Epidemiology of syndesmotic fixations in a pediatric center

Abstract

Syndesmosis injuries need to be accurately diagnosed and managed to avoid chronic pain, early arthritis, and instability. To this end, the present study aimed to analyze the epidemiology of syndesmotic injuries in a pediatric ankle fracture cohort and identify patient and surgery-related characteristics. A retrospective review of all the ankle fractures during a 12-year period at a single pediatric referral center was conducted. Inclusion criteria were: a fractured ankle that underwent a surgical fixation, at least 1 radiograph available for review before fixation, available information regarding surgery, including operative report and fluoroscopic images, and younger than 18 years at the time of surgery. Demographic information, trauma, radiographs, surgical details, clinical examination, follow up, outcomes, and physeal status (skeletally immature, transitional, or mature) were recorded. Finally, patients were divided in 2 groups: with or without syndesmotic fixation. Statistical analysis included descriptive statistics, Mann–Whitney test for nonparametric data to compare continuous parameters, and χ 2 test for categorical parameters. A total of 128 patients were included with a mean age of 14.1 years. There were 80 boys and 48 girls. There were 51 skeletally immature patients, 23 with transitional fractures, and 54 that were skeletally mature. The main finding of this study is that only 11 patients from the mature group underwent syndesmotic fixation. There were no cases of syndesmotic fixation in the skeletally immature and transitional groups. This is the first retrospective study to focus specifically on syndesmotic injuries in a pediatric population who underwent ankle fracture fixation. Only 11 skeletally mature patients underwent syndesmotic fixation out of 128 patients in this cohort. This result raises the question of whether there are accurate diagnostic tools to evaluate syndesmosis in children.

Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population

“…Our finding that operative ankle fractures with and without SF had equivalent functional outcomes differs from some studies in the adult population. 19 , 26 - 29 Egol et al 27 conducted a large study on 347 patients with unstable ankle fractures, finding that those with SF had significantly worse functional outcome and pain scores at minimum one-year follow-up. Still and Atwood 29 also found that fractures requiring SF had worse functional outcomes.…”

“…While the effect of syndesmotic injury on functional outcome in the adult population remains unclear, data on adolescent syndesmotic injuries is even more limited. Lamer et al 19 reviewed 128 paediatric ankle fractures but only identified 11 patients that underwent SF and found similar functional outcomes at approximately one-year follow-up. Our study had a much higher proportion of skeletally mature adolescents that required SF and, therefore, we were able to perform an adequately powered comparison between adolescent ankle fractures treated with and without SF.…”

“…The ligaments are stronger than the physeal plate, which often leads to fractures over purely ligamentous injury. 19 , 37 Furthermore, an open distal tibial physis is believed to result in Salter Harris type I or II injuries but as the physis closes, ligamentous injuries and transitional fractures become more common. 11 , 38 Kramer et al 13 supported this theory of the protective nature of an open physis against purely ligamentous injury requiring surgical fixation.…”

“…Accurate diagnosis without radiographic examination under anaesthesia can be difficult due to the low sensitivity and specificity of clinical examination and static radiographs, especially in skeletally immature patients. 4 , 14 - 19 …”

“… 4 , 6 , 23 - 25 While prior studies have compared the outcomes of ankle fractures with and without syndesmotic injury, the results were mixed, inclusion and exclusion criteria varied significantly between studies and very few studies included a significant number of adolescent patients. 19 , 26 - 29 …”