Fractures of the Foot and

Ankle in Children

Sally Tennant

Contents Abstract
Fractures of the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4831 Fractures of the foot and ankle are not com-
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4831 monly seen in children. However correct man-
Applied Anatomy and Ossification . . . . . . . . . . . . . . . . 4832 agement is necessary to prevent potential
Classification and Mechanism of Injury . . . . . . . . . . . 4832 complications such as long-term articular dam-
Transitional Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4835
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4837 age, growth arrest, and even avascular necrosis.
Treatment-General Principles . . . . . . . . . . . . . . . . . . . . . . 4839 This chapter summarises the main principles of
Closed Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4839 management of the most important foot and
Indications for Surgery and Operative ankle fractures, emphasizing indications for
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4840
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4842 operative intervention where appropriate and
summarising possible techniques.
Fractures of the Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4846
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4846
Fractures of the Talus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4846 Keywords
Fractures of the Calcaneus . . . . . . . . . . . . . . . . . . . . . . . . . 4847 Anatomy  Ankle  Biomechanics  Classifica-
Tarso-Metatarsal Joint (Lisfrancs) Injuries . . . 4848 tion  Closed treatment  Complications  Foot 
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4849 Fractures  Surgical indications  Surgical
Base of 5th Metatarsal Fractures . . . . . . . . . . . . . . . . . . . 4850 Techniques
Jones Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4850
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4850
Fractures of the Ankle

Introduction

Fractures of the ankle in children are distinct

from those in adults. They occur most commonly
between the ages of 10 and 15. The surrounding
ankle ligaments are much stronger than the
physis, which forms a plane of weakness, so
that ligamentous injuries are not common in chil-
dren, and ankle injuries almost always involve
the distal tibial and fibular epiphyseal plate.
S. Tennant
They account for 11 % of physeal fractures [40],
Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK and are a common site of premature growth arrest
e-mail: Sally.pollock@yahoo.co.uk following fracture [3].

G. Bentley (ed.), European Surgical Orthopaedics and Traumatology, 4831

DOI 10.1007/978-3-642-34746-7_154, # EFORT 2014
4832 S. Tennant

a b
1
1
2
9
3 2
8 3
4
7 4
6

5 5

Fig. 1 (a) Lateral view of the ankle indicating ligamen-
tous anatomy. 1, fibula; 2, tibia; 3, anterior tibiofibular
ligament; 4, anterior talofibular ligament; 5, calcaneus; 6,
calcaneofibular ligament; 7, posterior talofibular liga-
ment; 8, posterior tibiofibular ligament; 9, epiphyseal
plate. (b) Medial view of the ankle indicating ligamentous
anatomy. 1, tibia; 2, epiphyseal plate; 3, deltoid liga-
ment; 4, talus; 5, calcaneus (From De Mesquita Montes
J. Surgical techniques in orthopaedics and traumatology.
Paris: Editions Scientifiques et Medicales Elsevier SAS;
Fig. 1 Paediatric lower leg and distal physeal fractures)

Applied Anatomy and Ossification
The ankle joint is a modified hinge joint between
the dome of the talus, the tibia and the fibula,
joined together by the syndesmosis consisting of
three ligaments: the inferior transverse ligament
and the anterior and posterior inferior tibiofibular
ligaments (Fig. 1). On the medial side the deltoid
ligament has deep and superficial components,
stablilising the distal tibia to the talus and foot.
On the lateral side, the anterior and posterior talo-
fibular ligaments and the calcaneo-fibular liga-
ments pass between the fibula and the foot
(Fig. 1). All ligamentous attachments occur distal
to the physis, and avulsion type injuries are com-
mon. Accessory centres of ossification are seen
medially (os subtibiale) and less frequently on the
lateral side (os subfibulare) and can be mistaken
for avulsion injuries.
The main distal tibial epiphysis ossifies
between 6 and 12 months of age, except the
medial malleolus which appears at 7 years in
girls and 8 in boys, usually as a downward exten-
sion of the main epiphysis. However, if it
develops as a separate centre of ossification it
can be mistaken for a fracture line. The distal
tibial physis contributes 45 % to the growth of
the tibia. It is completely ossified by 1415 years
and fuses with the diaphysis by 18 years.
Closure begins centrally, proceeds medially
and finally laterally, taking approximately 18
months, meaning that for a time, fractures can
occur on the lateral side without injury to the
medial side (Transitional fractures). The distal
fibula ossifies during the second year of life, and
closes 12 years later than the distal tibial
physis.
Classification and Mechanism of Injury
Fractures are usually caused by indirect violence,
for example when the fixed foot is forced into
abduction/adduction, rotation, eversion/inversion
or plantar or dorsi-flexion. The medial and lateral
ligaments transmit forces to the distal tibial and
fibular epiphysis, producing tension at the physis.
The Salter-Harris (SH) classification of
physeal injuries is simple and useful [35, 36]
however a classification scheme such as the
Lauge-Hansen classification that provides infor-
mation regarding the mechanism of injury can
predict the likelihood of achieving a closed
reduction and is extremely helpful in determin-
ing the technique [1822]. Dias and Tachdjian
modified the Lauge-Hansen classification to
Fractures of the Foot and Ankle in Children 4833

include the Salter-Harris classification so that it epiphysis with a posterior metaphyseal-diaphyseal

