Vol 10 | Issue 1 | January-June 2024 | page: 58-61 | Siddhartha Sablay, Sandeep Patwardhan, Vivek Sodhai, Rahul Jaiswal, Darshan Sonawane, Ashok Shyam, Parag Sancheti

https://doi.org/10.13107/jmt.2024.v10.i01.226

Author: Siddhartha Sablay [1], Sandeep Patwardhan [1], Vivek Sodhai [1], Rahul Jaiswal [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]

[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.

Address of Correspondence
Dr. Siddhartha Sablay,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and
Rehabilitation, Pune, Maharashtra, India.
E-mail: siddharthasablay200@gmail.com

Abstract

Background: Children’s ankles differ from adults’ — the growth plate (physis) is mechanically and biologically weaker than surrounding bone and ligaments, so twisting or sports injuries that would sprain an adult often produce physeal fractures in a child. Distal tibial physeal closure is asymmetric and creates a window in adolescence when transitional patterns (Tillaux, triplane) commonly occur and involve the joint surface. Accurate classification (Salter–Harris, Dias–Tachdjian), careful imaging (mortise views, CT, arthrography or MRI when needed) and prompt, anatomy-respecting treatment are essential because intra-articular step-off or physeal damage can lead to pain, malalignment, growth arrest and early arthritis. This abstract summarizes findings and conclusions drawn from the attached thesis on pediatric ankle fractures.
Hypothesis: When pediatric ankle fractures are evaluated with the proper imaging, classified correctly, and managed according to fracture type — non-operative immobilization for stable, non-displaced injuries and anatomic reduction with growth-respecting fixation for displaced or intra-articular injuries — most children will achieve good-to-excellent functional recovery at one year. Transitional and intra-articular physeal fractures that are reduced to near-anatomic alignment (residual articular step-off ≤2–2.5 mm) and stabilized appropriately will have functional outcomes comparable to simpler physeal fractures; greater residual displacement or delayed/inadequate reduction predicts worse pain, function or physeal complications.
Clinical importance: For clinicians: obtain adequate imaging when suspicion is high, aim for anatomic restoration of the joint surface (surgery if residual step-off exceeds ~2 mm), and choose fixation that minimizes additional physeal injury. Early, accurate treatment and planned follow-up reduce the risk of leg-length discrepancy, angular deformity and early osteoarthritis.
Future research: larger prospective, multicentre cohorts with standardized outcomes and longer follow-up to skeletal maturity are needed to define exact displacement thresholds for surgery, compare immobilization strategies, and quantify late physeal arrest and arthritic changes.
Keywords: Pediatric ankle fracture, Salter–Harris, Tillaux, Triplane, Physeal preservation, Anatomic reduction.

