Immature Skeleton/
Ankle Classifications
Ankle Classifications
The _______ is an area of fibroblasts, chondroblasts, and osteoblasts, providing peripheral growth of the physis. Both the perichondrial ring of La Croix and ______ provide additional stability to the region of the metaphysis and epiphysis
The zone of Ranvier is an area of fibroblasts, chondroblasts, and osteoblasts, providing peripheral growth of the physis. Both the perichondrial ring of La Croix and zone of Ranvier provide additional stability to the region of the metaphysis and epiphysis
Describe the distal tibial physeal closure pattern
In adolescence, the growth of the distal tibia physis begins closure centrally and extends medially first over a 12-18-month period. The anterolateral corner of the physis is the area last to close explaining the Tillaux fracture pattern.
Name 2 classifications for talar body fractures
Sneppen classification and Fortin Group
How do you examine a 3 year old for an occult cuboid fracture?
If lateral foot pain is elicited with the examiner holding the heel, and abducting the forefoot, this may be a sign of an occult cuboid fracture
Most of the metatarsal fractures in the pediatric age group are either ____ or ____ metatarsal fractures
Most of the metatarsal fractures in the pediatric age group are either first or fifth metatarsal fractures
The peak incidence of physeal fractures occurs between the ages of ___ and ___ years in females. In males, the peak incidence is slightly older at ___ years of age
The peak incidence of physeal fractures occurs between the ages of 11 and 12 years in females. In males, the peak incidence is slightly older at 14 years of age
Displaced SH I-II: If there is ___ mm of physeal displacement on the injury film, there is a ___% increase risk of growth arrest over nondisplaced injuries
Displaced SH I-II: If there is >3 mm of physeal displacement on the injury film, there is a 70% increase risk of growth arrest over nondisplaced injuries
How long should you follow a talar neck fracture?
18-24 months because of risk of AVN
In a 12-year retrospective review, 56 Lisfranc injuries in children and teenagers were identified from 3563 metatarsal fracture patients. In this retrospective review, all of the 56 Lisfranc injuries occurred in patients over ___ years of age.
In a 12-year retrospective review, 56 Lisfranc injuries in children and teenagers were identified from 3563 metatarsal fracture patients. In this retrospective review, all of the 56 Lisfranc injuries occurred in patients over 11 years of age.
Double Jeopardy
Studies providing recommendations on the criteria for the amount of displacement for metatarsal fractures in children and adolescents are lacking. Consideration for reduction of metatarsal fractures in adults is suggested for____mm of displacement of the metatarsal fracture and >____ degrees of angulation in the sagittal plane
Studies providing recommendations on the criteria for the amount of displacement for metatarsal fractures in children and adolescents are lacking. Consideration for reduction of metatarsal fractures in adults is suggested for 4 mm of displacement of the metatarsal fracture and >10 degrees of angulation in the sagittal plane
Double Jeopardy
Name 2 pediatric ankle fracture classification systems
Salter-Harris and Dias-Tachdjian
Name the fixation used for author's preferred treatment of displaced distal tibia SH I? SH II?
SH I: 1.6-, 2.0-, or 2.4-mm smooth cross pins are used depending on patient size
SH II: percutaneous cannulated 4.0- or 4.5-mm screw(s) are placed using a lag technique within the metaphysis above the physis
In a displaced type II talar neck fracture, _______ with _______ is a typical maneuver to realign the fracture
In a displaced type II talar neck fracture, plantarflexion with pronation is a typical maneuver to realign the fracture
Adult recommendations are that patients with a >___ mm gap at the base of the second metatarsal to have a reduction of the injury performed. The talometatarsal angle of 15 degrees or more was associated with poor outcomes by Myerson et al., so a talometatarsal angles >___ degrees should be evaluated for intervention
Hill et al. found that 67% of patients with closed physes underwent open reduction and internal fixation.
Myerson et al. reported patients with good results had an average first metatarsal second metatarsal base distance of 2.9 mm and an average lateral talometatarsal angle of 5 degrees
Adult recommendations are that patients with a >2 mm gap at the base of the second metatarsal to have a reduction of the injury performed. The talometatarsal angle of 15 degrees or more was associated with poor outcomes by Myerson et al., so a talometatarsal angles >5 degrees should be evaluated for intervention
What is the post-operative management for screw fixation for a Herrera-Soto type II/III?
Herrera-Soto type I avulsions of the apophysis are treated with a below knee cast or fracture boot depending on comfort. Weight bearing is often delayed for 2-3 weeks, but once comfortable, weight bearing is allowed. After 3-4 weeks, patients are changed to a fracture boot if they are in a cast. Rehabilitation begins around 8 weeks and anticipated return to activity occurs at 12 weeks.
Type II Herrera-Soto fractures are treated non–weight bearing in a cast until healing is visualized. These are slow to heal, and resorption of bone across the fracture site is common. Progressive displacement does occur. It may take longer than 8 weeks to heal and up to 3 months to achieve adequate union for return to activity.