applies to paediatric injuries, and is commonly
used [9, 10]. This classification proposes 4
mechanisms of injury: the first term refers to
the position of the foot at the time of injury,
and the second to the direction of the deforming
force (Table 1).
Supination Lateral Rotation Injury
This injury is produced by a lateral rotation force
on the supinated foot. Grade 1 injuries represent
a Salter-Harris type 2 fracture of the distal tibial
fragment and posterior displacement. The fibula
remains intact (Fig. 2). A Grade 2 injury results
from further lateral rotation producing a spiral frac-
ture of the fibula which begins medially and
extends superiorly and posteriorly (Fig. 3).
Pronation-Eversion-Lateral Rotation
Injury
Eversion and a lateral rotation force is applied to the
fully pronated foot (Fig. 4). A Salter-Harris type 1
or 2 fracture of the distal tibia occurs, with
a transverse or short oblique fibular fracture.

Table 1 A classification of paediatric ankle injuries

Supination-Plantarflexion Injury
Class 1 Supination-lateral rotation fractures A plantarflexion force is exerted on the supinated
Grade 1 and 2
foot (Fig. 5). Most commonly this produces
Class 2 Pronation-eversion-lateral rotation
fractures a Salter-Harris type 2 injury of the distal tibial
Class 3 Supination-plantar flexion fractures physis with posterior displacement and no fibular
Class 4 Supination-inversion fractures Grade fracture and is often easiest to see on the lateral
1 and 2 radiograph.
Class 5 Axial compression fractures
Class 6 Juvenile Tillaux fractures Supination-Inversion Injury
Class 7 Triplane fractures An inversion deforming force occurs while the
Class 8 Other physeal injuries foot is supinated. Grade 1 injuries represent

Fig. 2 Supination external

rotation fracture of the
ankle grade 1. (a) AP
view. (b) Lateral view.
Salter-Harris type II
physeal injury of the distal
tibial epiphysis. The
metaphyseal diaphyseal
fragment is posteriorly
displaced (From De
Mesquita Montes J.
Surgical techniques in
orthopaedics and
traumatology. Paris:
Editions Scientifiques et
Medicales Elsevier SAS;
Fig. 3 Paediatric lower leg
and distal physeal
fractures)
4834 S. Tennant

Fig. 3 Grade 2 supination-

external rotation fracture of
the ankle (From De
Mesquita Montes J.
Surgical techniques in
orthopaedics and
traumatology. Paris:
Editions Scientifiques et
Medicales Elsevier SAS;
Fig. 5 Paediatric lower leg
and distal physeal
fractures)

a b

Fig. 4 AP and lateral radiographs of pronation-eversion-lateral rotation fracture of the ankle

