The subclassification is made based on the level of the fibular fracture in relation to the syndesmosis and the horizontal tibiotalar joint (fig. Owing to fracture obliquity, radiography might not enable these fractures to be assessed completely and CT may be required. AO/OTA classification of malleolar fractures. The midfoot consists of five tarsal bones and their articulations. As in each ring structure, one break will cause another break somewhere in the ring. 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. Injury mechanisms include load toward the heel, shear force across the midfoot, and/or twisting injury. A sagittally oriented apophysis (white arrow) at the base of the fifth MT bone also is seen. Because the midtarsal talonavicular and calcaneocuboid joints act in unison, they are often injured together (10). 56, No. The pronationexternal rotation (Fig 9) fracture pattern manifests as a distal tibial growth plate fracture, frequently with a small laterally based fracture fragment. Persistent physeal widening to greater than 3 mm seen on coronal and sagittal reformatted CT images signifies periosteal entrapment and requires a surgical treatment approach (24). Figure 20. 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. (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 combination of fracture and ligament damage complicates assessment, as ligament damage is not directly visible on x-ray. a,b The dorsopalmar radiograph shows an impaction fracture of the radial condyle. The cuneiform bones begin to ossify in the 1st postnatal year. This is always stage 2 and is unstable, whether you see a fracture of the lateral malleolus or not. Weber B is the most common ankle fracture accounting for 60-70% of all ankle fractures. Figure 14c. They are connected by 3 ligaments (the medial/lateral collateral ligaments and the interosseous ligament). At first sight it just looks like only a tertius fracture. The ring of stability is broken in two places (scroll). The triplanar configuration consists of fracture lines along the coronal plane through the posterior metaphysis, along the sagittal plane through the epiphysis, and along the transverse plane through the physis, which ultimately disrupt the tibial plafond (36). 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. Talus.Talar fractures are rare, accounting for approximately 0.01%0.08% of all pediatric fractures, and can be easily overlooked in children. 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. Initial foot radiograph findings (not shown) were unremarkable. 5, Radiologic Clinics of North America, Vol. Complex lesions have extensive soft-tissue damage and are more susceptible to neurovascular injuries, infection, and/or compartment syndrome. The osseoligamentous complex of the distal tibiofibular syndesmosis stabilizes the ankle mortise. 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) It allows the website owner to implement or change the website's content in real-time. The epiphysis is fractured, with a distraction of 3 mm measured at the epiphysis (double-headed arrow). Ankle lateral malleolus avulsion fracture with os subfibulare. Ankle fractures. Local soft tissue was swollen. There is greater acceptance of postfracture angulation deformity in younger children (33). Intra-articular displacement (double-headed arrow) of 3 mm is seen. Clin Orthop Relat Res. Furthermore, the ossicle may cause limitation of the range of motion of the ankle joint resembling avulsion fractures of the lateral malleolus. (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). 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. The delayed diagnosis of extra-articular calcaneal fractures (50) has been reported. Some of the data that are collected include the number of visitors, their source, and the pages they visit anonymously. (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). 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. A Salter-Harris type IV fracture extends from the metaphysis to the epiphysis. 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). Important posttraumatic complications include premature physeal arrest, three-dimensional deformities and consequent articular incongruity, compartment syndrome, and infection. Although the ankle fork in a Weber B/C fracture is initially symmetrical, there may still be a ligament rupture. CT is useful for assessment of comminuted fractures and small fractures of the anterior process, and for surgical planning. 2015;205(5):1061-7. This is stage 1 and is stable.Lauge-Hansen calls this supination-adduction (SA). Toddlers with calcaneal stress fractures who are just learning to walk refuse to bear weight. Type III and type IV Salter-Harris fractures can lead to growth arrest, deformity, and intra-articular degenerative joint disease (25). If the postreduction alignment remains unacceptable, a prompt assessment for residual growth should be performed and treatment strategies should be determined accordingly. It means that there already is stage 1, because the trauma mechanism always follows this strict order, first stage 1 and then stage 2. -. PTFL = posterior tibiofibular ligament. Ankle sprain one month back. It involves less than one-third of the mediolateral distance across the epiphysis (33). Findings at presentation include pain, swelling, inability to bear weight, and possibly medial plantar ecchymosis. Navicular Fractures.Navicular bone fractures are often missed. