Ankle Fracture

Ossification

 

Distal tibia

- appears by 2 years

- closed at maturity

- asymmetrical closure

- central initially, then posteromedial to anterolateral

- accounts for Tillaux and Triplanar fractures

 

Distal fibula

- appears by 2 years

- closes 2 years after distal tibia

 

Medial Malleolar Extension

- begins age 7

- closes age 10

 

Types of Fractures

 

SH I

SH II

SH III - medial malleolus / Tillaux

SH IV

Triplanar

SH V

 

Salter Harris I

 

SH 1 Distal FibulaPaediatric Distal Tibia Salter Harris 2

 

Incidence

 

15% of distal tibial physeal fractures

Distal fibular most common

 

Mechanism

 

Through zone hypertrophy

 

Management

 

Operative if require realignment

 

Salter Harris II                                                

 

SH2 distal tibia 1SH2 distal tibia 2

 

Epidemiology

 

40% of distal tibial physeal fractures

 

Pathology

 

Thurston-Holland fragment

- large metaphyseal component

 

Non operative Management

 

Acceptable distal tibial alignment

Short leg case 6 weeks

 

Operative Management

 

SH2 distal tibia 3SH2 distal tibia 4

 

Unacceptable alignment

 

Attempt closed reduction

- sometimes anterior periosteum can block reduction

- anterior approach / remove periosteum / reduce fracture

 

Unstable reduction

- screws into Thurston Holland fracture if large enough

- if fragment too small need fixation across medial malleolus into metaphysis

 

Late presentation 7-10 days

- may be best left

- prevent damage physis

- later osteotomy if needed

 

Complications

 

LLD

- complete growth arrest

 

Angular deformity

- partial growth arrest

- uneven Harris growth lines

 

Salter Harris III / Medial Malleolus

 

 

Issues

 

2 problems

- articular disruption

- possible physeal bar

 

Management

 

ORIF any > 2mm step

- physeal cannulated screws

 

Complications

 

Joint incongruity

Growth arrest

 

Salter Harris III / Tillaux

 

Tillaux Fracture CT Coronal Tillaux Fracture CT Sagittal

 

Definition

- SHIII of anterolateral distal tibia

- epiphyseal avulsion of AITFL

- supination / ER injury

 

Incidence

- usually near skeletal maturity

- transitional fracture

- as distal tibial physis is closing

- anterolateral fragment is last to close

 

Tillaux Fracture ORIF

 

Management

 

ORIF

- reduce articular step / prevent physeal bar

- anterolateral incision to reduce

- either anterolateral 4 mm cannulated screw or

- place screw percutaneously from medial side

 

Salter Harris IV

 

 

Incidence

- 25%

- usually associated with triplanar

 

Complications

- bony bar

- articular step

 

Management

 

ORIF > 2 mm step

- restore articular surface

- reduce risk of bar

 

Triplanar Fracture

 

Triplanar AP

 

Definition

- fracture in coronal, sagittal and transverse planes

- 2, 3 or 4 part

 

Varieties

 

2 part

- can be medial or lateral based of site of main distal fragment

- typically anterolateral epiphysis attached to posterior metaphysis

- anteromedial intact distal tibia

 

3 part

- additional separate anterolateral epiphysis / Tillaux

 

4 part

- additional separate metaphyseal fragment

 

Extra-articular

- fracture extends into medial malleolus

 

Xray

 

Type III / Tillaux on AP

Type II on lateral

 

CT

 

Type III on coronal

Type II on sagittal

3 point star on axial

 

Management

 

ORIF

- > 2mm displacement

- usually anterolateral approach to reduce

- epiphyseal medial-lateral screw

- metaphyseal AP screw

 

Complications

 

Growth arrest 10%

 

Salter Harris V

 

Usually late diagnosis

Growth arrest / LLD