Review Article

Pediatric Physeal Ankle Fracture

Abstract
Thomas H. Wuerz, MD, MSc David P. Gurd, MD

Ankle fracture is the second most common fracture type in children, and physeal injury is a particular concern. Growing children have open physes that are relatively weak compared with surrounding bone and ligaments, and traumatic injuries can cause physeal damage and fracture. Tenderness to palpation over the physis can aid in the clinical diagnosis of ankle fracture. Swelling, bruising, and deformity may be identied, as well. Plain radiographs are excellent for initial evaluation, but CT may be required to determine displacement and to aid in surgical planning, particularly in the setting of intra-articular fractures. The SalterHarris classication is the most widely used system to determine appropriate management and assess long-term prognosis. Complications of physeal injury include shortening and/or angular deformity. Tillaux and triplane fractures occur in the 18-month transitional period preceding physeal closure, which typically occurs at age 14 years in girls and age 16 years in boys. Management is determined by the amount of growth remaining, with the intent of maintaining optimum function while limiting the risk of physeal damage and joint incongruity.

From the Cleveland Clinic Foundation, Cleveland, OH. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Wuerz and Dr. Gurd. J Am Acad Orthop Surg 2013;21: 234-244 http://dx.doi.org/10.5435/ JAAOS-21-04-234 Copyright 2013 by the American Academy of Orthopaedic Surgeons.

n growing children, the physes tend to be more susceptible to injury than the surrounding tissues. This is especially true during the adolescent growth spurt, in which both activity and growth are accelerated. Ankle injuries are among the most common injuries sustained by children.1 In children aged 10 to 15 years, ankle injuries are second only to those of the wrist and hand.2-4 Ankle injuries account for approximately 9% to 18% of physeal injuries. The deltoid ligament provides medial ligamentous stability to the ankle. The lateral ligamentous stabilizers are the posterior talofibular ligament, calcaneofibular ligament, and anterior talofibular ligament. The distal stabilizers of the tibia and fibula are the posterior tibiofibular

ligament and the anterior tibiofibular ligament. These ligaments attach to the epiphysis of the tibia and fibula, respectively, and are generally stronger than the growing physis; thus, traumatic ankle injuries are more likely to cause physeal and osseous injury than ligamentous injury. The distal tibial physis accounts for 45% of overall tibial growth.5 Growth typically continues until age 14 years in girls and age 16 years in boys.6 Prior to complete closure, there is an 18-month transitional period in which specific injuries can occur (ie, Tillaux, triplane). During this period, the physis begins closure centrally, followed by closure anteromedially and posteromedially and, finally, laterally. The unfused portions of the physis are at risk of injury during this period.

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History
Typically, pediatric ankle injury occurs with a twisting mechanism to the lower leg during sport or play. Sports that involve lateral motion and jumping have the highest risk of inversion and eversion ankle injuries. Both of these common injury types cause pain and swelling, and it is difficult to differentiate between sprain and fracture. Persistent inability to bear weight is indicative of fracture.7

Physical Examination
A thorough examination should be performed, focusing on skin defects, swelling, neurologic deficits, vascular injury, and deformity. Sensation should be checked on the plantar and dorsal aspects of the foot. The sensory nerves for the dorsum of the foot are the saphenous nerve (medial) and the sural nerve (lateral). The superficial peroneal nerve supplies the middle portion, with the exception of the great toe web space, which is innervated by the deep peroneal nerve. The lateral plantar nerve innervates the lateral one fourth of the plantar surface, and the medial plantar nerve innervates the medial three fourths. Motor evaluation can be performed with toe flexion and extension. In particular, the examiner should evaluate the function of the extensor hallucis longus muscle as well as ankle dorsiflexion, plantar flexion, inversion, and eversion. If the dorsalis pedis and posterior tibialis pulses are not evident on palpation, a Doppler probe should be used to assess for signals. Capillary refill to the toes is useful in checking for distal perfusion. Abnormal findings warrant further vascular assessment with a Doppler probe. Palpation above and below the ankle can help
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to rule out associated injuries such as Maisonneuve fracture, which is rare in adolescents, and fifth metatarsal fracture, which is commonly associated with inversion or rotation injuries. Pain, swelling, and ecchymosis are common with both fracture and sprain. The integrity of the soft tissue affects the timing of surgical intervention. Excessive swelling and fracture blisters warrant delayed surgical intervention because of increased risk of wound healing problems and infection. Immobilization and elevation are warranted until the swelling has largely resolved. Syndesmotic sprain presents with tenderness over the anterior tibiofibular ligament or pain when the foot is dorsiflexed and externally rotated. Signs of compartment syndrome include excruciating pain, especially in association with painful passive motion, significant swelling, and potential motor and sensory deficits.

