis, Skeletal injury in the child, Fractures of the Os Calcis: A Long-Term Follow-up Study of 146 Patients, Operative treatment in 120 displaced intraarticular calcaneal fractures: results using a prognostic computed tomography scan classification, Complications of talus fractures in children, Fractures of the neck of the talus. Spinal and extremity radiographs should be obtained if there is clinical suspicion for injury to these areas. This leaflet explains the ongoing management of your injury. Lateral Ankle Sprain may be associated with: ankle dislocation, distal lateral malleolar avulsion or spiral fracture, medial malleolar fracture, talar neck or medial compression fractures. 2a, b). Since the ankle is a weight-bearing joint, tolerance for residual deformities from ankle and foot fractures is significantly lower than that for deformities related to upper extremity fractures (6). Dias-Tachdjian Classification of Ankle Fractures.In the Dias-Tachdjian classification system, radiologic classification models to describe ankle fractures in adults, including the Lauge-Hansen model (34), are used in conjunction with Salter-Harris classifications to describe injury patterns relative to the physis (35). Navicular fracture in a 14-year-old girl who had dorsal midfoot pain after a twisting injury during soccer. 10, No. Figure 6. In Weber C finding a high fibula fracture means unstable stage 3. Growth arrest is uncommon with types I and II Salter-Harris fractures. As in each ring structure, one break will cause another break somewhere in the ring. Anatomic variants and developmental phenomena can mimic or obscure the diagnosis of osseous and ligamentous trauma in skeletally immature patients (Fig 25). Children who are at risk for these disruptions are those who participate in sports that involve cutting or pivoting movements (eg, soccer and football) or a rigidly immobilized ankle (eg, hockey and skiing) (16,19). When confronted with ankle fractures, remember that fractures may resume their anatomical positions immediately after the trauma. A Salter-Harris type IV fracture of the medial distal tibia (arrow) with a medial Thurston-Holland fragment and some associated comminution also is seen. Drawing illustrates the Dias-Tachdjian classification of growth plate fractures at the ankle. It is our job as radiologists to find clues on the x-rays of the ankle that will lead us to these high fibula fractures and the algoritm will help us. The direction of force rotates around the ankle. 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. The plantar portion of the ligament is the strongest (68). Enter your email address below and we will send you the reset instructions. The hindfoot consists of the talus and calcaneus, which articulate at the subtalar joint. Study these images. An avulsion of the fibular attachment is even more rare. (1972) ISBN: 9783456002071 -. Diffuse thickening of the superior extensor retinaculum. Figure 22a. Although not that common, the injury may proceed and cause a push off fracture on the medial side resulting in a vertical fracture of the medial malleolus . Arthrodesis, which is sometimes used to address Lisfranc fractures in older adolescents and adults, is contraindicated in children with open physes (68). When you see a Weber B fracture, which is always good visible on either the AP- or the lateral view, the only thing you need to check is whether there is an unstable stage 3 with posterior injury or even stage 4 with medial injury. The closure of most physes begins centrally and expands peripherally. The injury mechanism is generally categorized as plantar flexion with inversion. The injury mechanism is often a traffic accident or fall from a height, and the injuring force is a combination of axial compression and shear. The supinationexternal rotation (Fig 8) mechanism first results in a physeal fracture of the distal tibia, with a large and medially to posteromedially based Thurston-Holland fragment. The different types of ankle and foot fractures are described, and the American College of Radiology guidelines used to determine appropriate imaging recommendations for patients who meet the Ottawa ankle and foot rules are discussed. Complex lesions have extensive soft-tissue damage and are more susceptible to neurovascular injuries, infection, and/or compartment syndrome. Describe the complications related to different fracture types to ensure appropriate follow-up and patient and parent counseling. The frequency and severity of these injuries are higher in older children (56). The most common navicular fractures are fractures of the navicular tuberosity, dorsal cortical avulsion, and stress fracture. Oblique fibula fracture at level of syndesmosis. In case of a lateral ankle sprain the report should include the following: 1. Usually this is a rupture of the anterior syndesmosis and we don't see anything on the x-rays, but the patient will have a lot of pain on this specific anterolateral spot. Stage III: rupture of interosseous membrane + high fibular fracture. Figure 19b. The distal tibial physis closes in a unique eccentric pattern, from central to medial to lateral. This is a stage 1 stable Weber A fracture. However, in retrospect, growth arrest occurs in the absence of a prior visualized fracture or in the presence of what initially appeared to be either a Salter-Harris type I fracture or no injury. Pain and swelling at the right ankle and foot since this morning after a twisted ankle while step down the stairs. The ankle transfers force between the foot and the rest of the axial skeleton, enabling stability and foot movement (7). Skin tenting signifies soft-tissue injury. The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. Intra-articular displacement (double-headed arrow) of 3 mm is seen. The associated fracture of the distal fibular shaft (arrow) does not involve the fibular physis. PTFL = posterior tibiofibular ligament. (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. Here and in the lateral radiograph only one small fragment can be seen. 1758. As the exorotation force continues the anterior syndesmosis will rupture (stage 2). Figure 23a. On the enlarge view we also recognize a small avulsion fracture. A Salter-Harris type IV fracture extends from the metaphysis to the epiphysis. The talonavicular and calcaneocuboid articulations form a functional unit referred to as the transverse tarsal joint, midtarsal joint, or Chopart joint. (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. The Chopart joint allows the hindfoot to pivot while the forefoot remains stationary (10), acting together with the subtalar joint to facilitate foot inversion and eversion. Court-Brown C & Caesar B. This is a normal developmental variant; there is no associated soft-tissue swelling. Syndesmotic disruptions are ligamentous, but they may be accompanied by tibial or fibular fractures. 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? 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. 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. Revista Ciencias Biomdicas, Vol. Lateral. (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). Movement at the talonavicular joint is closely linked to subtalar and calcaneocuboid motion (9). Combined Experimental-Surgical and Experimental-Roentgenologic Investigations. In the Bozic et al study (15), the incisura fibularis appeared at a mean age of approximately 8 years in girls and approximately 11 years in boys. 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. Triplane fractures represent a complex, transitional, multiplanar subset of Harris-Salter type IV fractures that occur in adolescents during the portion of the developmental window when asymmetric partial closure of the distal tibial physis has occurred (36). Radiologists must recognize the developmental phenomena, anatomic variants, and fracture patterns and associated complications that affect the skeletally immature foot and ankle. We use cookies to keep statistics (Google Analytics cookies are completely anonymised), to store preferences, but also for marketing purposes. Rupture of anterior syndesmosis or less common Tillaux fracture (avulsion of tibial attachment). The cuneiform bones begin to ossify in the 1st postnatal year. (a) AP radiograph of the ankle shows a medially displaced talar neck fracture (arrow). Disruption of the tibiofibular joint seen on static radiographs signifies syndesmotic injury. The first classification system was proposed by Percival Pott 3, describing fractures in terms of malleoli involved: unimalleolar, bimalleolar, and trimalleolar. Am J Sports Med. There may be an accompanying fibular fracture that does not involve the physis (33). Postreduction radiographs are useful for assessing the adequacy of alignment and physeal reduction. An associated spiral fracture of the fibular shaft (arrowhead) also is present. High fibular fracture and a tertius fracture. 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