Either is acceptable. Acta Orthop Scand. If multiple MT bones were fractured, they always involved contiguous bones (75). Ossification of the lateral distal tibial metaphysis leads to the creation of two separate lines on the AP and mortise views. The central portion closes first. A nondisplaced Salter-Harris type I fracture may manifest with soft-tissue swelling centered over the growth plate and focal clinical tenderness (12). In the same study (75), fractures of the second, third, and fourth MT bones were frequently found to be associated with fractures of another MT bone (Fig 22), whereas the majority of the first and fifth MT bone fractures were isolated. The fracture line then propagates horizontally along the patent physis until it meets the fused physis; at this point, it proceeds through the epiphysis into the joint. 2, Radiologic Clinics of North America, Vol. There may be an accompanying fibular fracture that does not involve the physis (33). Note: in the most severe form (= stage IV), there is ligament damage and/or fracture. Foot radiograph findings were unremarkable. In rare case you may find a vertical fracture of the medial malleolus in combination with a collateral band rupture on the lateral side. Tibiotalar dislocation in a 14-year-old girl that occurred after a trampoline injury. Weber B and Weber C fractures are very different in the type of fibula fracture. Early-manifesting complications of foot and ankle fractures include infection, neurovascular injuries, compartment and extensor retinaculum syndromes, complications of cast placement, and reflex sympathetic dystrophy and/or complex regional pain syndrome (9). (b) Volume-rendered CT image in a different patient with a similar injury pattern more clearly depicts a posterior fracture fragment. https://radiopaedia.org/articles/weber-classification-of-ankle-fractures (b) Accompanying lateral radiograph also depicts the talar neck fracture. This is a normal developmental variant; there is no associated soft-tissue swelling. Injury. Open fracture . 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) AP radiograph of the ankle shows a distal tibial fracture (single-headed arrow) with lateral displacement and slight angulation of the Tillaux fragment. There may be overlap in the fracture types, and treatments should be individualized to specific patients. The practical application of this classification is intended to facilitate closed reduction by immobilizing the ankle in a direction opposite to the direction of the injury. Injuries of the midfoot include fractures of individual bones and fracture dislocations involving the midtarsal (ie, talonavicular and calcaneocuboid) or tarsometatarsal articulations. The Arch Surg. Step 2If it is not a type A. If the force is high enough, the medial malleolus can be pushed away as it were (= vertical fracture) by the rotating talus (stage II) (fig. 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). The patients skeletal maturity must be considered in treatment decisions. Knijnenberg et al (69) found that the distances between the first and second MT bases measured on AP radiographs obtained in skeletally healthy pediatric patients were consistently shorter than 3 mm. (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). In Weber C finding a high fibula fracture means unstable stage 3. Swelling and ecchymosis over the cuboid should raise suspicion of this injury and when other midfoot injuries are present , the cuboid articulations should be carefully inspected for subtle injury. We, and third parties, use cookies on our website. Dias-Tachdjian grade 2 supination-inversion ankle fracture in a 15-year-old boy who sustained an ankle injury after falling from a height. Malunion, which is more frequently seen in older adolescents, can lead to angular and rotational deformities. Stage III: rupture of interosseous membrane + high fibular fracture. 56, No. Centers for Disease Control and Prevention website, Extensor retinaculum syndrome of the ankle after injury to the distal tibial physis, Management of Pediatric Ankle Fractures, Open in Image Check for errors and try again. This is a more common complication of talar fractures when it is associated with displacement or a high-energy injury mechanism (56). 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). Figure 12. However, 2 weeks later, calcaneal tuberosity sclerosis is visible radiographically, with subsequent spontaneous recovery (4). Swelling. 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. Supination-adduction Mechanism (fig. The latter are commonly caused by inversion injuries in the clinical setting of ankle sprains. The supination-inversion (SI), supinationexternal rotation (SER), pronationexternal rotation (PER), and supinationplantar flexion (SPF) mechanisms of injury are depicted. The second break can be a fracture or ligament damage (= sprain/tear/rupture). Normal developmental appearances of the ankle with age in three boys. The ankle transfers force between the foot and the rest of the axial skeleton, enabling stability and foot movement (7). Avulsion Fracture of the Lateral Ankle Ligament Complex in Severe Inversion Injury: Incidence and Clinical Outcome. 