Background

Children’s ankles are not just “small adult” ankles — their bones, cartilage and growth plates behave differently under stress. The physis (growth plate) at the distal tibia is relatively weaker than the surrounding ligaments and often bears the brunt of rotational or axial forces. As a result, injuries that would produce ligament sprains in adults commonly produce physeal fractures in children. This basic anatomic truth underlies the distinct fracture patterns and treatment priorities in the pediatric population. [1][2]
The distal tibial physis closes in a predictable, asymmetric fashion during adolescence, which gives rise to transitional fracture patterns such as Tillaux and triplane fractures near skeletal maturity. These transitional patterns cross the physis and involve the joint surface, so they demand careful imaging and precise reduction to avoid long-term joint dysfunction. [3][4] Mechanistic classifications — for example the Dias–Tachdjian system — help relate foot position and force direction to the fracture pattern and therefore guide the treating surgeon toward an appropriate strategy. [5]
Epidemiologically, ankle fractures are a frequent subset of physeal injuries in children and are commonly linked to sports and playground injuries; high-energy mechanisms such as road traffic collisions account for more complex patterns and a greater risk of complications. [6][7] Clinically, affected children present with pain, swelling, and inability to bear weight; however, physeal or cartilage injuries can be subtle on routine radiographs, so a low threshold for additional views and advanced imaging is recommended when clinical suspicion remains high. Mortise views, CT scans for intra-articular detail, and arthrography or MRI for cartilage and physeal assessment are tools that frequently change management decisions. [8][9]
Classification carries prognostic weight. The Salter–Harris scheme remains the foundation for describing physeal injuries because higher-grade injuries (types III and IV) more often involve the joint surface and carry a higher risk of growth disturbance. [10] Complementary classifications that describe injury mechanism furnish practical guidance for reduction and fixation. In transitional injuries, the articular involvement is the dominant concern: even small steps or gaps in the joint surface predispose to early arthritis and functional problems later in life. [11][12]
Treatment principles for pediatric ankle fractures balance three goals: restore joint congruity, maintain mechanical alignment, and preserve the physis. For minimally displaced and stable patterns, immobilization in a cast or functional brace is reliable. Indications for operative fixation include irreducible or significantly displaced fractures, intra-articular step-off beyond accepted limits, and specific patterns — for example displaced medial malleolar fragments or transitional fractures with articular incongruity. [13][14] When operating, implant choice and technique must minimize additional physeal insult: smooth K-wires or percutaneous techniques are preferred when crossing an open physis is unavoidable, whereas cannulated compression screws are chosen when physeal crossing is acceptable (often in transitional injuries or near-mature physes). Intraoperative imaging (fluoroscopy, arthrography) and preoperative CT are commonly used to confirm reduction and plan fixation. [15][16]
Despite decades of experience, robust randomized trials comparing specific treatments are sparse; much practice rests on cohort studies, systematic reviews and expert consensus. This relative paucity of high-level evidence makes careful case-by-case decision-making essential and reinforces the importance of accurate imaging, anatomic reduction and growth-respecting fixation techniques. [17][18]
Finally, the clinical focus must extend beyond early bone healing. Growth arrest, angular deformity and leg-length discrepancy may not become apparent until months or years after the injury, so both the initial management and planned follow-up must anticipate and detect these late complications. [19][20]

Hypothesis
This study rests on two complementary hypotheses intended to link fracture morphology and management strategy to outcomes.
Primary hypothesis: When pediatric ankle fractures are assessed with the appropriate imaging, classified accurately, and managed with a treatment plan that prioritizes anatomic articular reduction and growth-plate preservation, the majority of children will reach good-to-excellent functional outcomes at one-year follow-up. The aim is to show that classification-guided care — using closed reduction and immobilization for stable, nondisplaced injuries and operative reduction ± fixation for displaced or intra-articular injuries — leads to predictable functional recovery. [21]
Secondary hypothesis: Transitional and intra-articular physeal fractures (Tillaux, triplane, Salter–Harris III/IV) that are reduced to near-anatomic alignment (residual articular step-off ≤2–2.5 mm) and stabilized appropriately will achieve functional outcomes similar to less complex physeal fractures. Conversely, fractures with greater residual displacement or delayed/inadequate reduction will show higher rates of persistent pain, reduced function and possible physeal complications. [22][23]
Rationale: The distal tibial physis contributes substantially to tibial length and alignment. Disruption to the physis or residual articular incongruity can therefore produce clinically meaningful consequences, from gait disturbance to early degenerative changes. By quantifying functional outcomes (for example, using AOFAS and VAS scores) and documenting complications (including evidence of growth arrest on follow-up radiographs), the study evaluates whether careful imaging and technique can mitigate these risks. [24]
Operational definitions and thresholds are important. The literature commonly cites an intra-articular residual of approximately 2 mm as the cutoff beyond which operative fixation should be considered to reduce the risk of poor joint outcomes. The study tests whether this threshold correlates with functional results in the patient cohort. Imaging modalities such as CT scans and intraoperative arthrography are used to detect occult displacement and confirm reductions that fluoroscopy alone might miss. Technique selection — closed reduction and percutaneous fixation when possible, open reduction for irreducible or soft-tissue–interposed fractures — is explicitly tied to the fracture classification and patient skeletal maturity. [11][12][25]
In short, the study hypothesizes that a disciplined, classification-informed approach — diligent imaging, anatomic reduction, and physeal-conscious fixation — will deliver reliable short-term function while minimizing the risk of complications that threaten future growth and joint health.