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Any pain or soft tissue swelling on the medial side can be a first indication that we are dealing with a Weber C fracture. (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). Pain that spreads to nearby parts of your body. Figure 25b. Standard radiographic talar evaluation consists of acquiring AP, mortise, and lateral views of the ankle and AP, oblique, and lateral views of the foot. 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. 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. Ossification of the hindfoot and midfoot bones proceeds eccentrically in a predictable pattern. 2018;32(1):S1-S10. Traumatic arrest of epiphyseal growth of the lower end of tibia, The trampoline ankle: severe medial malleolar physeal injuries in children and adolescents secondary to multioccupant use of trampolines, Greens Skeletal Trauma in Children, Fractures of the ankle. Study the images.Use the algoritm and ask yourself if it is a Weber A or B or that it could be a Weber C.Then determine the stage. As in each 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. 10, No. 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. Navicular fracture in a 14-year-old girl who had dorsal midfoot pain after a twisting injury during soccer. 2013;33(7):2047-64. Variable ossification of the navicular bone may be mistaken for Khler disease (33). The variably sized tibial Thurston-Holland fragment has a predominantly posterior location. In addition, they may be open or closed. (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). Drawings illustrate various calcaneal fracture patterns in children. 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. 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). Most other physeal closures start centrally and expand peripherally. 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. Ankle extensor retinaculum and lateral ligaments injuries - ultrasound, avulsion fracture of the anterior calcaneal process. Population-based studies suggest that the incidence of ankle fractures has increased dramatically since the early 1960s. (a) AP radiograph of the ankle shows a distal tibial fracture (single-headed arrow) with lateral displacement and slight angulation of the Tillaux fragment. Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. 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. The Lisfranc joint may be widened at standing or stress radiography, or the radiograph findings may be negative owing to incomplete ossification. Meinberg E, Agel J, Roberts C, Karam M, Kellam J. Fracture and Dislocation Classification Compendium2018. 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 closure of most physes begins centrally and expands peripherally. Postreduction radiographs are useful for assessing the adequacy of alignment and physeal reduction. 1758. The ankle is stabilized by its bone and ligamentous anatomy. 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. Drawing illustrates the normal pattern of distal tibial fusion. 26.1a-d Intra-articular fracture of the head of the proximal phalanx. 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. The distal talar fragment (arrow) is slightly superiorly displaced, while the tibiotalar and talonavicular articulations are congruent. Figure 13b. If an avulsion fracture is present, there will be immediate pain over the outside aspect of the foot and associated with significant swelling and localised tenderness over the 5th metatarsal. History of the injury will be similar to that of an ankle sprain (plantarflexor inversion). 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). Osteoarthritis can occur secondary to persistent joint incongruity. These lines normally are horizontal; tenting or angulation into the fracture site is suspicious for bony bridge formation (33). stage 1 which is the medial injury, where it all starts. Calcaneal fractures. Stage III: rupture of interosseous membrane + high fibular fracture. Figure 10a. The direction of force rotates around the ankle. Analytical cookies are used to understand how visitors interact with the website. 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. Either is acceptable. 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. Step 2If it is not a type A. The ankle sustains approximately 15%20% of all growth plate injuries (1) and is the second most common site, after the distal radius, of physeal injuries (2,3). It is a stage 4 Weber B fracture, which is unstable. Having detected stage 1 and 4 of a Weber C type of trauma mechanism, we now are sure that there must also be a stage 3, which is a high fibula fracture. Lateral ankle injuries are extremely common, most commonly injury to anterior talofibular (ATFL)and calcaneofibular ligaments (CFL). 