Heterotopic Ossification

							          Pediatric Ankle &
           Foot Fractures

                Steven Rabin, MD
                    Revised: March 2011




Original authors (2004): Laura Phieffer, MD & Steven Frick, MD
               Revised (2006): Steven Frick, MD
Pediatric Ankle Fractures
            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
                          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
           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
               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
Distal Tibial Physeal Closure
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.
              Classification
               Anatomic
• Salter-Harris
  – High
    interobserver
    correlation
  – Correlated with
    outcomes
 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-
     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)
      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
     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
       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
          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
         Salter I Distal Tibia Fractures:
                    Treatment
• Less than 3 mm displacement
   – Cast
   – 4-6 weeks depending on the patient’s 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
      Salter I Fracture Distal Tibia
• Salter I fracture of the
  distal tibia (with
  metaphyseal fibula
  fracture)
• Treated with closed
  reduction and pin
  fixation
    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
        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
 Salter II Fracture of the Distal Tibia
• Salter II fracture
  of the distal tibia
   – treated with
     closed reduction
     and cannulated
     screw fixation
   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.
   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.
    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.
 Closed reduction with incomplete
reduction because of interposed soft
    tissues – removed at ORIF
   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
    Salter II Fracture of the Distal Tibia

•
 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
 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.
 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
Salter IV Minimally Displaced
     Distal Tibia Fracture




               *Fixation avoids physis
 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
Salter III Injury- Closed reduction
with percutaneous internal fixation
Salter IV Distal Tibia Fracture
 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
Delayed diagnosis Salter IV medial malleolus
    fracture in 6 yr multi-trauma patient
• Initial radiographs 15 days out from injury
• ORIF 16 days after injury
• Anterior approach
  Note Harris growth line parallels physis and
 increased distance between markers – normal
                    growth
• Nine months post-operative
      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
 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
 High energy distal tibia
   fracture/subluxation
11 year old female in MVC
CT scan demonstrates significantly
 comminuted articular surface and
   anterior subluxation of talus
 Intraop views – bridging external
fixation and ORIF with pin fixation
One Year Follow Up
    12 Year Old – High Velocity GSW
– loss of tibial epiphysis/anterior soft tissues/tendons
              - bridging external fixator
                 - latissimus free flap
                      -ankle fusion
           “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
         “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
             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
           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.
          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
           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
         Adequate Imaging Helps
• CT gives 3D visualization
  of fracture patterns
• Essential for planning
            Triplane Fracture
• Surgical Correction
          “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
      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
      Tillaux Fractures Treatment
• 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 Fracture Example
• Child with
  ankle pain:
   – Fracture
     difficult to see
           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
     Tillaux Fracture Example
• Post-operative and healed x-rays after hardware
  removal: no residual deformity
   “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.
       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.
          Salter I Distal Fibula
typical “goose egg” swelling over distal fibula
   with tenderness over distal fibular physis
       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.
                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
              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)
             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
               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.
Physeal Injury Simulating Bone
            Tumor




               • Arrow points to growth arrest line
    Other Complications of Ankle
             Fractures
•   Arthritis
•   Malunion
•   Delayed/nonunion
•   AVN distal tibial
    epiphysis (rare)
10 year old – 3 months after distal
          Tibia fracture
CT shows anterior central bar
            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
Pediatric Foot Fractures
              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)
            Pediatric Foot Fractures
• Types of foot injuries1
    –   Metatarsal fractures    90%
    –   Phalangeal fractures    18%
    –   Navicular fractures      5%
    –   Talar fractures          3%
    –   Calcaneal fractures      3%
    –   Cuboid fractures         2%
•   1Data from Cleveland Fracture Service, A.Crawford
    (Skeletal Trauma)
          Pediatric Foot Anatomy
• Hindfoot: talus, calcaneus
• Midfoot: navicular, cuboid,
  3 cuneiforms
• Forefoot:
   – 5 metatarsals (distal epiphyses
     except for 1st MT - proximal
     epiphysis)
      • Distal 1st Metatarsal
        pseuodoepiphysis may occur
   – 14 phalanges (proximal
     epiphyses)
• Variable number of
  sesamoids/accessory ossicles
Foot Accessory Ossicles
              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
              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.
      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.
     Lateral or Medial Process
          Talus Fractures
• Lateral/medial process fractures
  – Rarely displace
  – Symptomatic treatment only
  – Non-unions rare
     • Usually asymptomatic, if they occur
      Talar Dome Fracture
• Example: 14 year old girl.
• Treatment: similar to an adult.
        Talar Dome Fracture
• Fixation
  Talar Neck & Body Fractures
• Rare injuries
• Neck fractures most common with apex
  plantar angulation
• Monitor for 1 year for possible AVN (rare)
  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.
          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.
Hawkins 2 Talar Neck Fracture with
     Distal Fibula Avulsion
• Example: Talar neck fracture
• Distal fibula avulsion with ankle instability.
   Talar Neck Fracture with Distal
          Fibula Avulsion
• ORIF of both
  fractures
   – To restore
     stability
Displaced talar neck fracture with medial
     and lateral malleolar fractures
 • Initial x-rays
 • Postop x-rays - Anatomic reduction required
   (same as in adults)
         Talar Neck Fracture
     (with bi-malleolar fractures)
• Complication:
  – Avascular Necrosis
  – Less common than in
    adults but can still occur
  – Long term follow-up
    necessary
 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
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
  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
        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.
       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.
Ankle sprain that didn’t heal-
    Anterolateral Talar
   Osteochondral Lesion
             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.
  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.
       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.
             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
           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.
            Metatarsal Fractures
• Most common pediatric foot fracture (60%)
  – 5th metatarsal base is most frequent
• Usually caused by direct trauma
  – Except base of 5th 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.
         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.
         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.
         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.
   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.
            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.
  Pediatric Phalangeal Fractures
• 18% of children’s 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
  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.
          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.
           Lawnmower Injuries
• Highly contaminated
  injuries
  – Initial irrigation &
    debridment/antibiotic
    coverage
  – Repeat debridements
    until wound is clean
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.
         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.
        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.
   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 1st
    MT,PP,DP and 2nd MT
    physes) without lateral
    growth (loss of 3rd, 4th, and
    5th MT physes)
               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.
                       Lawnmower Injuries
     • Education/ Prevention key
     • Children
           – < 14 years old shouldn’t operate a lawnmower
           – And no riders other than mower operator
           – Small children should not be present in yard
             while mower is being operated

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                          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.
                           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–
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                           Bibliography
• Higuera J, Laguna R, Peral M, Aranda E, Soleto J: Osteochondritis dissecans of
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• 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
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• 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.
                                  Bibliography
• Spiegel P, Cooperman D, Laros G. Epiphyseal fractures of the distal ends of the
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• von Laer L. Classification, diagnosis, and treatment of transitional fractures of
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  1981;1:255-260.




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                                                     E-mail OTA        Return to
updates to any of the following slides, please                         Pediatrics
                                                       about
send an e-mail to ota@aaos.org                    Questions/Comments     Index