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C OPYRIGHT ! 2012 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Ankle Fractures in Children
Ethan W. Blackburn, MD, David D. Aronsson, MD, James H. Rubright, MD, and Jennifer W. Lisle, MD

Investigation performed at the Department of Orthopaedics and Rehabilitation, McClure Musculoskeletal Research Center,
University of Vermont, Burlington, Vermont

! Computed tomography is useful for preoperative planning and postreduction assessment for intra-articular pe-
diatric ankle fractures.

! Nondisplaced pediatric ankle fractures can be effectively managed with cast immobilization and close radio-
graphic follow-up evaluation.

! Physeal ankle injuries in younger children with considerable growth remaining should be followed closely for at
least one year after injury as growth arrest may result in substantial angular deformity.

! Open reduction and internal fixation should be strongly considered when an articular step-off of <2 mm cannot be
maintained by closed means for Salter-Harris type-III and IV and transitional ankle fractures.

Ankle fractures in children are the third most common fracture
involving the growth plate after finger and distal radial physeal
fractures1,2. The ligamentous anatomy and the complex pro-
gression of physeal closure in the distal tibial and fibular physes
predispose children to age-specific patterns of ankle fractures3.
Epidemiology
Peterson et al. reported that distal tibial physeal fractures rep-
resented 11% (104) of all 951 physeal injuries seen during a
ten-year period1. Children are at risk for physeal ankle injury in
sports requiring sudden changes in direction, such as basket-
ball, soccer, and football4. Scooters and skateboards are also
associated with a high risk of ankle injuries5,6.
There is evidence to support a higher risk of athletic in-
juries in obese children7-9. Body mass index (BMI) is an im-
portant risk factor for ankle sprain in high-school football
players10. Zonfrillo et al.11 conducted a case control study, in-
cluding 180 children with nonspecified ankle injuries and 180
control subjects, and found a significant (p < 0.0001) association
between overweight children (a BMI percentile of ‡95) and
ankle injury.
Anatomy
The ankle is a hinge-type joint that is formed from the artic-
ulation of the talus with the distal ends of the tibia and fibula.
The distal tibial ossification center appears at six to twenty-four
months of age. The distal tibial physis closes during an eighteen-
month period centrally, then medially, and finally laterally with
closure complete at the chronologic age of fifteen years in girls
and seventeen years in boys. Growth in the distal tibial physis
contributes 40% of tibial length or approximately 3 to 4 mm/yr.
There is minimal longitudinal growth from the distal end of
the tibia after the age of twelve years in girls and fourteen years
in boys12.
The distal fibular ossification center appears at nine to
twenty-four months of age, and the distal fibular physis closes
approximately one to two years following the distal tibial
physis. It is important to remember that the fibular growth
plate should be at the same level as the ankle joint on antero-
posterior radiographs.
Accessory ossicles may mimic a fracture on radiographs
(Fig. 1). The os subtibiale is an accessory ossification center of
the medial malleolus present in 0.9% to 20% of individuals,

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of
this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also,
no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence
what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online
version of the article.

J Bone Joint Surg Am. 2012;94:1234-44 d http://dx.doi.org/10.2106/JBJS.K.00682

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Fig. 1
Figs. 1-A through 1-E A ten-year-old girl who was diagnosed with an ankle sprain after an inversion, twisting injury. Fig. 1-A Mortise radiograph demonstrates
an osteochondral defect in the talar dome (red arrow). Fig. 1-B Anteroposterior radiograph, made six months following injury and a trial of immobilization,
demonstrates slightly improved osteochondral defect and a newly formed os subtibiale (yellow arrow), which may be misinterpreted as a new fracture.
Fifteen months after the initial injury and a subsequent fall from standing height, T1-weighted sagittal (Fig. 1-C) and coronal (Fig. 1-D) sequences
demonstrate the persistent osteochondral defect (red arrow). The os subtibiale (yellow arrow) is visible in the coronal view. The patient underwent open
arthrotomy with microfracture for the osteochondral defect. Fig. 1-E Anteroposterior radiograph, made at the two-month postoperative visit, shows the os
subtibiale nearly united with the medial malleolus (yellow arrow). The osteochondral defect demonstrates increased mineralization consistent with healing
(red arrow). Figs. 1-B and 1-E Symmetric Park-Harris lines (blue arrows) are present. Compare these with the asymmetric line in Figure 8.