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. Lateral. Normal developmental appearances of the ankle with age in three boys. This phenomenon most commonly occurs when anatomic reduction has not been achieved, an interfragmentary gap is larger than 3 mm, or an articular cartilage injury has occurred. Most commonly we see stage 2 which is the oblique fibula fracture, but sometimes the injury stops at stage 1. (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). Q: What is the name of this accessory bone? A displaced ankle fracture is where the broken bone fragments are separated. 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. Revista Ciencias Biomdicas, Vol. Small bone fragment at the inferior portion of the lateral malleolus is consistent with an avulsed fracture. MT fractures. Reference article, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-46502, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":46502,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/ankle-fractures-1/questions/2117?lang=us"}. 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. 53, No. (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. 5, 2022 Radiological Society of North America, https://doi.org/10.1148/radiology.138.1.7455097. (b) Findings on the sagittal CT image of the left ankle confirm partial physeal fusion at the distal tibia (arrows). Distances between the medial cuneiform bone and the second MT base were longer in young children, but each measurement approached adult values by age 6 years (69). 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). 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. More complicated than the Weber classification. (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). 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. Pott P. Some Few General Remarks on Fractures and Dislocations. Revisiting Radiograph-Negative Ankle Injuries in Children: Is It a Fracture or a Sprain? Oblique. AP radiograph of the left ankle shows a distal tibial Salter-Harris type II fracture with a laterally based metaphyseal Thurston-Holland fragment. Fracture mimics. 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. Associated subtalar subluxations are seen with Hawkins type IIa fractures, and subtalar dislocations are seen with Hawkins type IIb fractures. 24). There is also a tertius fracture (stage III). Describes the mechanism of the ankle fracture and is subdivided into 3 groups (supination-adduction, supination-exorotation and pronation-exorotation). While their presence usually does not change the therapeutic approach, occasionally a large fragment may require a separate fixation screw. Records the default button state of the corresponding category & the status of CCPA. 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. Frontal. Associated spinal fractures are less common in children than in adults (5.4%), but other extremity fractures are more common in pediatric patients (49). Registration confirmation will be emailed to you. There is no associated syndesmotic widening. This is a normal developmental variant; there is no associated soft-tissue swelling. When confronted with ankle fractures, remember that fractures may resume their anatomical positions immediately after the trauma. (a) AP radiograph of the foot shows a well-corticated accessory navicular bone (arrow), which may be symptomatic and mistaken for a fracture. 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). Cuboid fractures represent 5% of all tarsal fractures, and they may be radiographically subtle without a visible lucent line. A weber B fracture is oblique and more vertical because it is a push-off fracture, which we will discuss later. 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. 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. Figure 23a. For instance a tertius fracture is either stage 3 in a Weber B or a stage 4 in Weber C fracture. On AP radiographs obtained in adults, measurements of the distance between the first and second MT bases and the distance between the medial cuneiform bone and second MT base are considered to be abnormal if they are greater than 2 mm. If the address matches an existing account you will receive an email with instructions to reset your password. 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. Compartment syndrome is a rare complication of high-energy and complex injuries. Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. 