Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA
Growth Arrest Risk
- Incidence after distal tibial physeal injury:
- Up to 50%
Higher Risk In
- Displaced fractures
- Intra-articular injuries
- Medial malleolar injuries
Salter-Harris classification (Ankle)
Type I & II
Treatment
- Closed reduction + casting
Key Point
- Surgery does not reduce the risk of growth arrest
Type III & IV
Key Feature
- Intra-articular fractures – require anatomical reduction
Treatment
- ORIF / CRIF
Fixation Principles
- Epiphyseal screws:
- Parallel to the physis
- Metaphyseal screw:
- Used if a large metaphyseal fragment is present (Type IV)
Important Precautions
- Avoid crossing:
- Joint surface
- Growth plate
Highest Risk of Growth Arrest
- Medial malleolus – Type IV injury
Outcome
- Varus deformity of the ankle
Special Radiological Sign
Anterior Widening of Distal Tibial Physis
- Cause:
- Periosteal interposition
Clinical Significance
- Prevents proper reduction
- May require surgical intervention
Important Fracture Types
Tillaux fracture
Cause
- Avulsion by:
- Anterior inferior tibiofibular ligament (AITFL)
Mechanism
- External rotation injury
Pathophysiology
- Lateral physis remains open
- Other portions of the physis are already closed
Treatment
- < 2 mm displacement ? Casting
- 2 mm displacement ? Reduction + fixation
Triplane fracture
Definition
- Fracture occurring in three planes:
- Coronal
- Sagittal
- Axial
Radiographic Appearance
- AP view resembles Type III
- Lateral view resembles Type II (posterior metaphyseal fragment)
Mechanism
- Supination–external rotation / inversion
Physeal Closure Pattern (Key Concept)
- Distal tibial physis closes sequentially:
- Central
- Posterior
- Medial
- Lateral (last)
Clinical Relevance
Explains:
- Tillaux fracture
- Triplane fracture
Core Treatment Principle
- Restore articular congruity
Prevents
- Post-traumatic arthritis
- Growth disturbance
Exam Pearls
- Type I & II Conservative management
- Type III & IV Operative management (due to joint involvement)
- Tillaux fracture:
- AITFL avulsion
- Triplane fracture:
- Three-plane injury
- Highest growth arrest risk:
- Medial malleolar Type IV injury
- Anterior physeal widening:
- Indicates periosteal interposition
Final Takeaway
- Management of pediatric ankle fractures depends on:
- Physeal involvement
- Articular congruity
- Stability
- Missing reduction in intra-articular fractures leads to:
- Deformity
- Long-term joint degeneration
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