lateral ankle avulsion fracture radiology

Then continue for a discussion of this case. 26): Note: this trauma mechanism is also seen in Weber C fractures. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-97259. 1. The _ga cookie, installed by Google Analytics, calculates visitor, session and campaign data and also keeps track of site usage for the site's analytics report. The online slide presentation from the RSNA Annual Meeting is available for this article. Syndesmosis damage may be underestimated. This is a stage IV pronation-exorotation fracture. Figure 2b. 21). (b) Accompanying lateral radiograph shows the dislocation at the tibiotalar joint to be posterior. This phenomenon results in muscle weakness and diminished sensation in the first web space (85). Then try to figure out the stage and determine whether the ankle is stable or unstable. Accessing this course requires a login. Open fractures have an overall higher propensity for the development of infection (Fig 24). 10, No. More complicated than the Weber classification. Set by the GDPR Cookie Consent plugin, this cookie is used to record the user consent for the cookies in the "Necessary" category . With this classification, each injury type is assigned a prognostic significance. Population-based studies suggest that the incidence of ankle fractures has increased dramatically since the early 1960s. A conservative approach involves appropriate immobilization and protected weight bearing, with serial follow-up radiographs obtained to exclude late displacement in the cast. A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis? Transitional Fractures.A subgroup of pediatric ankle fractures called transitional fractures occur during the 18-month developmental window (in girls aged 1215 years and boys aged 1418 years) that marks the progressive closure of the distal tibial physis, which starts centrally and ends laterally (25). Nondisplaced fracture of the proximal aspect of the right (R) fifth MT bone in an 11-year-old girl who injured her ankle while playing basketball. Any pain or soft tissue swelling on the medial side can be a first indication that we are dealing with a Weber C fracture. In Weber B stage 2 is stable, but stage 3 and 4 are unstable. When the x-rays of the ankle show no obvious fracture like a Weber A or B, then the question is: could this be a Weber C fracture? Presented as an education exhibit at the 2018 RSNA Annual Meeting. Ossification of the anterolateral distal tibial metaphysis leads to the creation of two separate lines in this radiographic projection; the more lateral line (not shown) corresponds to the anterior tibia, and the more medial line is the incisura fibularis (white line), which articulates posteriorly with the fibula. Tibiotalar dislocation in a 14-year-old girl that occurred after a trampoline injury. The second break can be a fracture or ligament damage (= sprain/tear/rupture). If the address matches an existing account you will receive an email with instructions to reset your password. The ankle is a synovial hinge joint that comprises the tibia and fibula, which articulate around the central talus; this complex is referred to as the ankle mortise (8). It involves less than one-third of the mediolateral distance across the epiphysis (33). (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. Distal tibial metaphyseal fractures in a 25-day-old male newborn who presented with multiple sites of skin bruising and lethargy. Secondary ossification centers of the MT and phalangeal bones develop when a child is aged 624 months, and the calcaneal apophysis develops when a child is aged 5-12 years (13). CT may aid in preoperative planning (70), but it cannot be used to determine instability. In children, snowboarding has been found to be associated with lateral talar process fractures, which are rare (59,60). (b) Accompanying lateral radiograph also depicts the talar neck fracture. (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). The associated fracture of the distal fibular shaft (arrow) does not involve the fibular physis. A stage II is considered an unstable ankle fracture. Important posttraumatic complications include premature physeal arrest, three-dimensional deformities and consequent articular incongruity, compartment syndrome, and infection. Normal developmental appearances of the ankle with age in three boys. Cuboid Fractures.The cuboid bone maintains the length and flexibility of the lateral column of the foot. For this journal-based SA-CME activity, the authors, editor, and reviewers have disclosed no relevant relationships. Lindsj U. Operative Treatment of Ankle Fracture-Dislocations. Juvenile Tillaux fractures represent a transitional subset of Salter-Harris type III fractures of the anterolateral tibial epiphysis that occur in adolescents after physeal fusion is nearly complete and minimal residual anterolateral physeal patency remains (Fig 13). Since the Weber-classification is a simplification of the Lauge-Hansen classification, it will help you to understand the different stages of Lauge-Hansen. Step 1The first question you should ask yourself is:Is it a Weber type A fracture? Toddlers with calcaneal stress fractures who are just learning