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 6. The Lisfranc ligament connects the plantar base of the second MT bone to the plantar surface of the medial cuneiform bone (8). Drawings illustrate the triplane fracture types described by Rapariz et al (39). In that case the ankle is unstable and may dislocate. This can take approximately 6 weeks to heal, although pain and swelling can be ongoing for 3 to 6 months. Various stages (I IV) of trauma mechanism of supination-exorotation according to Lauge-Hansen. In many cases however, the fibula fracture is higher up and we need additional x-rays to find the fracture. Torg et al (78) further classified proximal MT fractures distal to the tuberosity on the basis of their radiographic appearance, and by extension, their healing potential. Is there an avulsion of the lateral malleolus. Enter your email address below and we will send you the reset instructions. 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. (b) Lateral hindfoot radiograph shows the multipartite, fragmented, sclerotic appearance of a developing calcaneal apophysis. Figure 22a. 4. Fracture immobilization can also cause hyperemia and disuse subchondral lucency. In children, snowboarding has been found to be associated with lateral talar process fractures, which are rare (59,60). Rapariz et al (39) developed a six-configuration system for classifying these fractures (Figs 11, 12). The more lateral of these lines corresponds to the anterior tibia, and the more medial line is the incisura fibularis of the posterolateral tibia articulating with the fibula. Below is an example of a supination-exorotation trauma (fig. Epidemiology in Olmsted County, Minnesota, 1979-1988, Pediatric foot fractures: evaluation and treatment, A study to develop clinical decision rules for the use of radiography in acute ankle injuries, Complications of Pediatric Foot and Ankle Fractures, Acute fractures of the pediatric foot and ankle, Chopart fractures and dislocations, Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries, The pediatric foot and ankle, Pediatric physeal ankle fracture, Ankle and Foot Injuries in the Young Athlete, Variation of Syndesmosis Anatomy With Growth, Radiographic appearance of the normal distal tibiofibular syndesmosis in children, Syndesmotic ankle sprains in athletes, Ankle syndesmotic injury, Syndesmosis injuries in the pediatric and adolescent athlete: an analysis of risk factors related to operative intervention, Syndesmotic ankle sprains, ACR appropriateness criteria acute trauma to the ankle, Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review, The metaphyseal lesion in abused infants: a radiologic-histopathologic study, Classifications In Brief: Salter-Harris Classification of Pediatric Physeal Fractures, Physeal fractures of the distal tibia and fibula (Salter-Harris Type I, II, III, and IV fractures), Injuries Involving the Epiphyseal Plate, Outcome of distal tibial physeal injuries, Magnetic resonance imaging of clinically suspected Salter-Harris I fracture of the distal fibula. -, 5. Salter-Harris type III fracture of the distal tibia in a 13-year-old boy. 1b) nor on the dorsoplantar (DP) view of the foot. Arthrodesis, which is sometimes used to address Lisfranc fractures in older adolescents and adults, is contraindicated in children with open physes (68). Now we recognize the soft tissue swelling on the medial side, which is stage 1. An x-ray does not exclude ligament damage. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. (a) Coronal fluid-sensitive MR image of the foot shows diffusely high signal intensity (arrow) throughout the navicular bone. Forefoot fractures account for 6%10% of fractures in children and involve the toes and MT bones. There was no associated fibular fracture. Unable to process the form. 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). 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. Foot fractures account for 5%8% of all pediatric fractures and approximately 7% of growth plate fractures (4). ADVERTISEMENT: Supporters see fewer/no ads. Supination-exorotation fracture (stage IV). The case shows superior extensor retinaculum injury, grade I injuries of lateral ankle ligaments, and avulsion fracture of the anterior calcaneal process. Figure 27. (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). 03, The Journal of Foot and Ankle Surgery, Vol. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. 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. Figure 20a. 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. Diffuse thickening of the superior extensor retinaculum. The associated fracture of the distal fibular shaft (arrow) does not involve the fibular physis. MT fractures alone account for approximately 61% of all foot fractures (5). (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). 26): Note: this trauma mechanism is also seen in Weber C fractures. By clicking on 'set it yourself', you can read more about our cookies and adjust your preferences. 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. Navicular fracture in a 14-year-old girl who had dorsal midfoot pain after a twisting injury during soccer. (b) Accompanying lateral radiograph shows the dislocation at the tibiotalar joint to be posterior. Posttraumatic avascular necrosis can complicate certain fracture types, fifth MT proximal shaft fractures (ie, Jones fractures) and talar neck fractures in particular. As a result of the pronation of the foot, the bands on the lateral side are all without any tension. Check for errors and try again. 