Fractures of the Foot and Ankle in Children
Fig. 5 AP and lateral
radiographs of a a b
supination-plantar flexion
fracture of the ankle
a Salter-Harris type 1 or 2 fracture of the distal
fibular physis (Fig. 6), the type 1 fracture being the
commonest ankle fracture in children. There may
be minimal displacement and this injury may
therefore go undiagnosed or be confused with
an ankle sprain, however since children are more
likely to sustain a physeal injury than an ankle
sprain there should be a high index of suspicion.
Soft-tissue swelling and tenderness will be
found clinically and swelling will also be appar-
ent on the radiograph directly over the physis,
which may be widened. Comparison views of
the opposite ankle may be useful. Oblique views
may be required to visualise the usual minimal
displacement. Occasionally the lateral ligament
may rupture or the tip of the lateral malleolus
may fracture.
Grade 2 injuries occur with more severe force.
The talus is pushed medially and tilted against the
medial malleolus, usually producing a Salter-
Harris 3 or 4 fracture (Fig. 7) although occasion-
ally type 1 and type 2 distal tibial fractures are
seen. The epiphyseal fracture component of the
4835
type 3 fracture is always medial to the midline and
may be associated with a distal fibula fracture.
Axial Compression Fractures
Salter- Harris type 5 injuries result from an axial
load applied to the distal tibia, and are often
recognised only in retrospect following physeal
arrest. If suspected, MRI may be useful in
diagnosis.
Salter Harris Type 6 Injuries- Ablation of
the Perichondrial Ring
Severe injuries which remove the perichondrial
ring (e.g., lawnmower, de-gloving) result in
a callus bridge producing varus deformity and
growth arrest. Again, this may only be recognised
in retrospect.
Transitional Fractures
These are injuries occurring close to skeletal
maturity as the physis is closing from medial
4836
Fig. 6 Grade 1 Supination Inversion injury-SH type 1
fracture with separation of the distal fibular physis
Fig. 7 AP radiograph of a Grade 2 supination-inversion
injury
S. Tennant
to lateral. The progression of closure of the
physis at the time of injury determines the pattern
of injury. Because they occur close to the time of
complete physeal fusion, growth arrest is
not usually a clinical problem, however
articular incongruity is, and these fractures
require accurate analysis and reduction.
Juvenile Tillaux Fractures
This occurs within the final year of closure of the
distal tibial physis, when the central and medial
parts of the physis have closed but the
anterolateral aspect is still open. It represents
a Salter-Harris type 3 fracture of the antero-
lateral portion of the epiphysis. When an
external rotation force is applied to the foot,
separation begins through the physis at its lateral
corner, and when the force reaches the fused
portion of the physis, the separation changes
direction and passes through the epiphysis into
the joint, producing an avulsion of the
anterolateral distal epiphysis attached to the
anterior tibiofibular ligament. The more skele-
tally mature the child the more lateral the frac-
ture line (Figs. 8 and 9).
The diagnosis is often missed and is easy to
mistake for an ankle sprain. A mortise view
should show the fracture. The lateral view should
be carefully evaluated to differentiate this from
a tri-plane fracture.
Tri-Plane Fractures
The tri-plane fracture occurs at an average age of
13.5 years, slightly younger than the typical child
with a Tillaux fracture. An external rotation force
passes through the open part of the physis, then
changes direction when it reaches the closed part
of the physis, often passing in two directions.
This fracture is therefore named because the frac-
ture line occurs in sagittal, coronal and transverse
planes (Figs. 10 and 11). The transverse fracture
travels through the physis, the coronal fracture
runs proximally from the physis through the pos-
terior metaphysis, and the sagittal fracture travels
from the joint line to the physis, producing an
anteromedial and often anterolateral fragment.
These can result in either a 2-part or a 3-part
fracture, although the extra-articular tri-plane
Fractures of the Foot and Ankle in Children
Fig. 8 Tillaux fracture in the adolescent. A Salter-Harris
type III fracture of the lateral part of the distal tibia,
which is closed medially (From De Mesquita Montes J.
Surgical techniques in orthopaedics and traumatology.
Paris: Editions Scientifiques et Medicales Elsevier SAS;
Fig. 3 Paediatric lower leg and distal physeal fractures)
and a 4 part fracture have also been described
[6, 7, 13, 17, 28, 29, 39, 41].
AP, lateral and mortise xrays are required,
demonstrating a Salter Harris type 3 fracture on
the AP radiograph and a Salter-Harris type 2
fracture on the lateral view (Fig. 10). The fibula
may be fractured in up to 50 %. Since
the metaphyseal fracture is often overlaid by the
shadow of the fibula, radiographs must be
analysed carefully. CT scanning can help to visu-
alise the fracture clearly, assess the degree of
articular incongruity and plan the placement of
internal fixation (Fig. 11).
Avulsion Fractures
Avulsion by a ligament of the lateral cartilagi-
nous model can occur, producing ankle swelling
4837
Fig. 9 AP radiograph of a tillaux fracture
but normal radiographs. Eventually the cartilage
model forms an ossicle and occasionally this pre-
sents much later with symptoms. Most lateral
avulsion fractures can be treated closed with
eversion of the ankle and a short leg cast.
Avulsion fractures of the medial malleolus are
less common. If displaced they may require fixa-
tion. A Maissoneuve proximal fibular fracture
should be excluded.
Diagnosis
Examination must include careful inspection of
the state of the soft tissues e.g., soft tissue
swelling and lacerations, for clues as to the
nature of the injury and causative force, as
well as a full neurovascular examination.
Although ligamentous injuries are rare in chil-
dren, tenderness of the soft tissues is important,
for example medial soft tissue tenderness in the
presence of a distal fibular fracture may imply
a threat to ankle stability and require fixation of
the lateral fracture.
It is important to elicit the exact area of bony
tenderness, bearing in mind that undisplaced SH1
fractures may not be visible on radiographs.
4838 S. Tennant