Fracture Classications Salter-Harris

The Salter-Harris classification of physeal fractures is the most commonly used anatomic system11 (Figure 1). It is simple, and each injury type has prognostic significance. Type I fractures extend through the growth plate only and do not enter the metaphysis or epiphysis. Type II fractures extend through the physis and metaphysis. Type III fractures involve the physis and epiphysis. Type IV fractures involve the epiphysis, physis, and metaphysis. Type V fractures are crush injuries to the physis. The risk of physeal arrest is lower with type I and II injuries than with types III, IV, and V. Type III and IV injuries often require open reduction and internal fixation (ORIF) to minimize articular incongruity and to reduce the risk of physeal arrest by facilitating reduction of the physis.12 The risk of growth arrest is higher in type IV injuries because they encompass the epiphysis, physis, and metaphysis. Left displaced, metaphyseal bone can heal to epiphyseal bone, creating a bony bridge across the physis and compromising further growth. Type V injuries are at increased risk of growth disturbance because of the local crush injury and damage to the physis. Type V fractures are difficult to identify initially, which often delays management and further increases the risk of longterm sequelae of growth disturbance. These fractures are rare, however. Perichondrial ring injuries have been proposed as a distinct sixth category. These result from direct open injuries or from trauma caused by surgical dissection.

Imaging
AP, mortise, and lateral radiographs should be obtained of patients with persistent ankle pain, especially those who cannot bear weight. According to the Ottawa Ankle Rules, radiographs should be obtained if the patient cannot bear weight immediately after the injury and for four steps at the time of evaluation, and in the presence of bone tenderness at the posterior edge or tip of either malleolus.7 MRI has been shown to provide superior anatomic detail and information regarding fracture lines.8 MRI can also aid in diagnosing cartilaginous, ligamentous, and tendinous injury. CT can be invaluable in surgical planning, particularly for intraarticular fractures, because it offers enhanced delineation of fracture alignment and displacement.9,10

Lauge-Hansen
The Lauge-Hansen classification is the most commonly used system for defining mechanism of injury of an-

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Figure 1

Illustration of the Salter-Harris classication of pediatric ankle fractures. A, Type I. B, Type II. C, Type III. D, Type IV. E, Type V. The arrow indicates a compressive force. (Copyright Cleveland Clinic Foundation, 2011, Cleveland, OH.)

Figure 2

Illustration of the Dias-Tachdjian classication of pediatric ankle fracture. A, Supination-inversion. B, Pronation/ eversionexternal rotation. C, Supinationplantar exion. D, Supinationexternal rotation. (Copyright Cleveland Clinic Foundation, 2011, Cleveland, OH.)

kle fractures.13 It is based on several clinical and experimental studies and was developed to classify ankle fractures in adults. Dias and Tachdjian14 developed their own pediatric ankle fracture classification based on the principles of the Lauge-Hansen and SalterHarris systems (Figure 2). The four Dias-Tachdjian types are supinationinversion, pronation/eversionexternal rotation, supinationplantar

flexion, and supinationexternal rotation. The first term in each pairing indicates the position of the foot at the time of injury, and the second indicates the direction of the force of injury. Two additional fracture patterns have since been added: juvenile Tillaux and triplane. A vertical compression fracture was subsequently added; it has the same implications as Salter-Harris type V injury.14