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. The force then rotates anteriorly around the ankle to lateral (stage II) and continues behind the ankle (stage III), ending at the medial side of the ankle. Cuboid fractures represent 5% of all tarsal fractures, and they may be radiographically subtle without a visible lucent line. A fracture can easily be overlooked. Juvenile Tillaux fracture caused by a wrestling injury in a 15-year-old boy. Arthrodesis, which is sometimes used to address Lisfranc fractures in older adolescents and adults, is contraindicated in children with open physes (68). 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. Figure 14c. Local soft tissue was swollen. Figure 6. 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). Combined Experimental-Surgical and Experimental-Roentgenologic Investigations. Despite its ease to identify fractures and decreased inter/intraobserver variability, it has been superseded by two systems of classification which takes into consideration the rotational mechanism of injury and the stability of the fracture; each has its own advantages and disadvantages: ADVERTISEMENT: Supporters see fewer/no ads. These dislocations are predominantly posteromedial and associated with disruption of the lateral capsular ligamentous complexes and the fibular physis in children (33). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. In addition, the distance between the medial cuneiform bone and base of the second MT bone has been found to be larger in individuals younger than 6 years (70). Lindsj U. Operative Treatment of Ankle Fracture-Dislocations. (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). (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). 10, No. Table 4: Hawkins-Canale Classification of Talar Neck Fractures. Figure 23b. Impaction injuries can give rise to radiographically occult osteochondral fractures of the talar dome (61). a,b The dorsopalmar radiograph shows an impaction fracture of the radial condyle. 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. 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. A Salter-Harris type IV fracture extends from the metaphysis to the epiphysis. Note: in the 2 most severe forms (= stage III and IV), there is ligament damage and/or fracture.PTFL = posterior tibiofibular ligament. In Weber B there is a oblique oriented push-oof fracture at the level of the syndesmosis, while in Weber C there is a twist-like fracture above the level of the syndesmosis. The patterns seen with extra-articular (A) and intra-articular (B) fractures, and the associated significant soft-tissue injury, bone loss, and loss of Achilles tendon insertion (C), are depicted. They have a bimodal presentation, involving young males and older females. Anterior process fractures are classified into three types: type 1 fractures are small (< 1 cm) and nondisplaced, type 2 fractures have minimal (> 2 mm) displacement and no involvement of Below is an example of a supination-exorotation trauma (fig. Forefoot (toe, phalangeal, and metatarsal [MT]) fractures are the most frequent acute bone injuries of the foot. Salter-Harris type V injuries are rare or at least tend not to be diagnosed acutely. Since this fracture is usually not visible on x-rays of the ankle, you wanna study the ankle x-rays to look for stage 1 and 4, which can be a clue to image the whole lower leg to look for a high fibula fracture. These fractures result from forced dorsiflexion with an axial load after high-energy trauma. Table 2: Salter-Harris Classification of Physeal Fractures. (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. (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). On the enlarge view we also recognize a small avulsion fracture. Figure 2c. Bernhard Georg Weber. These fractures are remarkably displaced and angulated, with lateral translation and apical medial angulation occurring at the distal tibial epiphyseal fragment and apical medial angulation occurring at the fibular shaft fracture (33). Figure 21. A miniscule percentage (0.4%) of these cases were those of Salter-Harris type I fracture (26). Ossification of the anterolateral distal tibial metaphysis leads to the creation of two separate lines in this radiographic projection; the more lateral line (not shown) corresponds to the anterior tibia, and the more medial line is the incisura fibularis (white line), which articulates posteriorly with the fibula. This phenomenon results in muscle weakness and diminished sensation in the first web space (85). Figure 23. Ankle fractures in children can be broadly categorized as avulsion and physeal fractures. 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. CT is useful for assessment of comminuted fractures and small fractures of the anterior process, and for surgical planning. Pediatric ankle and foot fractures, second in incidence to hand and wrist injuries only, account for 13% of all pediatric osseous injuries. 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. 26): Note: this trauma mechanism is also seen in Weber C fractures. Am J Sports Med. The closure then extends to the medial side, while the lateral side closes last. Figures 9. 