and the os subfibulare, an accessory ossification center of the
fibula, is present in 2.1% of individuals13,14.
When a child’s ankle is injured, the classic teaching is that
the weaker physis usually fails prior to the stronger ligamentous
complex; however, ligamentous injury may be more common
than previously reported15,16.
When subjected to rotational forces, the anterior inferior
tibiofibular ligament and the posterior inferior tibiofibular
ligament may lead to an avulsion fracture (Fig. 2). When the
distal tibial physis is open, these injuries generally result in
Salter-Harris type-I or II injuries, but as the physis closes from
central medial to anterolateral at puberty, transitional fracture
patterns emerge as ligaments avulse bone adjacent to the re-
maining open physis17.
Evaluation
History and Physical Examination
A complete history and physical examination are critical in diag-
nosing physeal ankle injuries. High-energy injuries, such as motor
vehicle accidents, should raise concern for a possible physeal crush
injury that may not be evident on initial radiographs.
The physical examination should include the entire lower
extremity as there are reports of physeal injuries and premature
physeal closure with ipsilateral tibial diaphyseal fractures18,19. In
patients with an obvious deformity, the foot position will in-
dicate the direction of the deforming force and this knowledge
assists in fracture reduction. Swelling, ecchymosis, and skin
tenting are assessed, and the ankle must be visualized circum-
ferentially to exclude a possible open fracture. Urgent reduc-
tion is required when the soft-tissue envelope is in jeopardy
secondary to excessive skin tenting. The vascular, motor, and
sensory examination should be performed prior to and fol-
lowing any reduction maneuver.
Imaging
Anteroposterior, mortise, and lateral radiographs are required
to fully evaluate the ankle. The mortise radiograph is particu-
larly important to evaluate fractures without obvious deformity
as the tibiofibular overlap might disguise a minimally displaced
fracture20. The routine use of stress views is not recommended
as they are unlikely to change the treatment, are uncomfort-
able, and cause increased radiation exposure.
Advanced imaging is recommended for accurate diag-
nosis, preoperative planning, and assessment of reduction for
intra-articular fractures. Horn et al. compared computed to-
mography (CT) scans with radiographs in a cadaver model of
juvenile Tillaux fractures21. They reported that CT scans and
radiographs are accurate to within 1 mm 50% of the time, but
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Fig. 2
The lateral ligaments of the ankle include the syndesmotic ligaments and the lateral ligamentous complex. The syndesmotic ligaments include the anterior
inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, and the interosseous ligament (not shown). The lateral ligamentous complex
includes the anterior and posterior talofibular ligaments and the calcaneofibular ligament. The anterior inferior tibiofibular ligament and posterior inferior
tibiofibular ligament connect the distal fibular metaphysis with the lateral tibial epiphysis, and the calcaneofibular ligament connects the distal fibular
epiphysis with the lateral aspect of the calcaneus. The medial ligamentous structures include the superficial deltoid ligament, which connects the medial
malleolus to the medial calcaneus and medial aspect of the navicular, and the deep deltoid ligament, which connects the medial malleolus to the talus.