Discussion
The cohort examined in the thesis reflects the typical pediatric ankle fracture population: older children approaching skeletal maturity predominate, and transitional injury patterns (Tillaux, triplane) are well represented. Mechanisms are predominantly sports-related or low- to moderate-energy twists, although higher-energy events appear in the more complex fracture patterns. These demographic and mechanism profiles align with larger published series. [1][2][6]
Key management themes emerge from the data. First, imaging matters. Plain radiographs are the starting point, but the addition of mortise views, CT for suspected intra-articular extension and intraoperative arthrography for cartilage/physeal assessment frequently altered operative plans. CT in particular clarifies three-dimensional displacement in transitional fractures and is a valuable planning tool when anatomic reduction is the goal. [8][11][23]
Second, anatomic articular reduction predicts outcome. The dataset supports the commonly accepted threshold that residual intra-articular displacement beyond approximately 2 mm correlates with worse functional outcomes and should prompt fixation. In the series, operations aimed at restoring joint congruity — often using percutaneous cannulated screws or smooth pins depending on the physis status — achieved excellent short-term AOFAS and VAS improvements. These functional gains mirror results reported in other observational studies. [12][16][22]
Third, respect the physis. When growth remains, implants and techniques are chosen to limit additional physeal harm: smooth pins instead of transphyseal threaded screws when feasible, minimal soft-tissue dissection, and percutaneous approaches where possible. Transitional injuries, however, create a practical tension: the physis is partially closed and transphyseal fixation may be acceptable to secure the epiphyseal fragment. The clinical judgment here depends on skeletal age, fracture geometry and the need for rigid fixation to maintain joint congruity. [13][15][25]
Complications in the cohort were relatively infrequent and tended to be minor — superficial wound issues, temporary sensory changes, or transient stiffness. Growth arrest and angular deformity are the complications clinicians fear most, but they often require longer follow-up than the one-year window to become clinically obvious. For that reason, the thesis rightly highlights the need for continued surveillance to skeletal maturity in those at risk. [19][20]
Limitations merit emphasis. The small sample size limits statistical power and generalizability. The single-centre design reflects local practice patterns that may differ elsewhere. Most importantly, follow-up duration in many pediatric series is inadequate to fully capture physeal arrest or late degenerative changes, so short-term functional success cannot be equated with absence of late sequelae. These limitations underscore the need for larger, prospective multicenter studies with standardized outcomes and longer-term follow-up. [17][24]
In practice, this work supports a pragmatic algorithm: obtain precise imaging for suspected intra-articular or transitional fractures; pursue anatomic reduction when the articular surface is involved; choose implants and approaches that minimize additional physeal damage; and maintain vigilance for late growth-related complications. When applied consistently, this approach yields reliable short-term functional recovery while reducing the immediate risk of joint incongruity.

Clinical importance
Pediatric ankle fractures have the potential for lasting harm if joint congruity or physeal integrity is compromised. The practical takeaways are: (1) obtain appropriate imaging (including CT or arthrography where indicated) to detect articular involvement and plan treatment; (2) aim for anatomic reduction of intra-articular fractures — residual steps >2 mm usually justify fixation; and (3) select fixation techniques that respect remaining growth, using smooth pins or percutaneous techniques when crossing an open physis would otherwise risk arrest. Applying these principles minimizes the chance of long-term pain, deformity, leg-length discrepancy and early arthritis.

Future directions
Priority areas include prospective multicentre studies with longer follow-up to quantify physeal arrest and late arthritis rates, randomized trials comparing immobilization strategies for low-risk fractures, and research into biologic or regenerative methods to repair damaged physis. Standardized outcome sets and imaging protocols would also improve comparability across studies.

References

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Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022

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