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. The distal tibial physis closes in a unique eccentric pattern, from central to medial to lateral. (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). This manifestation is followed by a transverse, higher-grade fracture of the fibular diaphysis. 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. Physeal widening was noted at the anterior distal tibia on the accompanying lateral radiograph (not shown). Premature physeal arrest at the distal tibia can result in growth arrest, deformity, and subsequent leg length discrepancy. The highest incidence of ankle fractures occurs in elderly women. Lateral. The fracture line of the distal fibula continues to the level of the horizontal tibiotalar joint (stage II). Lauge-Hansen called this fracture mechanism supination exorotation or SER. 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). This is a stage 2 - unstable bimalleolar Weber A fracture. Ligament damage may be inferred by an abnormal configuration of the ankle fork. Lateral ankle injuries are extremely common, most commonly injury to anterior talofibular (ATFL)and calcaneofibular ligaments (CFL). Exorotation of the foot in Weber B results in a oblique push-off fracture because the fibula is held against the talus due to the supination, while in Weber C the fibula is quite loose resulting in a twist-like high fibula fracture. A Follow-Up Study of 306/321 Consecutive Cases. This mechanism manifests as a nondisplaced Salter-Harris type I or II fracture of the distal fibula that may progress to a Salter-Harris type III or IV injury of the medial malleolus. For example, lack of a tibiofibular overlap on the mortise view can be a normal variant in skeletally immature patients and should not be mistaken for syndesmotic disruption. A Salter-Harris type I physeal fracture passes along the width of the physis and may be visible at radiography if the growth plate is widened or the epiphyseal and metaphyseal components are malaligned. Ankle sprain one month back. Joint depression can be assessed at comparisons with the contralateral foot. Subsequent computed tomography (CT) of the foot confirmed the presence of a minimally displaced, predomi-nately coronal oriented avulsion fracture through the APC (Fig. Population-based studies suggest that the incidence of ankle fractures has increased dramatically since the early 1960s. I. Ankle lateral malleolus avulsion fracture with os subfibulare. Injury mechanisms include stubbing or kicking injuries, dropped objects falling on the toe(s), and falls from a height. Check for errors and try again. The Ottawa ankle and foot rules (OAFR) (Table 1) represent a clinical decision algorithm for medical imaging in patients suspected of having ankle and midfoot fractures (5). (a) AP radiograph of the foot shows a well-corticated accessory navicular bone (arrow), which may be symptomatic and mistaken for a fracture. These cookies help provide information about statistics, number of visitors, bounce rate, traffic source, etc. Forefoot fractures account for 6%10% of fractures in children and involve the toes and MT bones. 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. Revisiting Radiograph-Negative Ankle Injuries in Children: Is It a Fracture or a Sprain? Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Table 5: Pediatric Ankle and Foot Fractures with Highest Risk for Complications. The osseoligamentous complex of the distal tibiofibular syndesmosis stabilizes the ankle mortise. Set by the GDPR Cookie Consent plugin, this cookie is used to store the user consent for cookies in the category "Others". show answer. Tarsometatarsal Joint (Lisfranc) Injuries.The Lisfranc ligament, the major stabilizer of the joint that extends from the medial cuneiform bone to the second MT base, is composed of three bands (dorsal, interosseous, and plantar) that run from the medial cuneiform bone to the base of the second MT bone. Unable to process the form. A nondisplaced fracture with sclerosis of the distal cuboid bone is considered to be a type of toddler fracture (66) (Fig 18). Figure 19a. As the exorotation of the foot continues the distal fibula follows this exorotation movement, while the proximal fibula is held in position at the proximal tibiofibular joint and you get a twist-like fracture somewhere above the level of the syndesmosis (stage 3). The delayed diagnosis of extra-articular calcaneal fractures (50) has been reported. Fracture mimics. The tension in the anterior syndesmosis can sometimes lead to an avulsion of the tibial attachment of the anterior syndesmosis, which is called a Tillaux fracture. Tertius avulsion fracture or rupture of posterior syndesmosis, Avulsion fracture of medial malleolus or rupture of medial collateral bands. There was no associated fibular fracture. Figure 14a. It means that there already is stage 1, because the trauma mechanism always follows this strict order, first stage 1 and then stage 2. Yu S & Yu J. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. Other toe fracture types include shaft and tuft fractures. (a) AP radiograph of the foot shows a well-corticated accessory navicular bone (arrow), which may be symptomatic and mistaken for a fracture. Pott P. Some Few General Remarks on Fractures and Dislocations. Posttraumatic avascular necrosis can complicate certain fracture types, fifth MT proximal shaft fractures (ie, Jones fractures) and talar neck fractures in particular. Weber B is the most common ankle fracture accounting for 60-70% of all ankle fractures. More commonly there is a small avulsion fragment. 