a b

Fig. 10 (a, b) AP and lateral radiographs of a triplane fracture

a b

Fig. 11 (a, b) Sagittal and coronal CT scans of a triplane fracture

AP, lateral and mortise views are important basic
radiographs, and should be carefully analysed,
looking not only for obvious fractures but for
subtle signs such as soft-tissue swelling over
physes which may indicate occult injury.
In a young child an avulsion fracture may involve
cartilage only and radiographs may be normal.
Accessory centres of ossification may be seen on
both medial and lateral sides of the ankle and
these must be differentiated from a fracture.
Fractures of the Foot and Ankle in Children
It must also be borne in mind that the radio-
graph is not a reflection of the maximal force that
produced the injury, as this may have either
reduced spontaneously or prior to the radiograph
being taken. Oblique views, and comparison
views of the opposite ankle may sometimes be
necessary. CT scanning is often useful, and vital
for the full assessment of the tri-plane fracture.
Treatment-General Principles
All reductions, both open and closed, should be
gentle with minimal force. Epiphyseal separa-
tions should be reduced immediately, as any
delay makes reduction increasingly difficult
[1, 33]. After 710 days, type 1 and type 2 fractures
cannot be reduced without excessive force and
damage to the physis, and therefore it is better
to accept mal-union than cause a growth arrest
during treatment.
Type 1 and type 2 fractures can usually be
reduced easily, with bony remodelling capable of
correcting moderate residual deformities if reduc-
tion is not perfect. However type 3 and 4 fractures
require accurate reduction to restore articular con-
gruity and prevent growth arrest. In the case of
Salter-Harris type 4 fractures this will nearly
always be an open reduction although occasion-
ally a closed reduction will suffice but require
percutaneous fixation to maintain the reduction.
Smooth K-wires should be used, screws or
threaded wires should not cross the physis.
Closed Reduction
The majority of ankle fractures in children are
adequately treated using closed reduction and
external fixation, by using reduction techniques
that reverse the causative deforming forces.
Supination-Lateral Rotation Injuries
Both grade 1 and grade 2 injuries are reduced
by longitudinal traction and medial rotation
of the foot. An above knee cast is worn for
8 weeks.
4839
Pronation-Eversion-Lateral Rotation
Injuries
These fractures are reduced by longitudinal trac-
tion in the line of the deformity (lateral rotation
and with the hindfoot everted). Distal traction is
maintained while the hindfoot is inverted and
medially rotated. An above knee cast with the
foot in internal rotation and inversion is worn
for 8 weeks.
Up to 15 of valgus deformity can be accepted
and will disappear with growth. If there is more
than this after the first manipulation, it can be
repeated after 34 days but, if unsuccessful,
open reduction is not performed. Residual defor-
mity is better treated later with supramalleolar
osteotomy [8, 40]
Supination-Planter Flexion Injuries
Reduction requires longitudinal traction firstly
in plantarflexion, and then gentle dorsiflexion
of the foot. The leg is immobilised for 46
weeks in an above-knee cast with the ankle in
10 of dorsiflexion. Moderate residual deformity
will correct (including <10 angular
deformity) and is better accepted than risk
repeated traumatic manipulations. If the posi-
tion is not acceptable, open reduction should be
performed.
Supination-Inversion Injuries
These injuries are reduced by longitudinal
traction applied medially, and the foot is then
everted. It is immobilised in slight pronation,
with the ankle in neutral dorsiflexion.
In grade 1 injuries (affecting the distal fibula),
a below-knee walking cast can be worn for 46
weeks. A grade 2 injury with a SH3 or 4
fracture of the distal tibial epiphysis, requires
anatomical reduction, which will often
require an open reduction. An above-knee
non-weight-bearing cast is applied for 68
weeks. These fractures carry the risk of
medial growth arrest, producing varus
deformity and leglength discrepancy. Careful
follow-up is required to ensure that reduction
is maintained.
4840
Juvenile Tillaux Fracture
The aim of treatment is to restore articular congru-
ity. Traditionally, an initial closed reduction to
within 12 mm of the anatomical position has
been advised. This is performed by internal rotation
of the foot to allow the anterior tibiofibular ligament
to relax, together with digital pressure applied to the
distal tibial epiphyseal fragment. If successful, an
aboveknee cast is then applied with the foot in
internal rotation, and maintained for 34 weeks
with serial radiographs and conversion to a short-
leg cast with the foot plantigrade for a final 3
weeks. However, the limit of 2 mm has been
based on radiographs, on which displacement is
often difficult to see. When CT scans are used, the
acceptable level of displacement is unknown,
and there are no long-term outcome studies to
help. Therefore it is increasingly considered
better to perform open reduction and internal
fixation for any degree of displacement in order
to achieve an anatomical reduction.
Tri-Plane Fracture
Anatomical reduction is essential, as unsatisfac-
tory results are associated with more than 1 mm
of displacement [12]. Closed reduction may be
performed for fractures with minimal displace-
ment, and achieved by axial traction under GA
with internal rotation of the foot. Percutaneous
K-wire or screw fixation of the articular fragment
is advisable to prevent fracture displacement in
the cast. An aboveknee non-weight-bearing cast
is used initially for 34 weeks, with a short leg
cast for another 23 weeks. CT post-operatively
may be useful to confirm adequate reduction, and
serial weekly radiographs should be done to
ensure no loss of position in the cast. Sometimes,
reduction of the fibular fracture may be required
before reduction of the tri-plane fracture is
possible.
Indications for Surgery and Operative
Technique
Indications for operative treatment include
inability to obtain or maintain a closed recuction,
S. Tennant
displaced physeal fractures, displaced articular
fractures and open fractures. The Salter-Harris
classification is used to guide the surgeon in the
treatment plan.
Operative management should be carried out
as soon as the condition of the soft tissues, includ-
ing swelling, allows. The ankle should be gently
reduced and placed in a back slab with elevation
and ice to reduce swelling. Surgery is best done in
the first 24 h before maximal swelling, or after the
initial swelling has resolved, often after 1 week.
Salter-Harris Type I and II Fractures
Most SH type 1 and 2 fractures will be adequately
managed by closed methods. Occasionally inter-
position of soft tissues such as periosteum may
prevent reduction and require open reduction
possibly with internal fixation e.g., with smooth
K wires.
Open reduction will also be required for unac-
ceptable varus or valgus deformity, particulary in
children over 1213 years in whom significant
remodelling is unlikely.
Salter-Harris Type III Distal Tibial
Fractures
These represent approximately 20 % of all distal
tibiofibular fractures in children. They are always
caused by a supination-inversion injury, and are
associated with a fibular fracture in 25 %. The
epiphyseal fracture component is always medial
to the mid-line, differentiating it from a Tillaux or
tri-plane fracture when the epiphyseal fracture is
at the mid-line or lateral to it.
If there is more than 2 mm of displacement,
reduction either closed or open should be
followed by screw fixation. An anterior
arthrotomy between the EDL and the EHL can
be used to view the articular surface and guide the
reduction using bone reduction forceps. 3.5 or
4 mm cannulated screws are useful, although
small fragment 3.5 or 4 mm screws may provide
better compression and can also be placed percu-
taneously. Belowknee casting is used for
6 weeks. There is a 15 % incidence of premature
physeal closure with angular deformity, even
after fixation [34]. Early degenerative arthritis is
Fractures of the Foot and Ankle in Children
Fig. 12 Approach to the
medial aspect of the ankle
in the treatment of Salter- Incision
Harris type IV fractures
(With permission from
Tachdjian MO. Fractures of
the ankle. In: Herring J,
editor. Pediatric
orthopaedics. Philadelphia:
WB Saunders; 2008;
Vol. 3, [40], Chap. 43,
Fig. 43172, p. 2746)
also a risk, particularly if displaced fractures are
not reduced.
Salter-Harris Type IV Distal Tibial
Fractures
These are rare fractures, representing only 1 % of
all distal tibial injuries in children, and are pro-
duced by a supination inversion injury. ORIF is
usually required as they extend into the joint and
are usually displaced, hence there is a high risk of
degenerative arthritis and growth arrest if not
anatomically reduced.
A curvi-linear incision is made over the
antero-medial aspect of the distal tibia (Fig. 12).
This allows inspection of the articular component
and the metaphyseal fragment. After reduction,
screw fixation is performed parallel to the physis
in the epiphysis and the metaphysis. Serial mon-
itoring of the physis every 6 months is particu-
larly important in these fractures.
Juvenile Tillaux Fracture
Indications for open reduction with internal fixa-
tion have been discussed above. It is performed
via an anterior approach to the ankle between the
EHL and EDL tendons (Fig. 13). Haematoma is
evacuated and the joint surface is inspected.
Internal rotation of the foot allows reduction of
the fragment under direct vision. The physeal
fracture line should be restored as well as the
distal tibial articular surface. A 4 mm partially
threaded cancellous screw is passed from
anterolateral to posteromedial, with temporary
4841
Physis
Fracture
Fracture
Saphenous v. Saphenous
and n. V. and n.
K wire fixation if necessary (Fig. 14). The physis
may be crossed since it is in the process of clos-
ing. A belowknee non-weightbearing cast is worn
for 6 weeks.
Tri-Plane Fracture
Open reduction and internal fixation is advisable
if the fracture is displaced more than 3 mm, or
after failure to achieve a closed reduction. The
soft tissues should be carefully inspected for
swelling, which should be allowed to decrease
prior to operative treatment.
For a 2 part fracture, or where the SH type 2
posterior fragment is only minimally displaced,
an anterior exposure only is needed. Fracture
haematoma is removed and the fracture is
reduced with internal rotation of the foot then
compression across the fracture site. A 4 mm
cancellous screw can then be placed via a small
stab incision over the medial malleolus.
A belowknee cast is worn for 6 weeks.
If the metaphyseal fragment is more
displaced, usually with an associated fibular
fracture, an anterior approach is performed to
visualise the ankle. A closed reduction of the
posterior metaphyseal fragment is attempted
with compression and internal rotation of the
foot. This may require the use of a bone reduc-
tion forceps placed through a stab incision
just lateral to the Achilles tendon. Failing
this, an open reduction is perfomed through
a postero-lateral incision, lateral to the achilles
tendon and between FHL and peroneus brevis.
4842 S. Tennant