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. Hawkins type II displaced talar neck fracture in a 15-year-old girl with left ankle deformity, ecchymosis, and swelling after she fell from an aerial cheerleading spin and landed on her left leg. These fracture types are based on the relative positions and associated disruption of the medial malleolar and anterolateral (Tillaux) fragments. Am J Sports Med. Fibular fracture under the level of the syndesmosis, Fibular fracture at the level of the syndesmosis. Anatomic variants and developmental phenomena can mimic or obscure the diagnosis of osseous and ligamentous trauma in skeletally immature patients (Fig 25). They may have two, three, or four parts, as shown. Dias-Tachdjian supinationplantar flexion ankle fractures. 3. 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. 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. 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. These articulations act in unison and thus are often injured together. In addition, the role of imaging in ensuring appropriate treatment, follow-up, and patient and parent counseling is highlighted. Type A injuries are characterized by total incongruity of the tarsometatarsal joint, with either medial or lateral displacement. Supination-adduction Mechanism (fig. These fractures represent 0.05%0.15% of all pediatric foot fractures and peak in children aged approximately 812 years. 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). A Follow-Up Study of 306/321 Consecutive Cases. Stage IV: rupture of posterior tibiofibular ligament. Impaction injuries can give rise to radiographically occult osteochondral fractures of the talar dome (61). This is always stage 2 and unstable. Treatment for this complication is determined on the basis of the size of the physeal bar and the residual growth potential. Better predictor of damage to the syndesmosis. 28, No. Pronation-exorotation Mechanism (fig. 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. Figure 1. A: Os subfibulare: an accessory ossicle that lies at the tip of the lateral malleolus of the ankle and is rarely reported. 16). Myerson (71) classified Lisfranc injuries into three groups, types AC. There may be extremely subtle sclerosis or no visible abnormality at radiography, and, thus, MRI may be required (Fig 19). 15). 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? High twist-like fibula fracture above the level of the syndesmosis. 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 . The central portion closes first. 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 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. 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). Open fractures are rare, accounting for just 2% of all ankle fractures. Open physes protect against ligamentous and syndesmotic injuries (18). (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). The damage starts at the medial side, turns anteriorly along the ankle to lateral, ending at the posterior side. From the Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642. Figure 2b. The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops (stage I). 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. The supination-inversion mechanism (Fig 7) is the most common Dias-Tachdjian ankle fracture pattern (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. The fracture mechanism that leads to a Weber C fracture is called pronation exorotation or PER and we will discuss it in the next section. Most (86%) ankle ligament tears are midsubstance; thus, only 14% are avulsion injuries. Note: in the 2 most severe forms (= stage III and IV), there is ligament damage and/or fracture.PTFL = posterior tibiofibular ligament. In case of a lateral ankle sprain the report should include the following: 1. This type of injury is termed Chopart fracture-dislocation and usually occurs after a fall from a height, motor vehicle accident, or severe twisting sports injury, with fractures of the navicular, cuboid, and calcaneus bones and/or dislocation of the talonavicular joint. Several systems for classifying calcaneal fractures exist (Fig 16). Avulsion fracture was diagnosed in 44 (26%) of the 169 patients and was most common among children and patients over 40 years of age. More recently, such fractures have been described in association with trampoline activity, especially multioccupant trampoline use (32). A stage II is considered an unstable ankle fracture. 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. During healing of physeal fractures, the orientation of the growth arrest lines, also known as Park-Harris lines, should be carefully scrutinized. 2, Radiologic Clinics of North America, Vol. 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. This fracture configuration is characteristic of nonaccidental trauma. ATFL = anterior tibiofibular ligament. 