CTscans are more sensitive at detecting fractures displaced >2 mm.
CT scans also improve the surgeon’s ability to accurately plan
screw placement for the treatment of triplane fractures22,23.
Magnetic resonance imaging (MRI) provides fine detail
of bones and soft-tissue structures and does not involve radi-
ation. Carey et al. compared radiographs and MRI scans for
fourteen patients with suspected physeal injuries24. They re-
ported that the MRI scans led to a change in the Salter-Harris
classification for two of the nine patients with fractures seen
on radiographs, and they identified radiographically occult
fractures, which changed the management in five of fourteen
patients. In contrast, Petit et al. compared radiographs with
MRIs for twenty-nine patients with physeal ankle injuries. Only
one patient was misclassified with radiographs, and there
were no changes in the treatment plans because of the MRI
scans25. Lohman et al. studied sixty children with acute ankle
injuries with both conventional radiography and MRI26. Ra-
diographs produced five (18%) of twenty-eight false negatives
for fractures compared with MRI, but no complex ankle fracture
was missed and the MRI did not change the treatment plan in
any case.
Radiography is the imaging standard for pediatric ankle
fractures. The role of MRI remains unclear, but it may be useful
to identify occult fractures, assess for premature physeal clo-
sure, or identify sources of persistent pain after fractures have
healed.
Classification
Pediatric ankle fractures are classified by either the mechanism
of injury or anatomic classification schemes. The Salter-Harris
classification system is simple and reproducible, and it remains
the most widely used system for children’s ankle fractures17,27.
The fracture is classified according to its relationship to the
physis (Fig. 3). Type VI involves open injuries with physeal loss
and has been added to the original Salter-Harris classification
system28. The Dias-Tachdjian (Fig. 3) mechanism of injury
classification is based on the foot position at the time of injury
and the direction of the force29. This classification system is
useful to facilitate fracture reduction.
Triplane ankle fractures are transitional fractures that occur
toward the end of growth and are not easily classifiable with the
Salter-Harris or Dias-Tachdjian systems30. The classic triplane
fracture consists of three parts: a rectangular fragment of distal
tibial epiphysis, a large fragment that includes the remainder
of the epiphysis with a metaphyseal spike, and the tibial shaft.
Two, three, and four-part triplane fractures have been described31-33
(Fig. 4). Shin et al. described intra-articular and extra-articular
intramalleolar variants of the triplane fracture34 (Fig. 5).
The juvenile Tillaux fracture is also a transitional fracture35.
The anterolateral distal tibial physis is the last portion of the distal
tibial growth plate to close, and the anterior inferior tibiofibular
ligament produces an avulsion of an epiphyseal fragment during
an external rotational injury.
Treatment
The decision to treat pediatric ankle fractures is based on the
fracture type, amount of displacement, and the ability to restore
and maintain the alignment of the physis and the congruity of
the ankle joint. If a satisfactory closed reduction can be achieved
and maintained, internal fixation is unnecessary; however, if
closed reduction is unsuccessful, open reduction with or without
skeletal fixation is warranted.
Before a closed reduction is attempted, the child must
be comfortable and relaxed with either intravenous sedation or
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Fig. 3
The Salter-Harris classification system for physeal fractures (top row). Type
I is a fracture that only involves the physis; type II, a fracture through
the physis and metaphysis; type III, a fracture involving the physis and
epiphysis; type IV, a fracture that extends from physis into both the me-
taphysis and epiphysis; and type V, a physeal crush injury. An axial load is
indicated by the black arrow. Type VI, a physeal loss from open fracture,
was not part of the original Salter-Harris classification system. The red
arrow indicates the area of physeal loss. The Dias-Tachdjian classification
system (bottom three rows). Mortise views of variants of supination-inversion
injuries (A through E), lateral view of supination-plantar flexion (F), mortise
view of pronation-eversion-external rotation pattern (G), and mortise and