Management
Displaced physeal fractures must be reduced in a timely fashion. Those older than 1 week are at increased risk of physeal damage during the reduction maneuver. Some patients do not seek prompt medical attention. In grossly displaced fractures, the physician must weigh the risk of persistent fracture displacement against the risk of iatrogenic physeal dam-

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Figure 3

Figure 4

A, AP radiograph demonstrating a Salter-Harris type III fracture of the medial malleolus. B, AP uoroscopic image obtained following fracture reduction and screw xation. AP radiograph demonstrating a Salter-Harris type II fracture of the distal tibia with associated bular shaft fracture. Displacement is easily visualized.

age. The patient should be followed until near skeletal maturity to assess for physeal damage and deformity.

Salter-Harris Type I and II Fractures

Salter-Harris type I and II fractures have a low incidence of physeal arrest and typically are managed similarly. Type I fractures represent approximately 15% of distal tibial physeal fractures.15 The physis is disrupted through the zone of hypertrophy. Type II fractures account for approximately 40% of distal tibial fractures. The fracture crosses through the zone of hypertrophy and exits through the metaphysis, creating a triangular fragment (ie, ThurstonHolland fragment) (Figure 3). Displaced Salter-Harris type I and II fractures should be reduced to minimize subsequent growth disturbances. For physeal fractures in general, reduction is required in the
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presence of either an intra-articular gap of 2 mm or a step-off of 2 mm.16 In type I and II fractures in particular, a residual physeal gap of 3 mm has been found to be a significant risk factor for premature physeal closure.17 The acceptable degree of angulation has not been well established.18 However, angular deformity is associated with increased contact pressures in the ankle joint.19 Reduction should be attempted in as few attempts as possible, preferably only once or twice, to prevent further physeal injury. Reduction must be done under sufficient sedation or anesthesia. For well-reduced fractures, cast treatment of 4 to 6 weeks leads to good results. If closed reduction is not successful, open reduction should be performed. Failure of closed reduction is often caused by interposed soft tissue, such as periosteum or tendon. Typically, the fracture site is approached from the tension side (ie, the side on which the fracture gap is located) to gain access to interposed soft tissue. Fol-

lowing removal of the soft tissue, the fracture is reduced. These fractures usually are stable, and internal fixation is rarely necessary. Unstable fractures are managed with either ORIF or percutaneous fixation. The Thurston-Holland fragment provides an area of bone for screw placement and avoids fixation across the physis. Screws are inserted parallel to the physis to achieve a stable configuration. Two screws are typically used. If the fragment is too small for screw fixation, smooth wires can be used; these wires should be removed following fracture healing.

Salter-Harris Type III Fracture

This fracture type accounts for approximately 25% of distal tibial fractures.16-18,20 The fracture extends through the physis and exits through the epiphysis (Figure 4). Such fractures are frequently associated with intra-articular incongruity and physeal damage. Type III injuries are typically seen with medial malleolus

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Figure 5

Sagittal (A), coronal (B), and axial (C) CT scans of a displaced Salter-Harris type IV triplane fracture involving the metaphysis, physis, and epiphysis.

fractures and Tillaux fractures. Joint incongruity and growth disturbance are long-term risks of type III fracture. Incongruence within the joint can lead to abnormal articular cartilage forces and early cartilage degeneration. Displacement <2 mm should be managed nonsurgically with a long leg nonweight-bearing cast for 4 weeks, followed by a boot for 4 weeks. The patient is allowed to remove the boot for range-ofmotion exercises but must remain nonweight-bearing for the first 2 weeks. ORIF is recommended for all fractures with >2 mm of residual displacement after closed reduction.21 Typically, a medial approach is used for medial malleolar fractures and an anterolateral approach for Tillaux fractures. Unless the physes are near complete closure, fixation across the physis should be avoided. Preferably, screw fixation is achieved parallel to the physis and articular surface while remaining within the epiphysis. It is acceptable for smooth pins to cross the physis to achieve fracture fixation. However, the pins should be removed once the frac-

ture is stable and early healing has occurred. When using transepiphyseal cannulated screw fixation, the surgeon should consider removing the screws once the fracture is healed because peak contact pressures have been shown to be significantly increased with epiphyseal screws.22 Alternatively, bioabsorbable screws can be used, with similar outcomes; screw removal is not required.1