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. Figure 24. There may be extremely subtle sclerosis or no visible abnormality at radiography, and, thus, MRI may be required (Fig 19). 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. II. Mechanical irritation or joint instability may cause pain and recurrent ankle sprains [3, 7]. 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. Tibiotalar Dislocation.Pure ankle dislocation without fracture (Fig 14) is a rare injury in skeletally immature children due to the vulnerability of the physes, which fail before the more robust surrounding ligamentous structures do (44). Keep in mind that a tertius fracture can be stage III, and that damage may be more extensive than initially visible on the image, Indications/Requests for Radiological Examination. In young children with syndesmotic injuries, a cutoff value for widened medial clear space of greater than 5 mm (average, 6.4 mm) on the mortise view was found to be the strongest predictor of the need for surgical fixation (18). {"url":"/signup-modal-props.json?lang=gb\u0026email="}, Patel M, Ankle extensor retinaculum and lateral ligaments injuries - ultrasound. Ankle injuries play a major part in functional impairment after multi or polytrauma thereby necessitating a detailed evaluation. Movement at the talonavicular joint is closely linked to subtalar and calcaneocuboid motion (9). 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. (c) AP radiograph obtained after reduction and internal fixation shows restored ankle alignment and placement of a pin to repair the distal fibular physeal fracture. At presentation, the patient usually has plantar ecchymosis. Study these images. Some of the data that are collected include the number of visitors, their source, and the pages they visit anonymously. 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). Fracture mimics. Among these rare injuries, fractures to the talar neck, as classified by Hawkins (Table 4) (57,58), are the most common. 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 to tear during an injury. 28). These fractures are avulsion fractions of the ossification center of the lateral condyle and as such are sometimes referred to as a lateral epicondyle fracture and sometimes as a lateral epicondyle avulsion fracture. Then continue for a discussion of this case. Just by looking at the images, you can understand the trauma mechanism (scroll). 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. (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). Court-Brown C & Caesar B. The direction of force rotates around the ankle. The ankle is stabilized by its bone and ligamentous anatomy. Meinberg E, Agel J, Roberts C, Karam M, Kellam J. Fracture and Dislocation Classification Compendium2018. An approach to reading an ankle radiograph can be read here. As the exorotation force continues the anterior syndesmosis will rupture (stage 2). Die Verletzungen Des Oberen Sprunggelenkes. Comparison of the modified Brostrom procedure for chronic lateral ankle instability with and without subfibular ossicle. 16). https://www.physio-pedia.com/Avulsion_Fractures_of_the_Ankle In that case the ankle is unstable and may dislocate. Drawing illustrates the Dias-Tachdjian classification of growth plate fractures at the ankle. (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). 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. References Ng J, Rosenberg Z, Q: What is the name of this accessory bone? Figure 25a. Below is an example of a pronation-exorotation fracture (fig. MRI can be used to monitor vascularity. Vallier et al (58) divided Hawkins type II fractures into two subtypes (IIa and IIb) (Fig 17), which are used to predict the development of osteonecrosis. Normal anterior inferior tibiofibular and posterior talofibular ligaments. (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. Figure 15a. Ischemia can involve only part of the talar dome, usually the medial aspect, and result in a partial Hawkins sign, usually of the lateral talar dome. Thickening of the anterior talofibular ligament and calcaneofibular ligament without loss of continuity. 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) MT fractures. Figure 21. AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. In view of the widened medial clear space, this is a rupture of the medial collateral ligaments (stage IV). Initial foot radiograph findings (not shown) were unremarkable. Fractures of the cuboid bone or base of the second MT bone are suspicious for accompanying tarsometatarsal joint injury. 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. Certain fracture types have been identified as being associated with an overall higher risk of complications (Table 5). 