Physeal ankle fractures in children must be evaluated by considering the size of the displacement, the growth plate injury, management, and physeal growth remaining (Wuerz and Gurd 2013; Caterini et al. 1991; Barmada et al. 2003; Bible and Smith 2009). Management of these fractures is crucial to preventing early and late complications. Non-displaced physeal fractures can be successfully treated with conservative management (Kay and Matthys 2001). However, displaced or minimally displaced fractures can cause physeal growth, arrest, and deformity of the extremities (Wuerz and Gurd 2013; Kling et al. 1984; Barmada et al. 2003). Surgical treatment should be used for fractures that are displaced by greater than 2 mm and those that have greater than a 1 mm translation of fractures, such as triplane (Feldman et al. 1995) and tillaux fractures (Wuerz and Gurd 2013; Podeszwa et al. 2008; Kling et al. 1984; Caterini et al. 1991; Barmada et al. 2003; Bible and Smith 2009; Jones et al. 2003; Castellani et al. 2009). Salter Harris type 2, 3, and 4 fractures were evaluated in this study. These fracture types have an unstable displaced fragment and require screw fixation after reduction. Surgical intervention of unreduced Salter-Harris type 2, 3, and 4 fractures has been found to decrease growth arrest rate and deformity (Wuerz and Gurd 2013; Lintecum and Blasier 1996; Bible and Smith 2009). Fixation of these fractures also allows early cast removal and rehabilitation.
Meticulous examination is essential to achieve the correct diagnosis of physeal fractures around the ankle. We obtained plain radiographs for all the patients with traumatic ankle injuries by using the Ottawa ankle rules (Stiell et al. 1995). Bisset has revealed that diagnostic errors in pediatric fractures in the form of misses or overcalls occur in 2.7% of the radiographs (Bisset and Crowe 2014). Misses and overcalls are most common in the ankle (Bisset and Crowe 2014). We used computed tomography of the ankle if there was any suspicion of fracture. We also used CT to decide upon and plan operative treatment. Liporace has reported that the use of CT does not significantly change the impression of the amount of displacement per case and further results in patients’ reassignment from non-operative management to operative treatment (Liporace et al. 2012). We recommend taking CT scans of suspicious physeal fractures and displaced fractures before operative planning.
Ensuring the anatomic reduction of epiphyseal fractures is a very demanding procedure. Lintecum and Blaiser (Lintecum and Blasier 1996) have described a method of focusing on direct visualization for open reduction and internal fixation (ORIF). They have reported good results with the anterior surgical approach and percutaneous screw fixation method (Lintecum and Blasier 1996). Castellini has reported a method using Kirschner wires as joysticks to manipulate fractures that are difficult to reduce (Castellani et al. 2009). Here, we used closed reduction and Kirschner wires to assist in manipulation. We achieved a satisfying reduction with the percutaneous Kirschner wire-assisted method, as determined via fluoroscopy. The percutaneous reduction and fixation method resulted in less scar formation than did the open method.
Different types of implants are used for the fixation of epiphyseal fractures. Kirschner wires, smooth pins, tension band fixation, metallic screws, and bioabsorbable screws have all been used for fixation in previous studies (Wuerz and Gurd 2013; Podeszwa et al. 2008; Castellani et al. 2009; Sankar et al. 2013). Kirschner wires and smooth pins cannot be used for compression, but all the others are useful for compression. A recent biomechanical study has demonstrated that metallic screw fixation in the distal tibia significantly alters the articular pressure in the ankle joint (Charlton et al. 2005). A comparison of bioabsorbable screws and metallic screws for the distal tibial physeal fracture has demonstrated similar results for each screw type (Podeszwa et al. 2008). Here, we compared cannulated screws with headless cannulated screws in distal tibial physeal fractures. Screws were fixed parallel to the physis and articular surface while remaining within the epiphysis (Wuerz and Gurd 2013; Castellani et al. 2009). We inserted the cannulated screws percutaneously, fixing them parallel to the physis. None of the screws penetrated the physeal plate in our method, and we were able to achieve intraarticular fixation safely.
Percutaneous screws have been used for the fixation of epiphyseal ankle fractures in many studies in the literature (Podeszwa et al. 2008; Castellani et al. 2009; Sankar et al. 2013; Charlton et al. 2005; Podeszwa and Mubarak 2012). Lintecum and Blaiser have reported good clinical results after using percutaneous cannulated screws (Lintecum and Blasier 1996). Crawford has reported success by fixing percutaneous cannulated screws in tillaux and triplane fractures (Crawford 2012). Podezswa has demonstrated that bioabsorbable screws lead to similar outcomes (Podeszwa et al. 2008). In this technique, screw removal is not required. In this study, we used 3-mm headless compression cannulated screws and 3.5-mm cannulated screws. Although radiologic healing time and clinical healing time were better in the headless compressive screw group, the difference was not statistically significant. There were no significant differences between headless compression screws or standard cannulated screws in radiologic fracture healing time (p = 0.487) or clinical healing time (p = 0.192), even after accounting for age and fracture type, the type of implant used.
The AOFAS scoring scale is commonly used for ankle fractures. Although the AOFAS score has subjective components, it is still commonly used for orthopedic assessment of the ankle and the foot. The subjective components of this rating scale provide quality of life information that conveys acceptable validity regarding conditions affecting the foot and ankle (Ibrahim et al. 2007). A recent study has compared the psychometric properties of AOFAS and SEFAS (self-reported foot and ankle score) and has found similar results between the two scales (Cöster et al. 2014). We found a mean AOFAS score of 96 in our patients, thus indicating a good clinical result. The single patient who did have a low AOFAS score (83) had had a motor vehicle accident and presented with an open injury. High-energy trauma is a risk factor for poor clinical outcomes (Leary et al. 2009).
Epiphyseal ankle fractures can result in several complications. Early and late-term complications were encountered in 5 (20.8%) patients. Two patients had open fractures at the time of arrival at the emergency room. One patient needed skin grafting. We observed 3 (12.5%) premature physeal arrests, 2 of which were Salter Harris type 4 and 1 was type 3. The incidence of premature physeal closure varies by fracture type, with closure in 2–40% of Salter Harris type 1 and 2 fractures and in 8–50% of type 3 and 4 fractures. Premature physeal closure causes growth disturbance (Barmada et al. 2003). Leary has demonstrated that high-energy trauma is more likely to cause growth arrest than low-energy trauma or sports-related injuries (Leary et al. 2009). In our study, 2 patients with premature physeal closure were in motor vehicle accidents, and 1 suffered a sports-related trauma. The complications therefore do not reflect negatively on the clinical results of this study.
The limitations of this retrospective study were the small number of patients and the short follow-up time. The differences between the performance of the cannulated screw and the headless compressive screw could be better investigated in detail with a larger number of patients and a longer-term follow-up.