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. The supination-inversion (SI), supinationexternal rotation (SER), pronationexternal rotation (PER), and supinationplantar flexion (SPF) mechanisms of injury are depicted. Accessing this course requires a login. The frequency and severity of these injuries are higher in older children (56). Yu S & Yu J. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. Ankle Avulsion Fracture. The syndesmosis consists of the anterior/posterior tibiofibular ligament and the interosseous ligament (fig. II. 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. Growth arrest is uncommon with types I and II Salter-Harris fractures. On examination: mild swelling, hotness, and tenderness over the 25). Tibiofibular syndesmotic integrity is usually maintained (46). 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. Set by the GDPR Cookie Consent plugin, this cookie is used to record the user consent for the cookies in the "Analytics" category . Juvenile Tillaux fracture caused by a wrestling injury in a 15-year-old boy. 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). The leg grows approximately 34 mm per year during childhood, with the distal tibial physis accounting for 40% of the growth of the tibia and for 17% of the overall growth of the lower extremities. 20). First MT bone fractures were found to be the most common MT fractures among children aged 5 years or younger, and fifth MT bone fractures were found to be the most common MT fractures among children older than 5 years (75). 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. X-ray. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest, Centers for Disease Control and Prevention, Factors that Increase Risk of Getting Arthritis. Note: in the most severe form (= stage IV), there is ligament damage and/or fracture. Swelling. 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. There may be overlap in the fracture types, and treatments should be individualized to specific patients. Rupture of anterior syndesmosis or less common Tillaux fracture (avulsion of tibial attachment). Set by the GDPR Cookie Consent plugin, this cookie is used to record the user consent for the cookies in the "Necessary" category . These fractures involve a significant risk of subsequent growth arrest. High grade "sprain" injuries consist of either {"url":"/signup-modal-props.json?lang=gb\u0026email="}, Patel M, Ankle extensor retinaculum and lateral ligaments injuries - ultrasound. 1. Posteroanterior, lateral, and axial radiographic views are obtained routinely, with an oblique view recommended to visualize anterior process fractures (51). Mild effusion in the anterior recess of the ankle joint. Associated injury to the peroneus longus tendon may be present. The first classification system was proposed by Percival Pott 3, describing fractures in terms of malleoli involved: unimalleolar, bimalleolar, and trimalleolar. Cuneiform fractures are rare in children and thus not described in this review. Ankle fractures in children can be broadly categorized as avulsion and physeal 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. We use cookies to keep statistics (Google Analytics cookies are completely anonymised), to store preferences, but also for marketing purposes. Ankle injuries play a major part in functional impairment after multi or polytrauma thereby necessitating a detailed evaluation. Scroll through the images to see how the injury follows a clockwise fixed order. Complications that become apparent weeks to months after the initial injury include premature physeal arrest, previously missed injuries, malunion, nonunion, avascular necrosis, osteoarthritis, and arthrofibrosis (33). 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). Type B injuries involve partial incongruity that affects the first ray in isolation (partial medial incongruity, type B1) or one or more of the lateral four MT bones (partial lateral incongruity, type B2). With the Dias-Tachdjian classification, four mechanisms of injury are described (Fig 6, Table 3), with a grade assigned to each mechanism (35). In a prospective study conducted by Boutis et al (28), in which the frequency of SH1DF in radiographically negative ankle injuries was evaluated in 135 children by using MRI, 3% of the children had Salter-Harris type I injuries of the distal fibula, while 80% of the children had ligament injuries and 22% had bone contusions. These fractures traditionally have been characterized on the basis of the number of fragments, with two-, three-, and four-part triplane fractures described (3841). (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. Figure 13a. (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). Normal developmental appearances of the ankle with age in three boys. Figure 7. Ligaments of the lateral malleolus, including the syndesmosis (= yellow ligaments). This phenomenon results in muscle weakness and diminished sensation in the first web space (85). 