Fig. 13 Anterior approach

to the ankle for reduction a
of a Tillaux fracture. Incision
(a) A midline incision is
made directly over the
ankle joint. (b) The interval
between the extensor
digitorum longus and the
extensor hallucis longus is
developed. The surgeon
carefully identifies the deep b
peroneal nerve and anterior Extensor
tibial artery. (c) The Extensor retinaculum
interval is enlarged and the digitorum Extensor
neurovascular bundle is longus m. hallucis
retracted medially. After longus m.
incision of the capsule the
fracture is easily identified
(With permission from
Tachdjian MO. Fractures of
ankle. In: Herring J, editor. Deep peroneal
Pediatric orthopaedics. n. and anterior
Philadelphia: WB Joint capsule tibial a.
Saunders; 2008, Vol. 3,
[40], Chap. 43,
Fig. 43179, p. 2754)
Extensor c Extensor
digitorum retinaculum
longus m. Extensor
hallucis
longus m.

Physis

Deep peroneal
n. and anterior
Joint capsule tibial a.

The fracture is reduced and fixed with 2 cancel-
lous screws placed from anterior to posterior.
The fibular fracture is reduced temporarily dur-
ing the reduction of the metaphyseal fragment,
then re-reduced if necessary following fixation.
The antero-lateral epiphyseal fragment is then
reduced and fixed as before. An above-knee non-
weight-bearing cast is worn for the first 4 weeks
of 6 or 7 weeks immobilisation. Figure 15 shows
the fixation used to treat the tri-plane fracture
illustrated in Figs. 10 and 11.
Complications
Premature Closure of the Physis
Salter Harris 3 or 4 injuries are traditionally
thought to be at greatest risk of growth arrest.
Fractures of the Foot and Ankle in Children 4843