Salter-Harris Type IV Fracture

These fractures, which traverse the metaphysis, physis, and epiphysis, represent approximately 25% of distal tibial fractures16,17 (Figure 5). Type IV injury is seen with triplane fractures and shearing injuries to the medial malleolus. Patients with nondisplaced fractures are treated in nonweight-bearing long leg casts for 4 weeks, followed by non weight-bearing in a boot for 2 weeks and commencement of range-ofmotion exercises, followed by weight bearing in the boot for another 2 weeks.20

A step-off or gap >2 mm must be managed with ORIF to minimize articular incongruity and physeal bar formation. Medial malleolus fractures are managed with a medially directed approach using a J incision. A combination of metaphyseal and epiphyseal screw fixation can create a stable construct. The fibular fractures that typically present with Salter-Harris type IV distal tibial fractures are Salter-Harris type I and II injuries. These fractures usually are stable following reduction of the tibial fracture. Fractures fluoroscopically deemed to be unstable should be managed with internal fixation.

Salter-Harris Type V Fracture

These rare fractures are caused by compressive forces across the physis.16-18 Type V fractures are difficult to diagnose on initial radiographs. Physical examination elicits discomfort over the physis, but initial radiographs may not show definitive fracture. Growth arrest is a major concern. If recognized early after

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injury, excision of the damaged portion of the physis and placement of a fat graft may prevent deformity. These fractures, however, are frequently diagnosed months or years after injury and after the development of limb-length discrepancy or angular deformity. Late management is performed to correct limb-length discrepancy or angular deformity.

jury.24 Alternatively, in our experience, a pneumatic walking boot can be used.

Transitional Fracture
The distal tibial physis closes at approximately age 14 years in girls and age 16 years in boys.6 Prior to complete physeal closure, there is a transitional period lasting approximately 18 months in which the physis begins to close in a consistent fashion. Closure begins centrally, followed by anteromedial, posteromedial, and lateral closure. Transitional fractures occur in this period. While the physis remains open, the lateral aspect of the distal tibial physis is weaker, which makes this area more susceptible to injury when it is stressed. External rotation of a supinated foot, a common sports-related injury, can lead to separation of the anterolateral from the anteromedial quadrant of the epiphysis.25 Approximately 7% to 15% of all physeal fractures in adolescents are transitional fractures.20 Such fractures that involve the epiphysis only are juvenile Tillaux fractures. Triplane fractures extend into the metaphysis of the distal tibia.

Salter-Harris Type VI Fracture

This rare physeal injury represents a perichondrial ring injury; it is typically caused by a lawnmower scalping the medial ankle, but it can occur through indirect forces from athletic injuries or traffic injuries resulting in closed fractures.23 Closed fractures with minimal displacement (<2 mm) can be managed nonsurgically with immobilization. Displacement >2 mm must be managed with either closed reduction and percutaneous pinning or ORIF. Open scalping injuries require dbridement of the area of the perichondrial ring or plastic surgery with skin grafting and/or musculocutaneous grafting. Such injuries are difficult to manage and frequently result in physeal closure.

Isolated Distal Fibular Fracture

Most isolated distal fibular fractures are Salter-Harris type I or II injuries. Often, they are the result of lowenergy trauma. Typically, these isolated fractures heal well when managed with a short leg walking cast. Salter-Harris type III and IV injuries are rare. The treating physician must take care to distinguish fracture from an accessory ossification center (os fibulare). This anatomic variant is located at the distal tip of the fibula and should not be misinterpreted as an avulsion fracture. Immobilization in a short leg walking cast has been recommended for this specific inApril 2013, Vol 21, No 4