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). The _ga cookie, installed by Google Analytics, calculates visitor, session and campaign data and also keeps track of site usage for the site's analytics report. The distal talar fragment (arrow) is slightly superiorly displaced, while the tibiotalar and talonavicular articulations are congruent. The fracture types that are amenable to conservative versus surgical treatment are broadly summarized in Tables 6 and 7. This information is intended to supplement radiologists understanding of developmental phenomena, anatomic variants, fracture patterns, and associated complications that affect the pediatric foot and ankle. Intra-articular injuries increase the risk of subsequent arthritis sevenfold (84). The combination of fracture and ligament damage complicates assessment, as ligament damage is not directly visible on x-ray. Both the tibiofibular overlap on AP and mortise views and the relative fibular width on AP views increase with age. Owen et al (74) reported that fifth MT bone fractures were the most common pediatric MT fractures (Fig 21), accounting for approximately 45% of all MT fractures. When the broken bones break through the skin, the injury is called an open or compound fracture. In addition, they may be open or closed. The right image shows a vertical fracture of the medial malleolus (arrow). The subclassification is made based on the level of the fibular fracture in relation to the syndesmosis and the horizontal tibiotalar joint (fig. 53, No. Midtarsal or Transverse Tarsal Joint (Chopart) Injuries.Midtarsal joint injuries occur at the junction between the hindfoot and the midfoot. ImagesOn the AP-view and the coronal CT-reconstruction we see a Tillaux fracture as stage 1. AO/OTA classification of malleolar fractures. The damage starts at the medial side, turns anteriorly along the ankle to lateral, ending at the posterior side. Bony avulsion from anterior calcaneal process at the bifurcate ligament attachment site. Eismann et al (42) advocated the use of CT as an adjunct to radiography for triplane fracture classification, displacement identification, and treatment planning. 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? 03, The Journal of Foot and Ankle Surgery, Vol. The bar can be resected if more than 2 years of growth remain and less than 50% of the physeal width is involved. The plantar portion of the ligament is the strongest (68). Navicular fracture in a 14-year-old girl who had dorsal midfoot pain after a twisting injury during soccer. 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. Talar neck fractures are much more common than talar body fractures, which, in turn, are more common than lateral and posterior process fractures. 2a, b). An associated complete fracture through the distal fibula (*), with medial displacement of the detached distal fibular epiphysis, also is present. Ankle fractures. Compared with adults who have calcaneal fractures, children with these injuries have a higher proportion of extra-articular fractures and a better prognosis. Figure 3. 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. Variable ossification of the navicular bone may be mistaken for Khler disease (33). 1950;60(5):957-85. They are connected by 3 ligaments (the medial/lateral collateral ligaments and the interosseous ligament). A callus (arrowhead) surrounds the left (L) distal tibia. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. Set by the GDPR Cookie Consent plugin, this cookie is used to record the user consent for the cookies in the "Necessary" category . There also could be a stage 4 injury to the posterior syndesmosis. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. (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. It can occur at numerous sites in the body, but some areas are more sensitive to these types of fractures than others, such as at the ankle which mostly occurs at the lateral aspect of the medial malleolus or in the foot where avulsion fractures are common at the base of the fifth metatarsal, but also at the talus and calcaneus. Describe the complications related to different fracture types to ensure appropriate follow-up and patient and parent counseling. 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 authors describe normal developmental phenomena and injury mechanisms of the ankle and foot and associated imaging findings; mimics and complications of acute fractures; and dislocations that affect the pediatric ankle and foot. Better predictor of damage to the syndesmosis. These fractures traditionally have been characterized on the basis of the number of fragments, with two-, three-, and four-part triplane fractures described (3841). The exorotation movement produces a direction of force at the front of the ankle (stage I). 