lateral views of supination-external rotation patterns (H and I). Anterior is
to the left side of the image for all lateral views.
general anesthesia to facilitate the reduction and reduce the risk of
further physeal injury. Ideally, the reduction should be achieved
in one attempt, but Barmada et al. could find no evidence to
AN K L E FR AC T U R E S IN CHILDREN
support the concept that multiple reduction attempts caused a
physeal injury36. Leary et al. found a trend of increased primary
physeal closure with more reduction attempts, but the difference
was not significant37.
Distal Tibial Salter-Harris Type-I Fractures
Spiegel et al. reported that Salter-Harris type-I distal tibial
fractures represented 15.2% (thirty-six) of all 237 ankle fractures
in the children in their study who had a mean age of 10.5 years3,
whereas Leary et al. reported only a rate of 3% (four of 124
fractures)37. In children, distal tibial physeal fractures are rarely
severely displaced without a concomitant fibular fracture38.
We recommend immobilization in a below-the-knee cast,
or a walking boot, for three weeks as it is an effective treatment
for minimally displaced Salter-Harris type-I distal tibial frac-
tures. If there is concern about patient compliance or if the
fracture is unstable, an above-the-knee cast may be preferable.
Displaced Salter-Harris type-I fractures should have
closed reduction with immobilization in a below-the-knee cast.
Radiographic follow-up is recommended in the first week fol-
lowing injury to ensure that there is no recurrent displacement.
We have found that patients may be transitioned to a walking
cast or boot at three to four weeks.
Distal Tibial Salter-Harris Type-II Fractures
Spiegel et al. reported that Salter-Harris type-II distal tibial
fractures were the most common, comprising 38% (ninety-one)
of all 237 pediatric ankle fractures in their study3. Leary et al.
found type-II fractures in 32% (forty) of 124 pediatric ankle
fractures37.
A nondisplaced Salter-Harris type-II distal tibial fracture
may be immobilized in a short or long leg cast for three to four
weeks, followed by weight-bearing in a cast or walking boot for
two to three weeks. Patients with Salter-Harris type-II fractures
should be evaluated clinically and radiographically for a pos-
sible rotational deformity. Phan et al. reported that fourteen
(61%) of twenty-three patients had external tibial rotation
deformities after their distal tibial physeal fractures healed39.
There is controversy as to what represents an acceptable
reduction for displaced Salter-Harris type-II fractures. Spiegel
et al. reported that older children (an average chronologic age
of twelve years and seven months) sustaining type-II fractures
were unable to remodel angular abnormalities3. Six (9%) of sixty-
six patients with adequate follow-up examinations had angular
deformities of >5". The inability to anatomically reduce Salter-
Harris type-I and II distal tibial fractures is often caused by in-
terposed soft tissue, particularly the periosteum. Grace described
three patients in whom the anterior tibial neurovascular bundle
interposition blocked closed reduction of Salter-Harris type-II
distal tibial fractures40.
Barmada et al., in a study of forty-four patients with
Salter-Harris type-I and II distal tibial fractures, noted that
premature physeal closure occurred in 60% (twelve) of twenty
fractures with >3 mm of physeal widening after closed reduction
and in 17% (four) of twenty-four fractures with <3 mm of
physeal widening after reduction36. The authors suggested that
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Fig. 4
Figs. 4-A through 4-G Triplane fractures. Fig. 4-A Two-part fracture with the medial malleolus attached to a large metaphyseal spike. Fig. 4-B Two-part
fracture with the medial malleolus attached to the shaft fragment. Fig. 4-C Three-part fracture with the epiphysis completely detached from the shaft, and
the medial malleolus on the large metaphyseal spike. Fig. 4-D Three-part fracture with a completely detached medial malleolus. Fig. 4-E Three-part fracture
with the medial malleolus attached to the shaft fragment, and a separate anterolateral epiphyseal free fragment. Fig. 4-F Rare four-part so-called
32
quadriplane variant with a double metaphyseal spike as described by van Laarhoven and van der Werken . Fig. 4-G Four-part fracture with free medial
malleolus and anterolateral epiphyseal fragments.