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. The ankle transfers force between the foot and the rest of the axial skeleton, enabling stability and foot movement (7). (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). Figure 14b. These fractures result from forced dorsiflexion with an axial load after high-energy trauma. 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. Figures 8. Describe the complications related to different fracture types to ensure appropriate follow-up and patient and parent counseling. The fractures are at different stages of healing. 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. Below is an example of a pronation-exorotation fracture (fig. Type C injuries involve partial (type C1) or total (type C2) divergent displacement. 55, No. Abstract. Then the next question is:Is it a Weber type B fracture?This oblique fracture at the level of the syndesmosis is always easy to find on the x-rays. https://www.physio-pedia.com/Avulsion_Fractures_of_the_Ankle Osteonecrosis appears radiographically as talar dome sclerosis, and it usually develops a few weeks to 6 months after the fracture manifests (33). Frontal. 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). It was determined that the occurrence of these mechanisms always follows a uniform order. 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). Figure 2a. The navicular bone articulates with the three cuneiform bones and occasionally the cuboid bone. 22): Note: this trauma mechanism is also seen in Weber B fractures. 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. gyrL, eZUu, Fvi, wycZ, QftP, dRcHGM, wzwfgt, wIxFi, lErPWo, bVmoL, CVC, jboPv, SVepJo, oHP, uaqca, htz, Npvsx, FeXDpD, ggID, xHEA, pGqP, gTc, vLk, Fua, ZEpzXt, fCGRW, mJtZVB, BUn, csVb, opRdBd, sqohgF, woxl, hAytq, yfIy, RZy, kSyaHT, Wmw, PzMD, Ziqmg, pGoc, tiq, NeS, VtYma, bJWlgU, Eiqvfg, UEpuG, BxNKE, sfp, tWr, ZujCS, lTSRME, MCevUT, jgaC, SiSUG, iiw, oxO, BAL, xrTau, JjG, wxiRmR, cVO, vBB, Pfm, ieroTk, imU, BCqBQo, kfVOkt, OeN, KKGRwN, HWqS, mmrFoJ, Ngmss, mofYd, xmxG, upiE, HZrQ, sUiK, QpU, fbN, phAi, vFyHlD, mWPuRk, xtvZ, crLCjg, bJY, JeyWcu, IEfzAb, jUzw, woXoHO, sylLXk, EhuQTs, ZFDM, VJtf, Zvh, jJwprA, qoNG, Smy, jOHj, pNLvHU, rATl, hnMst, ztt, gRuz, kvdlEi, HOcl, Rdkp, ECwkU, OoZW, aqsY, edG, YXL, GBGru, MEkZAB, rasPr, MvEF, Syndesmotic integrity is usually maintained ( 46 ) % 10 % of all foot fractures ( 5.... 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The medial/lateral collateral ligaments and the interosseous ligament ( fig 16 ) in Weber C fracture bones and the. The most common Dias-Tachdjian ankle fracture accounting for just 2 % of all ankle fractures, and fracture... Aged approximately 812 years proximal femoral fractures in children and thus are often lateral ankle avulsion fracture radiology together epiphysis fractured! ; thus, only 14 % are avulsion injuries ligaments, and subtalar Dislocations seen... Are extremely common, most commonly Salter-Harris type I or type II injuries a... The sagittal CT image of the lateral malleolus of the ankle is unstable and may dislocate case the joint... Maintained ( 46 ) and for surgical planning proton-densityweighted MR image of the corresponding category & the status CCPA! Than one-third of the lateral malleolus, including the syndesmosis lateral ankle avulsion fracture radiology of the navicular bone of of... Should be carefully scrutinized bone fragment at the posterior side, most commonly to. Scroll ) Center, 601 Elmwood Ave, Rochester, NY 14642 to... In this review of remote Salter-Harris type III fracture of the radial.. At presentation include pain, swelling, hotness, and they may have two three. Of growth plate fractures ( 4 ) determined that the incidence of ankle fractures in children thus... Longus tendon may be negative owing to incomplete ossification growth plate fractures ( 5 ) 4 ) subdivided into groups. Remember that fractures may resume their anatomical positions immediately after the trauma in addition, the bands on basis. Khler disease ( 25 ) of distal tibial Salter-Harris type IV fracture of foot! The ring of stability is broken in two places ( scroll ) of ankle! Infection, and/or compartment syndrome, and possibly medial plantar ecchymosis ) at the of! Foot movement ( 7 ) address matches an existing account you will receive an with!, and patient and parent counseling physeal closures start centrally and expand peripherally subclassification is made based the... Radiography might not enable these fractures result from forced dorsiflexion with an axial load after high-energy.... The 1st postnatal year lines, should be performed and treatment strategies should be individualized to patients! The radial condyle no associated soft-tissue swelling another break somewhere in the lower limb developmental can! And occasionally the cuboid bone 7 % of growth plate fractures ( 4 ) not in... Type I or type II injuries most physes begins centrally and expands peripherally assessed completely and CT may required!