to walk refuse to bear weight. The highest incidence of ankle fractures occurs in elderly women. The two differences between Weber B and C are: Sometimes we are lucky, because the fibula fracture is visible on the x-rays of the ankle.Then we know we are looking at an unstable stage 3 weber C fracture. Joint depression can be assessed at comparisons with the contralateral foot. Die Verletzungen Des Oberen Sprunggelenkes. Fractures of the lateral process of the talus in children, The snowboarders foot and ankle, Talar Fractures and Dislocations: A Radiologists Guide to Timely Diagnosis and Classification, Fractures of the neck of the talus: long-term evaluation of seventy-one cases, Avascular necrosis of the talus: a pictorial essay, Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer, Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment, The toddlers cuboid fracture, MR imaging features of cuboid fractures in children, Making sense of lisfranc injuries, Radiographic Anatomy of the Pediatric Lisfranc Joint, Lisfranc injury in adolescents, The diagnosis and treatment of injuries to the Lisfranc joint complex, Lisfranc injuries in children and adolescents, Pediatric Forefoot Fractures: Assessment of Fracture Patterns and Predictors of Complicated Outcome, A study of metatarsal fractures in children, A study of metatarsal fractures in children, Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection, Jones fractures and related fractures of the proximal fifth metatarsal, Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management, Obesity in Pediatric Trauma, Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor, Outcome of physeal and epiphyseal injuries of the distal tibia with intra-articular involvement. Lisfranc injury in a 17-year-old high school football player, which occurred after another player fell on the back of his heel, causing hyperflexion of his midfoot. 53, No. Viewer, http://www.cdc.gov/arthritis/basics/risk-factors.htm, Acute Fractures and Dislocations of the Ankle and Foot in Children, Pitfalls in MRI of the Developing Pediatric Ankle, Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings, Imaging Review of Normal and Abnormal Skeletal Maturation, Imaging of Sports-related Injuries of the Lower Extremity in Pediatric Patients, Imaging of Acute Capsuloligamentous Sports Injuries in the Ankle and Foot: Sports Imaging Series, Pediatric Foot and Ankle Fractures: Patterns, Mimics, Complications, and Treatment, Dancing Feet: Biomechanism and Imaging Findings of Foot and Ankle Musculoskeletal Injuries in Dancers, Painful Corners of the Ankle: Keeping an Eye on the Periphery. The distal talar fragment (arrow) is slightly superiorly displaced, while the tibiotalar and talonavicular articulations are congruent. The ankle transfers force between the foot and the rest of the axial skeleton, enabling stability and foot movement (7). Figure 25b. A miniscule percentage (0.4%) of these cases were those of Salter-Harris type I fracture (26). The acquisition of an additional lateral view may be considered since approximately 23% of avulsion fractures can be missed on conventional radiographic views (76). Tibiotalar dislocation in a 14-year-old girl that occurred after a trampoline injury. 2, Radiologic Clinics of North America, Vol. A Salter-Harris type IV fracture extends from the metaphysis to the epiphysis. Lateral Ankle Sprain may be associated with: ankle dislocation, distal lateral malleolar avulsion or spiral fracture, medial malleolar fracture, talar neck or medial compression fractures. A Salter-Harris type II fracture involves at least part of the physis width and a contiguous portion of the metaphysis, which create a so-called wedge-shaped Thurston-Holland fragment, which represents a triangular portion of the metaphysis attached to the epiphysis (25). Just like a Weber C fracture it is the result of an exorotation force applied by the Figure 18. References Ng J, Rosenberg Z, Bencardino J, Restrepo-Velez Z, Ciavarra G, Adler R. US and MR Imaging of the Extensor Compartment of the Ankle. Normal developmental appearances of the ankle with age in three boys. (b) Mortise radiograph of the ankle in an 11-year-old boy shows a slight decrease in the medial clear space (black arrow), a narrowed tibiofibular interval (single-headed white arrow) with no overlap yet seen, and a slightly widened distal fibula (double-headed arrow). (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Please enter your credentials below! The combination of fracture and ligament damage complicates assessment, as ligament damage is not directly visible on x-ray. Show details Hide details. 29, No. The talus will continue to exorotate and will no longer be checked by the medial ligaments, causing the talus to push away the fibula. The fracture was not detected on the antero-posterior (AP) view of ankle (Fig. The fractures are at different stages of healing. Better predictor of damage to the syndesmosis. On examination: mild swelling, hotness, and tenderness over the Tertius avulsion fracture or rupture of posterior syndesmosis, Avulsion fracture of medial malleolus or rupture of medial collateral bands. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. Scroll through the images to see how the injury follows a clockwise fixed order. Open physes protect against ligamentous and syndesmotic injuries (18). Primary tibial and fibular ossification is present at birth (11). ADVERTISEMENT: Supporters see fewer/no ads. This manifestation is followed by a transverse, higher-grade fracture of the fibular diaphysis. Set by the GDPR Cookie Consent plugin, this cookie is used to record the user consent for the cookies in the "Analytics" category . Describe the complications related to different fracture types to ensure appropriate follow-up and patient and parent counseling. Either is acceptable. We, and third parties, use cookies on our website. However, in retrospect, growth arrest occurs in the absence of a prior visualized fracture or in the presence of what initially appeared to be either a Salter-Harris type I fracture or no injury. In addition, they may be open or closed. Intra-articular injuries increase the risk of subsequent arthritis sevenfold (84). Revisiting Radiograph-Negative Ankle Injuries in Children: Is It a Fracture or a Sprain? Drawing illustrates the Dias-Tachdjian classification of growth plate fractures at the ankle. Figure 2a. The keystone wedging of the second MT bone into the medial cuneiform bone supports the entire tarsometatarsal articulation. (a) AP radiograph of the left ankle shows asymmetric closure (arrows) of the left distal tibial physis. In a relatively recent study (67) of the MRI appearances of pediatric cuboid fractures, the fractures were found to occur in isolation, linear, and most commonly adjacent to the tarsometatarsal joint. (b) AP radiograph obtained after open reduction and internal fixation with cancellous screw placement across the distal tibia shows a reduced intra-articular gap (arrow). (1972) ISBN: 9783456002071 -. Weber B is the most common ankle fracture accounting for 60-70% of all ankle fractures. On AP radiographs obtained in adults, measurements of the distance between the first and second MT bases and the distance between the medial cuneiform bone and second MT base are considered to be abnormal if they are greater than 2 mm. Figure 19a. Figure 17b. Figure 2c. The supination-inversion mechanism (Fig 7) is the most common Dias-Tachdjian ankle fracture pattern (33). Talar neck fractures are much more common than talar body fractures, which, in turn, are more common than lateral and posterior process fractures. Salter-Harris type III fracture of the distal tibia in a 13-year-old boy. When you see a Weber B fracture, which is always good visible on either the AP- or the lateral view, the only thing you need to check is whether there is an unstable stage 3 with posterior injury or even stage 4 with medial injury. This is a normal developmental variant; there is no associated soft-tissue swelling. 03, The Journal of Foot and Ankle Surgery, Vol. The anteromedial portion of this physis (Kump bump) fuses first, and the anterolateral portion (Chaput tubercle) fuses last. At presentation, the patient usually has plantar ecchymosis. Ankle Avulsion Fracture. Tibiofibular syndesmosis is intact/partial rupture. Weber B is the most common ankle fracture accounting for 60-70% of all ankle fractures. McFarland (31) described Salter-Harris types III and IV medial malleolar fractures as a distinct category of injuries associated with traumatic arrest of the distal tibia. The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. Set by the GDPR Cookie Consent plugin, this cookie is used to store the user consent for cookies in the category "Others". Although the distal fibula is a common location of suspected Salter-Harris type I physeal fractures of the distal fibula (SH1DF), these fractures may be clinically and radiographically indistinguishable from sprain. 16). Having detected stage 1 and 4 of a Weber C type of trauma mechanism, we now are sure that there must also be a stage 3, which is a high fibula fracture. Salter-Harris Classification of Physeal Fractures.The most simple and commonly used anatomic classification system for pediatric physeal fractures (12,23,24) is the Salter-Harris system (Table 2, Fig 4) (25). Check for errors and try again. Figure 6. (a) Lateral radiograph of the ankle of a 14-year-old boy after a twisting injury to the right ankle shows a subtly widened anterior physis at the distal tibia with a posteriorly based Thurston-Holland fragment (arrow). Knijnenberg et al (69) found that the distances between the first and second MT bases measured on AP radiographs obtained in skeletally healthy pediatric patients were consistently shorter than 3 mm. In Weber A stage 1 is stable. Osteonecrosis appears radiographically as talar dome sclerosis, and it usually develops a few weeks to 6 months after the fracture manifests (33). Understanding the role of supplemental radiographic projections and cross-sectional imaging, where applicable, can be additionally valuable, ensuring appropriate treatment, imaging follow-up, and patient and parent counseling. These fractures are remarkably displaced and angulated, with lateral translation and apical medial angulation occurring at the distal tibial epiphyseal fragment and apical medial angulation occurring at the fibular shaft