Tillaux Fracture
The juvenile Tillaux fracture involves the anterolateral aspect of the distal tibia in adolescents.26 These SalterHarris type III fractures extend through the physis and epiphysis and exit intra-articularly; they account for 3% to 5% of pediatric ankle fractures.16,18 The fracture can be produced experimentally by everting a supinated foot. The anterior tibiofibular ligament attaches to the anterolateral distal tibial epiphysis; when an external rotation force is applied, the ligament causes avulsion fracture at the level of the open

growth plate. The fracture line extends horizontally through the physis and vertically through the epiphysis, creating an intra-articular fracture. Typically, the patient is too sore to bear weight on examination. Swelling and ecchymosis can be identified anterior to the ankle. There may be diffuse tenderness throughout the ankle, and point tenderness is elicited on the anterolateral aspect of the distal tibia. The fracture line is best seen on a mortise view. However, true delineation of the amount of displacement is difficult because of osseous overlap. CT is warranted in cases in which displacement >2 mm is suspected (Figure 6). CT better defines fracture displacement and can aid in surgical planning. Tillaux fractures are intra-articular, and those that are displaced can cause altered joint stresses and early degenerative changes.27 Patients with nondisplaced fractures are treated with 4 weeks in nonweight-bearing long leg casts applied in internal rotation, followed by nonweightbearing in a boot for 2 weeks while range-of-motion exercises out of the boot are started, after which weight bearing in the boot for another 2 weeks is allowed.28 Patients must be followed closely initially, with radiologic imaging performed to verify adequate alignment during cast treatment. Displaced fractures must be reduced. Manderson and Ollivierre29 described a technique for closed reduction using dorsiflexion and internal rotation. For fractures with mild displacement, it may be possible to improve alignment using a cast applied in internal rotation. Reduction and screw fixation is indicated for fractures with either displacement >2 mm or translation >1 mm30-32 (Figure 7). Typically, an anterolateral approach is used. Lintecum and Blasier33 described a method focusing on direct visualization for ORIF. Schlesinger and

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Wedge34 reported on six patients in whom closed reduction failed. However, they successfully manipulated the fracture fragments with the use of 2-mm smooth Steinmann pins, which were stabilized with 1.6-mm Kirschner wires. These wires were removed 6 weeks postoperatively. All patients were able to return to athletic activity. Long-term results of treatment of Tillaux fractures have been very good.35 Because there is minimal to no growth remaining, fixation that crosses the physis is unlikely to cause complications. Bioabsorbable implants also can be used.1 These patients are near the end of growth and physeal function, and thus, the risk of physeal damage with resultant deformity is low.17

fractures account for 5% to 15% of pediatric ankle fractures.18 Average patient age is 13 years (range, 10 to 17 years). This fracture typically occurs when a supinated foot is subjected to external rotation forces.30 AP, lateral, and mortise radiographs are essential for initial diagnosis (Figure 8). CT is valuable for
Figure 6

assessing the fracture configuration and for surgical planning (Figure 5). Jones et al31 reported that all surgeons questioned changed surgical planning for screw position after reviewing the CT scan. Management of triplane fractures depends mostly on the amount of displacement visualized on CT. Cast

Triplane Fracture
Triplane fractures are a subgroup of Salter-Harris type IV injuries. Typically, the fracture line is in sagittal orientation within the epiphysis, axial through the physis, and coronal within the metaphysis (Figures 5 and 8). Many variants of this fracture have been described.36-40 Triplane
Figure 7

Axial (A) and coronal (B) CT scans of a Tillaux fracture. Note the SalterHarris type III fracture with displacement.

AP (A), mortise (B), and lateral (C) radiographs demonstrating metallic screw xation of a Tillaux fracture.

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Figure 8

AP (A) and lateral (B) radiographs of an ankle with a triplane fracture and distal bular fracture.