The displaced Herrera-Soto type II fractures within 20 mm of the tip of the tuberosity have marginal fixation with a screw. If operative screw fixation is performed for a fracture within 20 mm of the tuberosity (Herrera-Soto type II), the postoperative treatment is non–weight bearing. Weight bearing is delayed until fracture healing occurs to avoid loss of fixation. In those patients with >3-5 mm of displacement, surgery is discussed if there is a possibility of adequate screw fixation. A surgical failure with loss of fixation is difficult to address. Attentive postoperative patience regarding weight bearing is a must.
For patients with Herrera-Soto type III fracture (the Jones fracture), surgery with screw fixation is discussed. In active patients, this is often chosen. If patients choose nonoperative treatment, non–weight-bearing immobilization is used until evidence of healing is seen.
Classify the juvenile Tillaux fracture with the Salter-Harris classification
The juvenile Tillaux is a Salter-Harris III fracture of the anterolateral epiphysis of the distal tibia
The fibula/tibia may reduce with treatment of the fibula/tibia fracture
Displaced fractures of the fibula are often associated with displaced Salter-Harris III and IV fractures of distal tibia.
The fibula may reduce with treatment of the tibia fracture.
Double Jeopardy
Which type of calcaneal fracture is more commonly seen in children, intra-articular or extra-articular?
Extra-articular fractures are more common in children. A total of 60% of the calcaneal fractures in patients <14 years are extra-articular. Under the age of 7 years, the percentage of extra-articular calcaneal fractures approaches 90% of the calcaneal fractures.
As patients reach the age of 14 years, the percentage of extra-articular fractures drops below 40% with the majority of calcaneal fractures having intra-articular involvement.
The hypothesis in the literature has been that the larger cartilaginous component with increased elasticity of the immature calcaneus is protective in the younger age groups. In children, and adolescents, the intra-articular calcaneal fracture patterns that occur tend to have less comminution compared to adult
Lisfranc pin fixation is typically removed at ____ weeks as long as there are no earlier signs of infection
Lisfranc pin fixation is typically removed at 6 weeks as long as there are no earlier signs of infection
Treatment for multiple metatarsal fractures with closed or open reduction is more often considered as patients’ approach 11-12 years of age, with shortening of more than ____ mm, or sagittal plane deformity approaching ____ degrees. Smooth pin fixation is commonly used as the internal fixation choice. Pins are removed at 4 weeks
Closed or open reduction is more often considered as patients’ approach 11-12 years of age, with shortening of more than 4-5 mm, or sagittal plane deformity approaching 10 degrees. Smooth pin fixation is commonly used as the internal fixation choice. Pins are removed at 4 weeks
What is the Salter-Harris classification I-V?
Type I—fracture of physis
Type II—fracture of physis with metaphyseal involvement
Type III—fracture of physis with epiphyseal involvement
Type IV—physeal, epiphyseal, and metaphyseal involvement
Type V—represents a previous injury with no known prior Salter-Harris I-IV pattern presenting with late physeal arrest
Name two ways to manage limb length discrepancy following physeal arrest
Limb length discrepancy can be managed with epiphysiodesis, acute shortening osteotomy, limb lengthening, or physeal bar resection
Name an indication for surgery with a tongue type calcaneal fracture.
Name an indication for surgery with an intra-articular calcaneal fracture.
The tongue fracture may create shortening of the Achilles or skin pressure concerns from fracture fragment displacement. If there is concern regarding soft tissue compromise, then the fracture should be addressed.
If the posterior facet is displaced in a tongue fracture, reduction and internal fixation is performed
Articular gaps or step-offs measuring 2 mm are being used as indications for open reduction and internal fixation
Screw fixation across an open physis base of the first metatarsal may lead to _____ and a _______
Screw fixation across an open physis base of the first metatarsal may lead to growth arrest and a short first ray
Salter-Harris I and II fractures of the great toe proximal phalanx are important to recognize as potentially open injuries. The eponym in the finger for an open fracture at the base of the distal phalanx with a nail bed injury is the “_____” fracture.
Salter-Harris I and II fractures of the great toe proximal phalanx are important to recognize as potentially open injuries. The eponym in the finger for an open fracture at the base of the distal phalanx with a nail bed injury is the “Seymour” fracture. In clinical practice, this fracture may present to the surgeon a few days later with early infection or several weeks later with established osteomyelitis. The initial radiograph may be unimpressive. The nail does not have to be grossly displaced to be an open injury. The patient will have bleeding at the base of the nail or in the area of the eponychial fold. The fracture is through the physis of the distal phalanx, and the displaced fracture tears through the soft tissue disrupting the germinal matrix and nail bed creating an open injury.
Open Salter-Harris I and II fractures of the base of the proximal phalanx require irrigation, debridement, and repair of the nail bed and matrix. Removal of any foreign debris from the physis is performed, and the fracture reduction is done. Smooth pin fixation of the fracture may be indicated to ensure stable reduction and to protect the soft tissue repair. Thorough inspection and irrigation are required. Antibiotic treatment in the literature varies on length of treatment. The literature, which includes hand literature for the similar Seymour fracture, reports a dose of parenteral antibiotics at the time of debridement, which is followed by 7-14 days of oral treatment.