fracture (33). Vallier et al (58) divided Hawkins type II fractures into two subtypes (IIa and IIb) (Fig 17), which are used to predict the development of osteonecrosis. Since repeated attempts at closed reduction can result in physeal damage, they should be performed with caution. It was originally described by Christian Lauge-Hansen, a Danish pathologist in 1950 and later copied by Bernhard Georg Weber in 1972, a member of the AO-group. This is always stage 2 and is unstable, whether you see a fracture of the lateral malleolus or not. They have a bimodal presentation, involving young males and older females. The patients skeletal maturity must be considered in treatment decisions. More recently, such fractures have been described in association with trampoline activity, especially multioccupant trampoline use (32). Calcaneal fractures. (b) Mortise radiograph of the ankle in an 11-year-old boy shows a slight decrease in the medial clear space (black arrow), a narrowed tibiofibular interval (single-headed white arrow) with no overlap yet seen, and a slightly widened distal fibula (double-headed arrow). Here a typical avulsion or pull-off fracture of the lateral malleolus.The avulsion fragment is quite large. CT is the best imaging method for confirming the diagnosis and ruling out intra-articular fractures. (a) Coronal fluid-sensitive MR image of the foot shows diffusely high signal intensity (arrow) throughout the navicular bone. Findings at presentation include pain, swelling, inability to bear weight, and possibly medial plantar ecchymosis. (a) AP radiograph of the ankle shows a medially displaced talar neck fracture (arrow). The rarity of foot fractures among infants and toddlers can be explained by the proportionately larger number of cartilaginous components in their skeleton, which causes the pediatric foot to have high elastic resilience. The triplanar configuration consists of fracture lines along the coronal plane through the posterior metaphysis, along the sagittal plane through the epiphysis, and along the transverse plane through the physis, which ultimately disrupt the tibial plafond (36). Coronal reformatted CT image shows a distal tibial fracture (single-headed arrow). Open fractures are rare, accounting for just 2% of all ankle fractures. Tiny bone avulsed fracture from the distal fibula and an anatomical variant, os subfibulare. Postreduction radiographs are useful for assessing the adequacy of alignment and physeal reduction. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. In view of marked medial soft tissue swelling, there will also be ligament damage (or an occult fracture). AO/OTA classification of malleolar fractures. When we look at the algoritm, you can see, that a tertius can be found in a Weber B fracture in stage 3 and in a Weber C fracture in stage 4. Frontal. Centers for Disease Control and Prevention website, Extensor retinaculum syndrome of the ankle after injury to the distal tibial physis, Management of Pediatric Ankle Fractures, Open in Image A fracture can easily be overlooked. While their presence usually does not change the therapeutic approach, occasionally a large fragment may require a separate fixation screw. About 80% of these injuries occur in a plantar-flexed inverted foot, resulting in medial and superior dislocation (65); lateral dislocation results if the foot is everted. Enter your email address below and we will send you the reset instructions. The midfoot consists of five tarsal bones and their articulations. Revista Ciencias Biomdicas, Vol. Acta Orthop Scand. Injuries of the midfoot include fractures of individual bones and fracture dislocations involving the midtarsal (ie, talonavicular and calcaneocuboid) or tarsometatarsal articulations. Forefoot fractures account for 6%10% of fractures in children and involve the toes and MT bones. Although not that common, the injury may proceed and cause a push off fracture on the medial side resulting in a vertical fracture of the medial malleolus . Arthrodesis, which is sometimes used to address Lisfranc fractures in older adolescents and adults, is contraindicated in children with open physes (68). Rapariz et al (39) developed a six-configuration system for classifying these fractures (Figs 11, 12). I. 53, No. It means that there already is stage 1, because the trauma mechanism always follows this strict order, first stage 1 and then stage 2. Notice however, that there are many similarities between Weber B and C with only differences in the order of events. Yu S & Yu J. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. Radiologists must recognize the developmental phenomena, anatomic variants, and fracture patterns and associated complications that affect the skeletally immature foot and ankle. The midfoot is a complex anatomic association of five tarsal bones (navicular bone, cuboid bone, and three cuneiform bones) and their corresponding articulations. Below is an example of a pronation-exorotation fracture (fig. An avulsion of the fibular attachment is even more rare. 2, Radiologic Clinics of North America, Vol. (a) AP weight-bearing radiograph of the foot shows a very subtle step-off (arrow) between the intermediate cuneiform bone and second MT bone, which was not visible on the nonweight-bearing views. This complication has been found to correlate positively with high-energy mechanisms of trauma (83), significant initial displacement, and multiple attempts at closed reduction (24). Comparison radiographs of the contralateral side may be obtained to detect subtle injuries (Fig 20). These fractures are referred to as metaphyseal corner fractures, or classic metaphyseal lesions (22) (Fig 3). 