Pediatric emergency medicine trisk 0795 0795
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possible implications of physeal injuries. The Salter–Harris (S-H) classification is
most commonly applied, as described in Chapter 111 Musculoskeletal Trauma .
Inversion ankle injuries in preadolescents most commonly cause an S-H type I
fracture of the distal fibula (Fig. 40.1 ). Clinically, the patient presents with
swelling about the lateral malleolus and tenderness at the distal fibular physis.
Fractures confined to the physes may not be visible on radiographs.
Consequently, routine radiographs may appear normal despite the presence of a
fracture.
In severe inversion injuries, the distal fibular fracture described previously may
be accompanied by a fracture of the tibia (Fig. 40.2 ). This additional fracture is
usually an S-H type III or IV injury through the medial malleolus that also
extends below or across the distal tibial physis. These patients will have
tenderness at the medial malleolus and the distal fibular physis.
Fractures resulting from eversion of the ankle are usually a combination of an
S-H type II fracture of the lateral tibia and a transverse fracture of the fibula (Fig.
40.3 ). The fibular fracture is often relatively high (4 to 7 cm above the fibular
physis). Therefore, it is important to examine the full length of the fibula in
patients with ankle injuries.
Direct axial compression of the ankle is uncommon but can cause an S-H type
V injury to the distal tibia. Given the mechanism, this type of injury may be
associated with fractures of the spinal column. External rotation injuries are
responsible for lesions known as transitional fractures. Transitional fractures
occur during adolescence when closure of the growth plates is beginning. Closure
of the distal tibial physis starts centrally and then spreads medially, posteriorly,
and finally laterally. The distal tibial physis closes before the distal fibular physis.
As skeletal maturity (and physeal closure) progresses, the relative strengths of
various parts of the tibia change. As a result, the same mechanism of injury may
cause very different fracture patterns, depending on the age of the patient. The
juvenile Tillaux fracture and the triplane fractures are examples of transitional
fractures.
In the juvenile Tillaux fracture, a fragment of bone is torn off the lateral border
of the tibia by the anterior tibiofibular ligament (Fig. 40.4 ). It is an S-H type III
injury of the distal tibia. This fracture is seen almost exclusively in patients
between the ages of 12 and 14 years. This is because the closure of the medial
aspect of the distal tibial physis begins around 12 to 14 years of age, whereas the
lateral aspect remains open and therefore less stable for approximately another 18
months. The greater the skeletal maturity of the patient, the more lateral the
epiphyseal fracture line occurs.
