Ankle injuries are common among school-age children, accounting for approximately one-quarter of all pediatric sports-related injuries and ranging from benign sprains to complex fractures involving the physis (growth plate). In fact, ankle fractures are the third most common physeal fracture in children. The distal tibial and fibular physes are located 1 to 2 fingerbreadths proximal to the joint and are the areas of the ankle most susceptible to injury. Identification of physeal injuries is crucial because they can lead to growth arrest and long-term disability. Although not covered herein, it is important to remember that aside from traumatic injury, ankle pain can be a manifestation of infectious, rheumatologic, or oncologic pathology.The ankle joint is composed of the distal tibia, distal fibula, and talus. The medial and lateral malleoli are the distal prominences of the tibia and fibula, respectively. Although the ankle is classified as a hinge joint, it also has multiaxial flexibility, allowing for inversion and eversion. The joint is stabilized laterally by the posterior and anterior (ATFL) talofibular ligaments as well as the calcaneofibular ligament. The deltoid ligament stabilizes the ankle medially.Evaluation of an ankle injury includes examination of the skin for erythema or swelling, ascertainment of bony tenderness and ligamentous instability, assessment of range of motion, and a detailed neurovascular examination. The mechanism of an ankle injury helps identify structures at risk. Eversion typically leads to injuries of the medial aspect of the ankle, and inversion leads to injuries of the lateral aspect. Forward distraction of the calcaneus and foot with respect to the tibia (anterior drawer test) is indicative of ATFL instability. Excessive inversion of the foot when the tibia and fibula are stabilized (talar tilt test) is indicative of calcaneofibular ligament instability, while excessive eversion of the foot when the tibia and fibula are stabilized (eversion stress test) is indicative of deltoid ligament instability.Identical mechanisms can result in different ankle injuries depending on the skeletal maturity of the child. Physeal fractures are more common in skeletally immature children because the physis is the weakest area of the joint. The Salter-Harris classification of physeal fractures (Table) is based on functional outcomes. Salter-Harris type I injuries generally have good functional outcomes, whereas Salter-Harris type V injuries have poor outcomes and cause growth disturbances. (See the Fig for diagrams of Salter-Harris fractures at the distal tibia.) Ankle sprains are less common in young children because the ligamentous structures are stronger than the physis. Conversely, older children and adolescents sustain ankle sprains much more frequently than fractures. Ankle dislocations are extremely rare in children given the stable structure of the ankle joint.Ankle sprains range from a minor tear of the ligament (grade I) to a complete rupture (grade III). Ligamentous injuries may be associated with avulsion fractures, such as an avulsion of the fifth metatarsal styloid, eponymously known as a pseudo-Jones fracture. This avulsion fracture results from an inversion injury that stretches the peroneus brevis tendon at its insertion on the fifth metatarsal.Ankle inversion is the most common mechanism of injury and manifests with swelling and tenderness at the lateral malleolus. Although tenderness over the distal fibular physis has classically been considered sufficient to make a clinical diagnosis of a Salter-Harris type I fracture, recent studies using magnetic resonance imaging have found that most previously diagnosed distal fibula Salter-Harris type I fractures are only ligamentous injuries or bone contusions. Suspected Salter-Harris type I fractures can be splinted with an air-stirrup ankle brace or an elastic bandage.A severe inversion injury may lead to a Salter-Harris type II fracture involving both the fibular physis and metaphysis. Salter-Harris type II fractures may require reduction and casting. A severe eversion injury may result in a Salter-Harris type II fracture of the distal tibia and a transverse fracture of the fibula 4 to 7 cm above the fibular physis.Salter-Harris type III fractures extend toward the joint surface and involve both the physis and epiphysis. Because this type of fracture includes the joint articulation, it is associated with a worse prognosis and often requires operative management. The Tillaux fracture, a Salter-Harris type III fracture in which the anterolateral portion of the tibial epiphysis is avulsed, typically occurs in children 12 to 14 years of age, when the medial aspect of the physis has fused before the lateral aspect, making the lateral epiphysis susceptible to avulsion by the ATFL when the foot is externally rotated. This fracture does require surgical repair.Salter-Harris type IV fractures involve the physis, metaphysis, and epiphysis. They are unstable fractures that typically require operative repair. A triplane fracture is a Salter-Harris type IV fracture that occurs in 3 planes of the distal tibia: coronal, sagittal, and transverse. Similar to the Tillaux fracture, the triplane fracture occurs during the period of partial physeal closure and involves the lateral aspect of the tibial physis. Computed tomography may be needed to diagnose Tillaux and triplane fractures.Salter-Harris type V fractures are crush injuries of the physis that are typically caused by a high-energy axial load. Although rare, they are associated with growth disturbance from premature physeal closure. A fracture of the lateral process of the talus (commonly known as the snowboarder’s fracture) occurs with extreme dorsiflexion and eversion of the ankle joint. This injury may be misdiagnosed as a lateral ankle sprain as the fracture line is difficult to identify on radiographs. Computed tomography may be required for diagnosis. Management of a snowboarder's fracture includes ankle immobilization, nonweightbearing, and possible operative repair.The Ottawa Ankle Rule is highly sensitive in identifying children with ankle injuries who are unlikely to have a fracture and therefore can forgo ankle radiographs. Anteroposterior, lateral, and mortise views of the ankle should be obtained if any of the following is present: tenderness at the posterior edge of the distal 6 cm of the medial malleolus; tenderness at the posterior edge of the distal 6 cm of the lateral malleolus; or inability to bear weight for 4 steps (regardless of limping) immediately after the injury and at the time of evaluation.In addition, tenderness at the base of the fifth metatarsal or at the navicular bone after an ankle injury should prompt radiographic evaluation of the foot. Computed tomography of the ankle may be indicated as noted previously herein for delineation of specific fractures.Treatment of ankle injuries is dependent on the specific injury. If casting or operative repair is not indicated, children should be managed with rest, ice, compression (ace bandage or stirrup splint), and elevation with gradual return to activity. Indications for orthopedic referral include obvious growth plate deformity; Salter-Harris type III, IV, and V fractures; neurovascular compromise; open fractures; and grade III ankle sprains.So-called RICE (rest, ice, compression, elevation) therapy for ankle sprains has long been the orthodox approach to management, but recently it has come into question, particularly the application of ice. The aim of all 4 measures is to reduce blood flow to the site of injury with the intent of reducing swelling and pain; and ice, by its numbing effect, does provide at least some analgesia. But several reviews of randomized controlled studies have found that, at best, the evidence for the efficacy of RICE is weak. Furthermore, the body’s inflammatory response, which may actually be an agent of healing, is dampened by the application of cold.This is not to say that RICE should be abandoned but rather to suggest that we do not really know what is best. We have been wrong in the past: babies should sleep on their bellies and the introduction of potentially allergenic foods should be delayed. What we need is evidence, not dogma.–Henry M. Adam, MDAssociate Editor, In Brief
Search from 250 M+ research papersSearch from 250 M+ research papers
Apr 8, 2024
Kacper Ruzik + 5
Open Access