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. Many avulsion fractures are apparent of plain radiographs. Accuracy of Point-of-Care Ultrasonography for Pediatric Ankle Sprain Injuries. Potential Pathologies Associated with Adolescent Ankle Injuries: 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. The syndesmosis consists of the anterior/posterior tibiofibular ligament and the interosseous ligament (fig. Ankle extensor retinaculum and lateral ligaments injuries - ultrasound, avulsion fracture of the anterior calcaneal process. AJR Am J Roentgenol. Viewer, http://www.cdc.gov/arthritis/basics/risk-factors.htm, Acute Fractures and Dislocations of the Ankle and Foot in Children, Pitfalls in MRI of the Developing Pediatric Ankle, Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings, Imaging Review of Normal and Abnormal Skeletal Maturation, Imaging of Sports-related Injuries of the Lower Extremity in Pediatric Patients, Imaging of Acute Capsuloligamentous Sports Injuries in the Ankle and Foot: Sports Imaging Series, Pediatric Foot and Ankle Fractures: Patterns, Mimics, Complications, and Treatment, Dancing Feet: Biomechanism and Imaging Findings of Foot and Ankle Musculoskeletal Injuries in Dancers, Painful Corners of the Ankle: Keeping an Eye on the Periphery. Figure 4. In Weber B stage 2 is stable, but stage 3 and 4 are unstable. Distal tibial physeal closure occurs in a unique eccentric pattern (Fig 1) over a period of 18 months, typically between 12 and 15 years of age in girls and between 14 and 18 years of age in boys. Although calcaneocuboid dislocation is generally less severe compared with talonavicular dislocation, it typically involves severe lateral joint space widening and comminuted calcaneus and cuboid fractures (64). At first sight it just looks like only a tertius fracture. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, All ankle fractures, even the ones that are not visible on the X-rays, Predict rupture of ligaments even if you cant see them on the images, Determine whether the ankle is stable or unstable, just by looking at the radiographs. The Lisfranc ligament connects the plantar base of the second MT bone to the plantar surface of the medial cuneiform bone (8). Myerson (71) classified Lisfranc injuries into three groups, types AC. The hindfoot consists of the talus and calcaneus, which articulate at the subtalar joint. In children, snowboarding has been found to be associated with lateral talar process fractures, which are rare (59,60). Since the Weber-classification is a simplification of the Lauge-Hansen classification, it will help you to understand the different stages of Lauge-Hansen. In this lecture we present a simple algoritm that helps you to find: The algoritm is based on the Weber-classification, because it is simple and everybody knows it. The first classification system was proposed by Percival Pott 3, describing fractures in terms of malleoli involved: unimalleolar, bimalleolar, and trimalleolar. A popping or cracking sound. Mortise radiograph of the ankle shows a Salter-Harris type III fracture of the medial malleolus (arrow) and open growth plates. 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). 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. Open fractures have an overall higher propensity for the development of infection (Fig 24). 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. Important posttraumatic complications include premature physeal arrest, three-dimensional deformities and consequent articular incongruity, compartment syndrome, and infection. In view of marked medial soft tissue swelling, there will also be ligament damage (or an occult fracture). The forefoot includes the MT and phalangeal bones and their articulations. Figure 10b. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Di Muzio B, Ankle lateral malleolus avulsion fracture with os subfibulare. 2018;32(1):S1-S10. Figure 19b. The incidence of these fractures is increased in older children (4). Table 6: Fractures Amenable to Conservative Treatment, Table 7: Indications for Surgical Management of Fractures. 3. Because the midtarsal talonavicular and calcaneocuboid joints act in unison, they are often injured together (10). These fractures represent 0.05%0.15% of all pediatric foot fractures and peak in children aged approximately 812 years. Three standard (AP, oblique, and lateral) radiographic views are usually adequate for the detection of fifth MT fractures. Anatomic variants and developmental phenomena can mimic or obscure the diagnosis of osseous and ligamentous trauma in skeletally immature patients (Fig 25). A sagittally oriented apophysis (white arrow) at the base of the fifth MT bone also is seen. 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. Tiny bone avulsed fracture from the distal fibula and an anatomical variant, os subfibulare. stage 4 is injury to the posterior syndesmosis, which sometimes can not be seen, but will be suspected if there is a widening of the ankle fork or when there is an avulsion of the malleolus tertius like we see in the illustration. There is greater acceptance of postfracture angulation deformity in younger children (33). 5, 2022 Radiological Society of North America, https://doi.org/10.1148/radiology.138.1.7455097. Sedentary level activity and low-energy injury were more common in the avulsion fracture group than in the ligament rupture group (77% vs 37%, respectively, P = .001; 68% vs 43%, respectively, P = .004). Figure 20. Figure 17b. 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. Small bone fragment at the inferior portion of the lateral malleolus is consistent with an avulsed fracture. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. (1972) ISBN: 9783456002071 -. (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). 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. (c) AP radiograph obtained after reduction and internal fixation shows restored ankle alignment and placement of a pin to repair the distal fibular physeal fracture. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Babu V, Feger J, Feger J, et al. 4, Seminars in Roentgenology, Vol. 2015;205(5):1061-7. It allows the website owner to implement or change the website's content in real-time. You have sustained an avulsion fracture to your ankle, which is treated like a soft tissue injury (sprain) to your ankle. Figure 11. (b) Findings on the sagittal CT image of the left ankle confirm partial physeal fusion at the distal tibia (arrows). We have to assume that there also is a rupture of the anterior syndesmosis (stage 2). For this reason, diagnosing one ankle fracture should always prompt an active search for a second fracture. AP radiograph of the left ankle shows a distal tibial Salter-Harris type II fracture with a laterally based metaphyseal Thurston-Holland fragment. In this case there is widening of the medial clear space between the medial malleolus and the talus indicating a rupture of the medial collateral bands (stage 1). Up to 22% of all MT fractures involve the base of the MT bone, and 90% of these injuries occur in children older than 10 years (33). Figure 24. Compartment syndrome is a rare complication of high-energy and complex injuries. Scroll through the images to see how the injury follows a clockwise fixed order. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. MT fractures. Navicular Fractures.Navicular bone fractures are often missed. AP radiograph of the right ankle shows a long spiral tibial fracture (black arrow) that begins laterally at the distal tibial physis. Please enter your credentials below! These articulations act in unison and thus are often injured together. Secondary ossification centers of the MT and phalangeal bones develop when a child is aged 624 months, and the calcaneal apophysis develops when a child is aged 5-12 years (13). 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 The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. Gill and Klassen (30) suggested that the findings in the Boutis et al studies (27,28) should help reduce uncertainty among clinicians, and, by extension, reduce overtreatment.. Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure? Enter your email address below and we will send you the reset instructions. 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. (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. Trauma mechanism of supination-adduction according to Lauge-Hansen. 2, Radiologic Clinics of North America, Vol. In the axial plane you can see that the injury starts on the medial side due to the pronation of the foot and follows a clockwise rotation through anterior and lateral to posterior. Step 1The first question you should ask yourself is:Is it a Weber type A fracture? Tibiofibular syndesmosis is intact/partial rupture. (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). MRI can be performed to assess the integrity of the Lisfranc ligament. The distal talar fragment (arrow) is slightly superiorly displaced, while the tibiotalar and talonavicular articulations are congruent. As in each Check for errors and try again. And finally in stage 4 there will be a rupture of the posterior syndesmosis or tertius avulsion (stage 4). (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. Table 3: Dias-Tachdjian Classification of Physeal Ankle Fractures. Since repeated attempts at closed reduction can result in physeal damage, they should be performed with caution. This is always stage 2 and is unstable, whether you see a fracture of the lateral malleolus or not. Show details Hide details. 1, The Journal of Foot and Ankle Surgery, Vol. When we've answered the above questions, then we end up in one of these three categories.In each of these categories we need to determine the stage of the fracture, which tells us if the ankle is stable or unstable. Ossification of the hindfoot and midfoot bones proceeds eccentrically in a predictable pattern. 4, International Journal of Emergency Medicine, Vol. 21). (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). Most commonly we see stage 2 which is the oblique fibula fracture, but sometimes the injury stops at stage 1. The precarious blood supply of the talus makes this bone vulnerable to osteonecrosis (61), the risk of which correlates strongly with the Hawkins-Canale classification (6163). A displaced ankle fracture is where the broken bone fragments are separated. These fractures involve a significant risk of subsequent growth arrest. (a) AP radiograph of the left ankle shows asymmetric closure (arrows) of the left distal tibial physis. These fracture types are based on the relative positions and associated disruption of the medial malleolar and anterolateral (Tillaux) fragments. 4. Radiologists must recognize the developmental phenomena, anatomic variants, and fracture patterns and associated complications that affect the skeletally immature foot and ankle. stage 1 which is the medial injury, where it all starts. Fahey and Murphy (47) classified tibiotalar dislocations according to the direction of the dislocation. Recognize the developmental phenomena and anatomic variants that may mimic acute ankle and foot fractures in children or hinder diagnosis of these injuries. 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