a b

Fig. 14 (a, b) AP & lateral post-operative radiographs of a tillaux fracture

Fig. 15 Post-operative
radiographs of a triplane
fracture
4844
a b
Fig. 16 (a, b) Salter-Harris IV fracture of the distal tibia resulting in medial growth arrest and varus deformity due to
inadequate reduction
Damage may occur at the time of initial
injury, although anatomical reduction is also
vital to prevent arrest secondary to displacement.
Recent studies have suggested that Salter-Harris
1 and 2 fractures may have a higher rate of
growth arrest than previously thought, perhaps
up to 40 % [2, 27]. In one study of Salter Harris
1 and 2 fractures, rates of premature physeal
closure of 60 % were seen if the residual fracture
gap was greater than 3 mm radiographically,
and this gap often represented trapped
periosteum [2].
Depending on the size and location of
the growth arrest, and on the age of the child,
premature closure may result in varus or valgus
deformity, with or without shortening of the injured
side (Figs. 16 and 17). Close follow-up should
continue for at least 2 years after a physeal
injury. Radiographs are monitored for the
presence of a bony bar, and growth arrest lines
can sometimes indicate an asymmetric growth
arrest. If suspected, any internal fixation devices
S. Tennant
should be removed and further imaging including
a CT or MRI performed.
Options for treatment depend on the location
of the bar, its size, and the amount of
skeletal growth remaining. If more than 2 years
of growth remain, and the bar is less than 50 %
of the width of the physis, an epiphysiolysis can
be performed, replacing the bar with adipose
or other tissue. If close to skeletal maturity,
then an epiphyseodesis of the rest of the tibial
physis and the fibular physis can be done to
prevent progression of deformity, combined
with a contralateral epiphyseodesis to prevent
a leglength discrepancy. Significant deformity
at skeletal maturity is treated with an opening
wedge osteotomy of the tibia 2 cm proximal
to the physis, with screw fixation and a fibular
osteotomy.
Valgus Deformity and Mal-Union
Valgus deformity may also be due to
inadequate reduction, particularly of a pronation
Fractures of the Foot and Ankle in Children 4845

a b

Fig. 17 (ac) Intra-articular fracture of the Medial indicates the direction of forces affecting the lateral part of
malleolus. This was adequately fixed following open reduc- the distal tibial physis which went on to arrest with progres-
tion but the fibular fracture on the original radiograph sive valgus deformity, in this case secondary to the injury

eversion lateral rotation fracture. Valgus defor- allow gradual correction. Use of an 8 plate or a
mity of 1520 requires surgical treatment. If single screw allows removal when correction is
there is sufficient growth remaining, a medial obtained, to prevent overcorrection. At skeletal
epiphysis of the distal tibia can be performed to maturity a distal tibial osteotomy can be used [43].
4846
Fractures of the Foot
Introduction
The commonest foot fractures in the paediatric
patient are metatarsal fractures which are usu-
ally relatively straightforward to diagnose and
pose little challenge in management. Other
injuries can be difficult to diagnose, particularly
in the young child, due to the small size of some
of the ossification centres, and the presence of
several normal apophyses in the foot. While
talar and calcaneal fractures are rare in children,
complications can be major, as in the adult.
In the adolescent, surgical treatment is more
likely to be needed, and treatment principles
may mirror those in the adult.
Fractures of the Talus
Fractures of the talus are rare in children,
accounting for only 0.08 % of paediatric frac-
tures [23], and consequently there are few
reports in the literature. However it has recently
been suggested that mechanisms of injury and
outcome patterns are comparable to adults,
including the risk of complications such as avas-
cular necrosis and arthritis, and therefore treat-
ment concepts should also be similar if not more
aggressive [26].
As in the adult, the talus is at risk of AVN
following displaced fractures because of the pre-
carious nature of its blood supply. The sole blood
supply enters on the dorsum of the neck which is
the only part not covered by articular cartilage.
Because of incomplete ossification, fractures
in the child under 6 years can be difficult to
diagnose [25] and the amount of displacement is
often underestimated.
The mechanism of injury is usually forced
dorsiflexion of the foot, for example a fall
from a height. Radiographs should include
AP, lateral and oblique views centred on
the ankle. A pronated oblique radiograph of
the talus [5] is also useful as it gives an
excellent view of the talus. CT scanning may
S. Tennant
occasionally be required to confirm a fracture or
the amount of displacement.
Talar Neck Fractures
Talar neck fractures are the commonest fractures.
The three-part classification of Hawkins which
was later modified by Canale based on the
amount of fracture displacement and providing
information on the risk of AVN, is appropriate for
use in children (Fig. 18) [15].
Most neck fractures in children are
undisplaced (Hawkins type 1) and can be treated
in a long-leg cast for 68 weeks, followed by
a short-leg walking cast for 23 weeks, with less
than 5 mm of displacement and less than 5 of
mal-alignment on the AP view deemed accept-
able [5].
Hawkins type 2 fractures show displacement
but without subluxation of the ankle or subtalar
joints. In a young child these can be treated with
an attempt at closed reduction by gentle plantar
flexion and pronation of the foot. Percutaneous
K wires can be used to improve stability. A long-
leg cast is worn for the first 4 weeks, usually with
the foot in some plantarflexion, followed by
a short-leg cast for 34 weeks. Open reduction
should be performed if the fracture cannot be
reduced to within 1520 [16].
Children older than 10 years have a worse
prognosis than younger children and a closed
reduction is harder to maintain, therefore they
are best treated as adults, i.e., with open reduction
and internal fixation. This is done via
a posterolateral incision, allowing reduction and
screw placement without further damage to the
blood supply. A limited anteromedial incision
can be added if necessary, with care to avoid the
deltoid branch of the posterior tibial artery. (For
more details see chapter on adult talus fractures).
Partially threaded cancellous screws are used to
compress the fracture site, from the posterior
talus into the neck anteriorly. A below-knee cast
is then worn for 46 weeks.
Type 3 fractures are displaced fractures
with dislocation of the talar body from both the
ankle and subtalar joints and should be treated
with open reduction and internal fixation
as above.
Fractures of the Foot and Ankle in Children 4847