the removal of interposed periosteum to close the physeal gap
may reduce premature physeal closure.
Phieffer et al. used a rat model to determine the effect of
interposed periosteum on physeal bar formation and leg-length
discrepancy41. They reported a small but significant (p < 0.05) leg-
length discrepancy in a physeal fracture group with interposed
periosteum compared with a group of fractures without interposed
periosteum. It is unclear whether this has clinical importance.
Rohmiller et al. reviewed ninety-one type-I and II frac-
tures to determine if the mechanism of injury was related to
premature physeal closure5. The overall rate of premature physeal
closure was 39.6% (thirty-six of ninety-one), and patients who
developed premature physeal closure had greater residual dis-
placement (mean and standard deviation, 3.2 ± 2 mm) following
treatment than those who did not (mean, 2 ± 1.5 mm) (p =
0.007). The treatment types were compared, and open reduction
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Fig. 5
Figs. 5-A, 5-B, and 5-C Intramalleolar triplane fracture variants as described by Shin et al. . Fig. 5-A Intra-articular fracture exiting at the junction of the
plafond and medial malleolus. Fig. 5-B Intra-articular fracture exiting in the articular portion of the medial malleolus. Fig. 5-C Extra-articular fracture.
resulted in the lowest residual displacement (mean, 1.8 ± 1.3 mm),
but this was not significant (p = 0.39). The authors advocated
for operative treatment for fractures with >2 mm of displacement
to remove interposed periosteum.
Leary et al. reported premature physeal closure in 25%
(ten) of forty type-II fractures37. They noted no premature
physeal closure with Salter-Harris type-I fractures. They con-
cluded that Salter-Harris type-II fractures of the distal end of
the tibia are more serious than previously believed as they may
cause premature physeal closure leading to angular deformities
and limb-length discrepancies. There is little evidence to sup-
port routine open treatment to remove interposed periosteum
in fractures displaced <3 mm following reduction; however, the
rate of premature physeal closure in fractures displaced >2 to
3 mm is as high as 60% and warrants consideration for open
treatment to remove interposed soft tissue.
Distal Tibial Salter-Harris Type-III and IV Fractures
Type-III and IV distal tibial fractures are problematic as both
articular incongruity and premature physeal closure must be
considered17. Spiegel et al. reported that forty-six of fifty-two of
these fractures occurred on the medial side of the tibial pla-
fond3. The mean age of the children was eleven years and ten
months for those with a type-III fracture and eleven years and
six months for those with a type-IV fracture, whereas Kling
et al. reported that Salter-Harris type-III fractures occurred in
children between eight and ten years old42.
Type-III and IV fractures result from supination inver-
sion injuries, which are similar to Lauge-Hansen supination
adduction injuries in adults29,43. A study by de Sanctis et al.
suggested that the physeal compression occurring during Salter-
Harris type-III and IV fractures might also result in concomitant
type-V injury to the proliferative layer of the physis44. Schurz
et al. reported that the adduction mechanism of injury causing
Salter-Harris type-III and IV injuries caused greater physeal
damage than the abduction and distraction forces that result in
type-II and III fractures45.
Nonoperative treatment is reserved for nondisplaced
Salter-Harris type-III and IV distal tibial fractures. A short leg
cast is recommended, and careful radiographic surveillance is
AN K L E FR AC T U R E S IN CHILDREN
34
necessary in the first weeks following injury. Kling et al. rec-
ommended radiographic follow-up for at least two years after
injury, but preferably until the patient is skeletally mature42.
There is consensus that displaced Salter-Harris type-III
and IV fractures should be treated with open reduction and
internal fixation3,36,42,44-46. Salter and Harris recommended ‘‘ac-
curate’’ and ‘‘perfect’’ reductions for type-III and IV fractures,
respectively17. Kling et al. found that patients treated with ana-
tomic open reduction and internal fixation were less likely to
have premature physeal closure than those treated by closed
means (p = 0.027)42. Leary et al. treated fractures with >2 mm
of displacement with open reduction and reported a premature
physeal closure rate for Salter-Harris type-III and IV fracture
of only 13%37.
Cottalorda et al. reviewed the cases of forty-eight patients
with Salter-Harris type-II (thirty) or type-IV (eighteen) distal
tibial fractures47. All fractures were displaced >1 mm, meeting
their operative indications, and were treated with open arthrot-
omy and fracture reduction under direct visualization with screw
(forty-six) or pin (two) fixation. They reported forty-five good
and two fair results, and only one patient with angular deformity
(6" of varus) at a mean follow-up of 3.25 years. Schurz et al.
advocated for open reduction in all displaced epiphyseal frac-
tures regardless of age45. Their study found good outcomes in
89% (seventy-three) of eighty-two patients with type-III and
IV fractures. There is not clear scientific evidence for what
represents an acceptable reduction in pediatric intra-articular
ankle fractures. The commonly accepted ‘‘2-mm rule’’ is not
based on clinical or experimental evidence, yet several studies
have demonstrated good results with operative treatment42,44,45,47,48.
Salter-Harris Type-V Fractures
These injuries involve axial or shear loading that damages the
proliferative zone of the physis17. Several studies have noted that
undiagnosed Salter-Harris type-V injuries may contribute to
the high rate of growth disturbance associated with type-III and
IV fractures44,45. No specified treatment algorithm exists for these
injuries. Radiographic follow-up is beneficial for any patient with
major axial or shear force to the ankle, despite initially normal
radiographic findings.
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TABLE I Recommendations for Care

