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Stable fixation, avoiding growth plates may improve pediatric ankle fracture outcomes
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The growing anatomy of a pediatric patient with a complicated acute ankle fracture can lead to considerable complications if the fact that patient is still growing is not taken into consideration during treatment, according to a presenter at a recent meeting.
After finger and distal radius fractures, ankle fractures are the most common fractures that involve the growth plates in young children. Complicated ankle fractures are rare, but those patients who incur them are prone to growth arrest if they are not treated appropriately, Manuel Cassiano-Neves, MD, said at the 16th EFORT Congress.
“Complicated ankle fractures are luckily rare, but prone to growth arrests in 11% of cases, even when very well treated. It is something we cannot avoid. But, on the other hand, if you want to stay on the low level of complications, I think we really have to bear in mind that we need to have an anatomical reduction and stable fixation. This is the only way to avoid complications,” Neves said.
Imaging to determine fracture classification
Determining the mechanism of injury and the classification of the fracture is important to select the proper form of treatment. A surgeon’s ability to evaluate a radiograph will therefore go a long way in establishing if closed or open reduction is appropriate or if, perhaps, conservative treatment is warranted, according to Neves.
Images: Cassiano-Neves M
If a radiograph cannot be used to qualify the type of fracture, like in the specific type of triplane fracture, where it is difficult to understand the nature of the fracture lines, Neves suggested using CT imaging or MRI. However, he said surgeons should seriously consider the risks of exposing a young patient to the radiation of a CT scan.
“What should be our principles of treatment? First, identify the fracture properly. This will allow you to better understand how you should reduce the fracture and how to stabilize the anatomical reduction you expect to have. Once again, a question of debate is what we can consider an anatomical reduction, but less than 2 mm of displacement should be acceptable,” Neves said.
Treatments vary by classification
Different types of fractures will lead to different types of treatment. The first step is to determine the fracture’s Salter-Harris type, each of which should be approached with a different plan of treatment since they are all distinct. Even types I and II can often lead to malalignment and possible arthritic complications in adult life, so they should be considered, Neves said.
For example, a Salter-Harris type III fracture (which is a MacFarland fracture) occurs typically in patients between the ages of 8 and 10 years old and has a high risk of growth arrest. According to Neves, the injury is not easy to reduce anatomically and, if the reduction is not perfect, it will make the patient prone to a growth arrest, leading to a severe varus deformity of the joint.
Neves said an arthroscope is appropriate to assist in the reduction of a Salter-Harris type III injury because it will help the surgeon know if the growth plate has been anatomically reduced.
“The important thing is fixation. You should go always for a stable fixation, using cannulated screws guided over a K wire. We have different sizes of cannulated screws so you can use [them] from young age to the adolescents. Putting them in the correct place is a key factor,” Neves said. – by Robert Linnehan
- Reference:
- Neves MC. Ankle fractures acute management. Presented at: 16th EFORT Congress; May 27-29, 2015; Prague.
- For more information:
- Manuel Cassiano-Neves, MD, can be reached at CUF Descobertas Hospital, R. Mário Botas, 1998-018 Lisboa, Portugal; email: cassianoneves.manuel@gmail.com.
Disclosure: Neves reports no relevant financial disclosures.