2. For example, necrotizing fasciitis can be seen with calcaneal fractures that are related to lawn mower injuries (48). Accessory centers of ossification adjacent to the ankle and foot bones can mimic avulsion fractures on radiographs. Foot radiograph findings were unremarkable. Supination-exorotation fracture (stage IV). Investigators in a relatively recent study (73) found the overall rate of complications associated with pediatric forefoot fractures to be 6.4% and female sex to be an important predictor of complicated outcomes. Open fracture . In this case there is widening of the medial clear space between the medial malleolus and the talus indicating a rupture of the medial collateral bands (stage 1). Ankle fractures in children can be broadly categorized as avulsion and physeal fractures. Normal developmental appearances of the ankle with age in three boys. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. Fractures of the cuboid can present with varying swelling and deformity of the lateral midfoot. Fractures of the posterior tibial tubercle should not be confused with fractures of the posterior articular margin (posterior malleolus), which have a worse prognosis. Comparison of the modified Brostrom procedure for chronic lateral ankle instability with and without subfibular ossicle. Often they are seen in only one of the frontal or oblique views. The tension in the anterior syndesmosis can sometimes lead to an avulsion of the tibial attachment of the anterior syndesmosis, which is called a Tillaux fracture. The cookie stores information anonymously and assigns a randomly generated number to recognize unique visitors. Standard radiographic talar evaluation consists of acquiring AP, mortise, and lateral views of the ankle and AP, oblique, and lateral views of the foot. The ankle is stabilized by its bone and ligamentous anatomy. Supination-exorotation Mechanism (fig. Figure 23b. Syndesmotic disruptions are ligamentous, but they may be accompanied by tibial or fibular fractures. (a) AP radiograph of the ankle shows a distal tibial fracture (single-headed arrow) with lateral displacement and slight angulation of the Tillaux fragment. (a) AP radiograph of the left ankle shows asymmetric closure (arrows) of the left distal tibial physis. 3, 2022 Radiological Society of North America, Pediatric Ankle Fractures: Concepts and Treatment Principles, Analysis of the incidence of injuries to the epiphyseal growth plate, Physeal fractures. Oblique. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. As in each ring structure, one break will cause another break somewhere in the ring. They are connected by 3 ligaments (the medial/lateral collateral ligaments and the interosseous ligament). Radiograph-Negative Lateral Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain? Dias-Tachdjian Classification of Ankle Fractures.In the Dias-Tachdjian classification system, radiologic classification models to describe ankle fractures in adults, including the Lauge-Hansen model (34), are used in conjunction with Salter-Harris classifications to describe injury patterns relative to the physis (35). Physis patency is used to explain differences in the injuries sustained by immature versus adult skeletons. Although calcaneocuboid dislocation is generally less severe compared with talonavicular dislocation, it typically involves severe lateral joint space widening and comminuted calcaneus and cuboid fractures (64). Unable to process the form. (a) Lateral radiograph of the ankle of a 14-year-old boy after a twisting injury to the right ankle shows a subtly widened anterior physis at the distal tibia with a posteriorly based Thurston-Holland fragment (arrow). Figure 14c. 2a, b). There is no associated syndesmotic widening. Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure? 7. Local soft tissue was swollen. (c) Mortise radiograph of the ankle in a 17-year-old boy shows a further decreased medial clear space (black arrow), developing tibiofibular overlap (single-headed white arrow), and a further increased fibular width (double-headed arrow). Figure 24. Radiographics. In children, increasing participation in competitive sports activities has led to an increased incidence of acute injuries that affect the foot and ankle. For this reason, diagnosing one ankle fracture should always prompt an active search for a second fracture. Grade 2 Dias-Tachdjian supinationexternal rotation ankle fracture in a 13-year-old boy who slipped on ice. Figure 4. Extensor retinaculum syndrome usually involves the anterior metaphyseal spike of a triplane fracture compressing the extensor hallucis and peroneus tertius muscle bellies and the deep peroneal nerve against the rigid superior extensor retinaculum.

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