Figure 9

AP (A) and lateral (B) uoroscopic images obtained following surgical xation of a triplane fracture.

ported that fractures with <2 mm of displacement did well following closed reduction, but fractures with >2 mm displacement developed degenerative changes and discomfort. ORIF is the traditional surgical option for triplane fractures42 (Figure 9). Lintecum and Blasier33 reported good results with an anterior surgical approach and percutaneous screw fixation to achieve anatomic alignment. Some surgeons have performed closed reduction and percutaneous fixation in an attempt to minimize length of the incision and scar irritation. Castellani et al43 devised a method using Kirschner wires as joysticks to manipulate fractures that were difficult to reduce. This approach enabled the use of small incisions. They reported good results, with a complication rate of 8.3%, including transient neuropathy and hardware irritation. Retained transepiphyseal metallic screws have been shown to significantly increase peak contact pressures over baseline; thus, removal is recommended.22 Podezswa et al1 compared bioabsorbable screw fixation with metallic screw fixation and reported similar results with each type. Each group had some loss of fixation requiring further surgery. Physeal damage and partial physeal closure occur in approximately 7% to 21% of cases.20,21,25,32 Longterm studies have not shown difficulties caused by physeal closure.32 This is likely because growth stops shortly after treatment. Patients in whom >2 years of growth is expected should be followed more closely.

immobilization is used for minimally displaced (<2 mm) and nondisplaced fractures. A long leg cast is used initially to help control rotation. Placing the foot in internal rotation may help reduce the displaced fracture
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and maintain alignment. Postreduction CT can be used to confirm satisfactory alignment. Long-term studies have shown reduction to be beneficial for fractures with >2 mm displacement.17,30,36,39 Rapariz et al41 re-

Growth Disturbance After Physeal Injury

In growing children, physeal ankle fractures have the potential to cause growth disturbance. The incidence of

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partial or complete premature physeal closure varies by fracture type, with closure in 2% to 40% of SalterHarris type I and II fractures and in 8% to 50% of type III and IV fractures.44-47 Physeal closure also was more likely in the setting of displacement >3 mm or periosteum trapped in the fracture site of SalterHarris type II fractures.44-48 Leary et al49 found that high-energy trauma (eg, motor vehicle accident) was more likely to cause growth arrest than either low-energy trauma or sports-related injuries. Every 1 mm of displacement increased the risk of physeal damage by 15%. Children with physeal ankle fracture should be followed and evaluated for signs of growth arrest or deformity for 2 years following the initial injury. Sclerotic lines are often seen radiographically within the metaphysis once the fractured bone resumes normal longitudinal growth. Figure 10 illustrates the appearance of physeal closure with resulting growth arrest lines. Lines that are not parallel to the physis are indicative of partial growth arrest. Partial arrest affects only part of the physis, which can result in increasing angular deformity in addition to limblength discrepancy. Surgical intervention may be indicated in patients with substantial growth remaining. Medial-sided growth arrest results in varus angulation, limb-length discrepancy, and relative fibular overgrowth, often with lateral impingement. Complete growth arrest affects most of the physis, resulting in limblength discrepancy. This is a concern in young children with significant growth remaining. In patients who are close to skeletal maturity at the time of injury, limb-length discrepancy is minimal, and intervention is not required. Complete distal tibial growth arrest results in relative fibular overgrowth and, potentially, lateral impingement.

Figure 10

Figure 11

AP radiograph demonstrating growth arrest lines (arrows) following ankle fracture in a pediatric patient. These lines lie parallel to the adjacent physes and thus do not represent asymmetric growth.

CT scan demonstrating evidence of bony bridging across the physis in a pediatric patient who sustained a Salter-Harris type IV fracture of the medial malleolus.

In the patient with substantial angular deformity, osteotomy can reestablish the mechanical axis. The degree of acceptable angular deformity has not been well established. In children who are close to skeletal maturity, the expected limb-length discrepancy is small, so in the absence of angular deformity, no corrective measure is required. Epiphysiodesis of the distal fibula should be considered to limit fibular overgrowth and resulting lateral impingement and concomitant lateral overload of the ankle. In younger children, physeal bar resection may be considered if <50% of the physis is compromised and >2 years of growth remain48,50 (Figure 11). The extent of physeal involvement is determined with CT or MRI. CT is typically best for delineating the extent of growth arrest in planning for a bar resection. Typically, peripheral physeal bars

are approached directly. Excision of the overlying periosteum and removal of abnormal bone is extended until normal physeal cartilage is uncovered. This resection may be performed instead of osteotomy in patients with angular deformity <20.50 Central bars can be reached by drilling through a metaphyseal window or through an osteotomy in cases that require concomitant correction of an angular deformity.51,52 Following excision of the bar, the resulting defect is filled with adipose tissue or cement (Figure 12). Contralateral epiphysiodesis can be performed as well to prevent limb-length discrepancy following bar formation.