Recommendation Grade*

Nondisplaced ankle fractures in children are effectively treated with cast immobilization for three to six weeks. B
To prevent iatrogenic physeal injury, no more than two closed reduction attempts should be performed. C
All pediatric ankle fractures should be followed for one year to assess for growth disturbance. This is also true for any child B
with a severe axial load (even with normal findings on radiographs) that is concerning for a Salter-Harris type-V physeal injury.
Surgeons should remove interposed periosteum in a Salter-Harris type-II distal tibial fracture when 3 mm of physeal B
widening is evident after reduction.
Nonoperative treatment should be reserved for completely nondisplaced or stable, anatomically reduced Salter-Harris B
type-III and IV fractures.
Two millimeters is the acceptable amount of residual articular step-off in pediatric distal tibial fractures. C
Children less than fourteen years old should not operate a lawnmower or be present in a yard where a lawnmower is in operation. B
Triplane fractures with >3 mm of initial displacement or >2 mm of residual articular step-off should undergo open C
reduction and internal fixation.
Bioabsorbable fixation is a safe alternative to metallic implants for some pediatric ankle fractures. C
Arthroscopy is useful in assessing articular reduction when transitional ankle fractures are treated operatively. C

*Grade A indicates good evidence (Level-I studies with consistent findings) for or against recommending the intervention; Grade B, fair
evidence (Level-II or III studies with consistent findings) for or against recommending the intervention; Grade C, conflicting or poor-quality
evidence (Level-IV or V studies) not allowing a recommendation for or against the intervention; and Grade I, there is insufficient evidence to
87
make a recommendation .

Salter-Harris Type-VI Distal Tibial Fractures
Lawnmower injuries account for many pediatric open ankle
fractures and may cause Salter-Harris type-VI fractures. Ap-
proximately 600 of these preventable injuries occur yearly, and
most involve riding lawnmowers49-53. The mower blades may
cause massive soft-tissue trauma and may remove a portion of
the physis. Loder et al. reviewed 114 lawnmower injuries in
children and reported eighty-seven unsatisfactory results at an
average follow-up interval of 1.9 years54. They concluded that
children who are less than fourteen years old should not op-
erate power lawnmowers or be allowed in the yard while it is
being mowed, and under no circumstances should passengers
be allowed on riding mowers.
Open pediatric ankle fractures should be treated with ap-
propriate antibiotics and tetanus prophylaxis followed by ir-
rigation and meticulous debridement of devitalized tissue and
foreign material. Necessary soft-tissue reconstruction ranges from
split-thickness skin-grafting to free tissue transfer53,55. Treatment of
these injuries with vacuum-assisted closure devices has shown a
trend to reduce the number of free flaps and revision amputations
needed for these injuries compared with traditional dressing
changes51. We recommend a multidisciplinary team approach to
treat these injuries.
Triplane Fractures
Spiegel et al. reported that triplane fractures are relatively un-
common, representing only 6.3% (fifteen) of 237 ankle fractures
in their series, and they occurred in adolescents with a mean age
of thirteen years and five months3. There are case reports of
triplane fractures occurring with ipsilateral extremity injuries
and rare fracture patterns18,31,32,56-61. In what we believe is the
largest series of triplane fractures evaluated with CT and
multiplanar reconstruction, Brown et al. reported that the
most common pattern was the two-part fracture (thirty-three
of fifty-one fractures)62. Extra-articular medial malleolar
fractures were seen in 24% (twelve) of the fifty-one fractures,
which is more common than previously reported. Fractures
without articular involvement are more amenable to non-
operative treatment30.
Minimally displaced and extra-articular triplane frac-
tures may be treated with reduction and long leg immobiliza-
tion63. Reduction is commonly accomplished by internally
rotating the foot, while the rare medial fracture requires ab-
duction. Ertl et al. reported difficulty in reducing fractures with
>3 mm of initial displacement64, and Schnetzler and Hoern-
schemeyer recommended open reduction and internal fixa-
tion for fractures with >3 mm of initial displacement or >2 mm
of residual intra-articular step-off30. There is not definitive
support for these recommendations, but authors have corre-
lated long-term results with the accuracy of reduction48,64,65.
Ertl et al. showed a trend toward worsening symptoms at the
time of the long-term follow-up (average, six years) for frac-
tures involving the tibial plafond with >2 mm of displace-
ment64. Weinberg et al., in an evaluation of fifty children with
triplane fractures, including thirty who had operative treat-
ment and twenty who had nonoperative treatment, reported
that all patients were doing well after a mean follow-up of
7.4 years63.
We believe that triplane fractures with >2 mm of weight-
bearing articular surface step-off visualized on a CT scan are
best treated with a closed reduction. If anatomic reduction can
be obtained by closed means, percutaneous screws may aid in
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maintaining reduction while immobilized. If a step-off of <2 mm