Fig. 18 Classification of
talar neck fractures. Type
1-Nondisplaced fracture,
Type 2 Displaced fracture
with subluxation or
dislocation of the subtalar
joint, Type 3 displaced Talus Naviculus
Fracture
fracture with dislocation of
the talar body from both the
ankle and subtalar joints,
Type 4, subluxation or
dislocation of talar head
and dislocation of talar
body (From Tachdjian MO.
Fractures of ankle. In:
Herring J, editor. Pediatric
orthopaedics. Philadelphia:
WB Saunders; 2008, Vol. 3, Type I Type II Cuboid
[40], Chap. 43,
Fig. 43192, p. 2763)

Type III Type IV

Fractures of the Body of the Talus
This is a much less common injury and carries a
worse prognosis. If the fracture is displaced, open
reduction and internal fixation will be necessary.
Lateral Process Fractures
This is a very uncommon injury, caused by forced
dorsiflexion and inversion of the foot. Diagnosis
can be very difficult, particularly if the fracture is
undisplaced. Undisplaced fractures can be treated
with a below-knee weight-earing cast. Displace-
ment more than 1 cm requires reduction and
internal fixation.
because of the rarity of these fractures. There is
some evidence that it is more common in children
older than 12 years [11].
AP and mortise views should be done 68
weeks after the fracture to look for Hawkins sign.
This is a radiolucency in the subchondral area,
which implies that the blood supply is intact and
there is a good chance that the talar body will
remain viable. An absent Hawkins sign is not
a definite predictor of AVN, but the patient should
be kept non-weight bearing to avoid collapse. An
MR scan of the talus should be done at 3 months if
Hawkins sign is still absent at this stage.