Summary
Physeal ankle fractures in children warrant special consideration with regard to the amount of displacement, the possibility of growth plate injury, management, and the amount of physeal growth remaining. Children are susceptible to such fractures

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diagnosis of distal tibia fractures in adolescents. J Pediatr Orthop 2003; 23(6):727-732. 9. Krrholm J, Hansson LI, Laurin S: Computed tomography of intraarticular supination - eversion fractures of the ankle in adolescents. J Pediatr Orthop 1981;1(2):181-187. Seitz WH Jr, LaPorte J: Medial triplane fracture delineated by computerized axial tomography. J Pediatr Orthop 1988;8(1):65-66. Salter RB, Harris WR: Injuries involving the epiphyseal plate. J Bone Joint Surg Am 1963;45(3):587-622. Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9(4):268278. Lauge-Hansen N: Fractures of the ankle: II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 1950;60(5): 957-985. Dias LS, Tachdjian MO: Physeal injuries of the ankle in children: Classification. Clin Orthop Relat Res 1978;(136):230233. Mizuta T, Benson WM, Foster BK, Paterson DC, Morris LL: Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop 1987;7(5): 518-523. Caterini R, Farsetti P, Ippolito E: Longterm followup of physeal injury to the ankle. Foot Ankle 1991;11(6):372-383. Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23(6):733-739. Bible JE, Smith BG: Ankle fractures in children and adolescents. Techniques in Orthopaedics 2009;24(3):211-219. Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C: The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle 1987;7(5):290-299. Krrholm J: The triplane fracture: Four years of follow-up of 21 cases and review of the literature. J Pediatr Orthop B 1997;6(2):91-102. Kling TF Jr, Bright RW, Hensinger RN: Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am 1984;66(5):647-657. Charlton M, Costello R, Mooney JF III, Podeszwa DA: Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia. J Pediatr Orthop 2005;25(5):635-640. Havranek P, Pesl T: Salter (Rang) type 6

Figure 12

10.

11.

12.

13.

Illustration demonstrating management of a physeal bar. A, Drilling to the affected physis and excision of the bar. B, Placement of adipose tissue to prevent further bar formation. (Copyright Cleveland Clinic Foundation, 2011, Cleveland, OH.)

14.

because of the relative weakness of the physis compared with the surrounding structures. The type of physeal fracture is one factor used to determine the likelihood of growth arrest. Transitional fractures occur within the 18-month period leading up to physeal maturation. CT can be helpful in determining displacement and in surgical planning. The goals of management are to maintain optimum function while limiting the risk of physeal damage and joint incongruity. The literature is lacking in level I clinical studies comparing different treatment modalities and long-term outcomes.

Copley LA: Comparison of bioabsorbable versus metallic implant fixation for physeal and epiphyseal fractures of the distal tibia. J Pediatr Orthop 2008;28(8):859-863. 2. King J, Diefendorf D, Apthorp J, Negrete VF, Carlson M: Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 1988;8(5):585-589. Peterson HA, Madhok R, Benson JT, Ilstrup DM, Melton LJ III: Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979-1988. J Pediatr Orthop 1994;14(4):423-430. Mann DC, Rajmaira S: Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop 1990; 10(6):713-716. Birch JG: Growth and development, in Herring J, Tachdjian MO, eds: Tachdjians Pediatric Orthopaedics, ed 4. Philadelphia, PA, Saunders, 2008, pp 3-22. Johnson EW Jr, Fahl JC: Fractures involving the distal epiphysis of the tibia and fibula in children. Am J Surg 1957; 93(5):778-781. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR: A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21(4): 384-390. Seifert J, Matthes G, Hinz P, et al: Role of magnetic resonance imaging in the

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Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 1 and 49 are level III studies. References printed in bold type are those published within the past 5 years.
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