cannot be achieved and maintained by closed reduction, open
reduction with internal fixation should be performed. Arthro-
scopically assisted reduction and fixation has been described
with good results66-68. We recommend postreduction CT if the
surgeon is unsure of the articular reduction, as long-term
outcomes seem to be improved with a more accurately reduced
articular surface48,64,65.

Juvenile Tillaux Fracture

The Tillaux fracture occurs in adolescents nearing the end of
distal tibial physeal closure. Spiegel et al. reported that these
injuries represented only 2.5% (six) of 237 pediatric ankle
fractures, occurring at an average age of thirteen years and
five months3. Articular congruity is the primary consideration
for treatment decisions. Nondisplaced and minimally dis-
placed fractures may be treated with immobilization in a
long or short leg cast. Reduction is usually achieved with in-
ternal rotation. For fractures with >2 mm of residual dis-
placement measured by CT scan following an attempted
closed reduction, anterior capsular interposition should be
considered69. Open reduction and removal of the capsule may
be necessary, and a single screw parallel to the physis is usually
sufficient for fixation (Fig. 6). Kaya et al. reported excellent
results at thirty-two to seventy-five months of follow-up for
ten fractures with >2 mm of displacement that were treated
operatively without attempted reduction70. Case reports have
described arthroscopically assisted reduction of Tillaux frac-
tures, but there is no evidence to suggest this method is su-
perior to open reduction68,71-73.

Fibular Fractures
Distal fibular fractures may occur in isolation or in association
with distal tibial fractures. Ligamentous injuries may be more
common than previously thought on the basis of a recent study
of children’s ankle injuries evaluated with magnetic resonance
imaging16. Eighteen children clinically diagnosed with Salter-
Harris type-I distal fibular fracture injuries underwent MRI.
Fourteen of them had sprains, eleven had osseous contusion,
and none were found to have a growth plate injury.
Displaced fractures with associated distal tibial fractures
are usually reduced and stable once the tibia is realigned. If
the fibula remains unstable, then Kirschner wire fixation may
be used. If the patient is nearing skeletal maturity, traditional
treatment with a plate is appropriate. Syndesmotic screws are
not commonly required for physeal ankle fractures as the distal
syndesmotic ligaments are typically intact.
Accessory Ossification Center Injuries
Case reports have described children with symptomatic os tib-
iale and os subfibulare74 (Fig. 1). These symptoms generally
resolve with activity modification and immobilization in a
short leg cast for three to four weeks. An additional one to two
weeks of immobilization may be necessary if the child remains
symptomatic. Authors agree that surgical intervention to re-
move the ossicle is exceedingly rare74,75.
Fig. 6
Mortise (Fig. 6-A) and lateral (Fig. 6-B) radiographs of a fourteen-year-old
girl with a Tillaux fracture after a twisting fall. Fig. 6-C Coronal slice from a
CT scan after closed reduction shows 3 mm of displacement in the articular
surface (yellow arrow) and wide lateral distal tibial physis (red arrow). Fig. 6-D
Six months after open reduction and internal fixation, the physis is closed
and the articular surface is anatomically aligned.
Metallic and Bioabsorbable Fixation
Internal fixation implants for ankle fractures in children are
Kirschner wires or small-fragment metallic screws. Transepi-
physeal screw fixation increases the force and contact pres-
sures across the tibiotalar joint compared with controls in
adult and pediatric cadaver models (p < 0.007)76. These forces
return to prefixation levels when the screws are removed,
suggesting that removal of fixation might be beneficial in
children.
Bioabsorbable fixation is reported to be safe and effective
in treating pediatric ankle fractures77. These results are prom-
ising, as bioabsorbable fixation would obviate the need for a
second procedure to remove the fixation. Bioabsorbable implants
are more expensive than metallic implants, and according to a
cost analysis, a clinician would need to remove 54% of the me-
tallic implants used for trimalleolar ankle fractures to break even
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Fig. 7
Figs. 7-A, 7-B, and 7-C An eight-year-old girl who had a twisting injury of the ankle. Fig. 7-A Mortise radiograph made after the injury. Soft-tissue swelling over
the distal end of the fibula was present. The patient was lost to follow-up. Fig. 7-B The same patient was seen again because of symptoms of progressive
‘‘flatfoot’’ when she was fourteen years old. The fibula is shortened (yellow arrow), and valgus deformity is evident in the ankle because of fibular physeal and
lateral tibial physeal arrest. Note the absence of the Park-Harris line in the lateral tibial metadiaphysis (red arrow). Fig 7-C The contralateral, normal ankle
when she was fourteen years old.