Complications
Avascular necrosis is the most serious complication
following a talar fracture. The incidence increases
with increasing Hawkins grade in the adult popula-
tion, but is not accurately known in children
Fractures of the Calcaneus
These are rare injuries, usually sustained by
a fall from a height. Most fractures involve
4848
the tuberosity. In the young child, the height of
the fall may seem innocuous and not arouse
suspicion and the diagnosis is often difficult
and may only be made in retrospect when frac-
ture callus is seen. Outcomes are usually good,
and often non-operative treatment only is
needed. In the adolescent with a displaced
intra-articular fracture, surgery is usually pref-
erable. Because of the association of calcaneal
fractures with vertebral compression fractures,
a lateral radiograph of the spine is advisable
[38]. In high energy injuries, it is important to
be aware of the possibility of compartment
syndrome. The traditional classification sys-
tems used for the adult fracture have been
modified for use in the child by Schmidt and
Weiner. A useful classification system for
intra-articular fractures has also been described
by Sanders et al. [37].
Diagnosis
Lateral, axial, straight dorsoplantar and oblique
dorsoplantar views should be taken. Brodens
views may be used when a fracture is not seen
on the lateral or oblique views. This view is taken
with the leg internally rotated 40 and the X-ray
beam directed 10 , 20 , 30 and 40 toward the
head and centred on the sinus tarsi. Intra-articular
fractures require CT evaluation to delineate the
degree of subtalar joint incongruity.
In the young child if a fracture is suspected
but not confirmed, the safest option is to treat
with a below-knee cast and repeat radiographs
23 weeks later.
In the older child, Bohlers angle and the cru-
cial angle of Gissane can be measured as in the
adult.
Treatment
Most calcaneal fractures in children can be
treated non-operatively with a below-knee cast
for 36 weeks, especially in young children.
Extra-articular fractures in the older child can
be treated in the same way but may need
a slightly longer period of immobilisation.
Displaced fractures may require open reduction
and internal fixation. In older children, fractures
are more likely to be intra-articular and these
S. Tennant
require consideration of open reduction and inter-
nal fixation as in the adult. Good results have
been reported [4, 30, 31].
Complications
The most common complications is early osteo-
arthritis in the subtalar joint.
Tarso-Metatarsal Joint (Lisfrancs)
Injuries
The tarsometatarsal joints form articulations
between the distal row of the tarsals and the
metatarsal bases. Weak dorsal and plantar
tarsometatarsal ligaments connect adjacent bor-
ders of the cuneiforms and the second and third
metatarsals. The intermetatarsal ligaments are
stronger. Lisfrancs ligament connects the second
metatarsal to the first cuneiform (Fig. 19).
Lisfranc injuries are rare in children, are often
undisplaced and easy to miss. They may be caused
by direct or indirect mechanisms, with the latter
being the commonest, for example violent abduc-
tion or forced plantarflexion of the forefoot.
The classification by Hardcastle et al. [14]
(Fig. 20) is useful, which divides these fractures
into those with total incongruity, partial incon-
gruity and those with a divergent pattern. In chil-
dren, the partial incongruity pattern is by far the
commonest and is usually minimally displaced.
The child presents with pain in the foot and
dorsal swelling, usually without gross deformity,
as spontaneous reduction of the injury often occurs.
Radiographs should include AP, lateral and
oblique views. A fractured base of second meta-
tarsal, sometimes with a fractured cuboid, should
raise suspicion of an associated tarsometatarsal
dislocation. The lateral border of the first meta-
tarsal should line up with the medial cuneiform
and the medial aspect of the second metatarsal
should line up with the medial aspect of the
middle cuneiform on the oblique radiograph.
Weight-bearing stress views and comparison
views of the opposite foot are helpful, as are CT
scans in certain cases. If radiographs are normal
but suspicion persists, MRI can be used to diag-
nose ligamentous injuries.
Fractures of the Foot and Ankle in Children
Fig. 19 Lisfranc ligament
Treatment
Undisplaced fractures or those displaced less than
2 mm can be treated non-operatively, with
a short-leg cast for 56 weeks. Sometimes this
needs to be preceded by a few days of elevation in
a protective dressing to allow the swelling to
settle.
For fractures displaced 2 mm or more, closed
reduction can be performed using axial traction
and manual pressure on the dorsum of the foot.
Stabilisation of the second metatarsal base frac-
ture is crucial. Radiographic assessment must
confirm that residual displacement is less than
4849
TYPE A
TOTAL INCONGRUITY
LAT MED LAT MED
TYPE B
PARTIAL INCONGRUITY
Medial dislocation
Lateral dislocation
TYPE C
DIVERGENT
Total Partial
displacement
Fig. 20 Lisfranc Injury patterns (With permission from
Hardcastle et al. [14]; Fig. 1 Classification of Lisfranc
Injuries)
1 mm, otherwise open reduction is needed.
Sometimes failure of satisfactory closed reduc-
tion can be due to entrapment of the tibialis ante-
rior tendon or fracture fragments in the fracture
gap.
Following reduction, percutaneous K- wire
fixation is recommended. One wire is passed
from the medial cuneiform to the second meta-
tarsal, with others depending on the type of frac-
ture. In the most common type of fracture (partial
incongruity) a second pin is placed between the
first metatarsal and the medial cuneiform or
between the first two metatarsals to stabilise the
medial displacement of the first metatarsal.
Open reduction and internal fixation are indi-
cated when an anatomical closed reduction can-
not be achieved, or for residual diastasis.
Longitudinal incisions over the 1st2nd and
3rd4th metatarsal interspaces are used. The frac-
ture is reduced under direct vision and pinned as
above. These can be left percutaneously and
pulled out at 6 weeks.
4850
Metatarsal Fractures
These are the most common fracture of the foot in
children, usually due to direct trauma from
a falling object, or a crush injury. The most com-
mon site is the 5th metatarsal, except in those less
than 5 years in which the first metatarsal is most
often affected. It is often a small buckle of the
base, and may be missed. Crush injuries must be
carefully assessed for compartment syndrome as
they are indicative of a significant energy force.
X-rays should include AP, lateral and
oblique views.
Many fractures can be treated non-operatively
in a weight-bearing cast for 36 weeks depending
on the age of the child. Significant displacement
and angulation of the middle metatarsals can be
accepted particularly in the young child, since it
will remodel. However, in the older child,
displaced and angulated fractures may require
reduction as there is less remodelling capacity,
and residual deformity may have significant
impact on weight-bearing dynamics. Finger traps
can be used on the affected toes if closed reduction
is difficult, and percutaneous K wires can be added
to aid stability if necessary. K wire fixation of the
first and 5th metatarsals may be particularly useful
in the case of multiple fractures to help maintain
reduction of fractured middle metatarsals.
Open fractures, irreducible fractures, and frac-
tures that cannot be held reduced by a cast may
require open reduction and internal fixation.
A dorsal skin incision is made over the fracture.
A K-wire is then drilled antegrade out of the
distal fragment, followed by reduction and retro-
grade pinning.
Base of 5th Metatarsal Fractures
Avulsion fractures of the base of the 5th meta-
tarsal are thought to arise due to the pull of
peroneus brevis or abductor digiti minimi.
A normal apophyseal growth centre may be pre-
sent between the ages of 8 and 1215, and can
lead to diagnostic difficulty. However, a fracture
is usually transverse, whereas the apophyseal
line is more vertical. Clinical examination
should help, although a traumatic avulsion of
S. Tennant
the apophysis can also occur. In the case
of either a fracture or apophyseal avulsion,
a below-knee weight-bearing cast should be
worn for 36 weeks.
Jones Fracture
Sir Robert Jones described his own 5th metatarsal
fracture and gave fractures which occur at the
metaphyseal-diaphyseal junction his name. Due
to a limited blood supply, healing is often delayed.
These fractures must be treated with a non-weight-
bearing cast and monitored carefully, although in
athletes some would advocate immediate intra-
medullary screw fixation [24, 32].
Phalangeal Fractures
Fractured toes rarely require more than taping
or other symptomatic protection. Occasionally
significant angulation requires closed reduction,
sometimes with percutaneous K wires. Care
should be taken with stubbed great toes, as if the
nail bed is also damaged in association with a
fracture, this is technically an open fracture, at
risk of infection, and the wound should be cleaned
and dressed and the patient given antibiotics.
Intra-articular fractures of the big toe proximal
phalanx require accurate reduction if displace-
ment is greater than 2 mm and sometimes internal
fixation is necessary.
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