with the initial cost of bioabsorbable implants78. Bioabsorbable
implants may be a practical way to eliminate the need for removal
of the fixation, but there is no clear evidence yet to support this
recommendation.
Complications
Osteochondral Defect
Osteochondral defect of the talus following ankle sprains and
fractures is an increasingly common diagnosis79-81 (Fig. 1).
Clinicians should suspect an osteochondral defect in any child
who has persistent pain following an ankle injury. MRI is the
gold standard for evaluating cartilage injury and provides ex-
cellent osseous detail as well. Treatment may be either open
or arthroscopic surgery and includes osteochondral defect sta-
bilization, microfracture, or drilling of the involved cartilage
area.
growth arrest. Lalonde and Letts advocate close radiographic
follow-up, MRI if necessary, to evaluate for physeal bar for-
mation, and excision of the physeal bar if <50% of the physis
is involved. CT or MRI may also be used to detect ‘‘secondary
tethers,’’ such as incomplete bar resection or recurrent bars
in cases of insufficient growth restoration85. Radiographs can
be followed for the presence of Park-Harris growth lines,
which should parallel the physis if normal growth resumes.
Angular deformity is detected when lines are not parallel86
(Fig. 8).

Compartment Syndrome
Extensor retinaculum syndrome is a compartment syndrome
unique to pediatric ankle fractures. In one report, six patients
with distal tibial physeal fractures (four type-II and two tri-
plane fractures) presented with severe ankle pain and swelling,
a hypoesthetic first web space, weakness of the extensor hallucis
longus and extensor digitorum communis, and pain with
passive toe flexion82. Extensor retinaculum release and fracture
fixation relieved pain and weakness, but two patients had persistent
altered sensation in the first web space. There are case reports of
traditional lower-leg compartment syndromes after pediatric ankle
fractures as well83.
Fig. 8
Growth Arrests Asymmetric Park-Harris growth arrest line resulting from premature closure
Injury to the distal tibial physis can result in premature physeal of the medial distal tibial physis two years following a displaced Salter-
closure, causing angular deformity or a limb-length discrepancy Harris type-III medial malleolar fracture. Note the convergence (red arrows)
(Fig. 7). Lalonde and Letts evaluated twelve children with ankle of the growth arrest lines toward the physeal bar (yellow arrow). Compare
fractures with a growth arrest84. Observation, bar excision, epiph- this with images in Figures 1-B and 1-E that demonstrate normal pro-
ysiodesis, and corrective osteotomies were used to treat the gression of a symmetric Park-Harris line (blue arrows).
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Overview
In summary, nondisplaced pediatric ankle fractures may be
managed with immobilization and radiographic follow-up.
Articular step-offs of >2 mm that are detected by radiographs
or CT scan following closed reduction should prompt con-
sideration for open reduction with internal fixation as needed.
Children should be followed for one year after injury to detect
growth abnormalities, but some physicians may choose to
follow them until they are skeletally mature. A complete
summary of recommendations for care is given in Table I87. n
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