Functional Outcomes of Unstable Ankle Fractures in Adolescents

Abstract

Background: The purpose of this study was to describe the functional outcomes and complications of unstable supination external rotation (SER) and pronation external rotation (PER) ankle fractures in adolescents. A secondary outcome was to compare functional outcomes of SER stage IV injuries that were treated definitively with closed reduction and cast application to a similar group of minimally displaced fractures treated with open reduction and internal fixation (ORIF). Methods: A retrospective review of adolescents aged 10 to 18 years with unstable ankle fractures treated at a single institution between 2009 and 2017 was conducted. All patients had functional outcomes data from the Foot and Ankle Ability Measure obtained at a minimum of 1-year follow-up. Results: In total, 67 adolescents (41 SER, 26 PER) were included (mean follow-up: 52.3±24.8 mo). A total of 56 were treated with ORIF and 11 were closed reduced and casted. No patients treated nonsurgically had a loss of reduction and none required subsequent surgical intervention. Preoperative radiographic predictors of syndesmotic injury (>6 mm of tibiofibular clear space or <2 mm of tibiofibular overlap) were not sensitive and only moderately specific predictors of intraoperative syndesmotic injury. There was no difference in functional outcome between the 11 SER stage IV fractures treated nonoperatively and a group of minimally displaced SER injuries treated with ORIF. Patients with open or partially open physes had better functional outcomes. Patients with syndesmotic injuries, medial malleolus fractures, or fracture-dislocations were not associated with lower functional outcome scores in our adolescent cohort. Conclusions: Unstable SER and PER injuries in adolescents have favorable functional outcomes at intermediate-term follow-up, though a minority continue to have impaired ankle function. Minimally displaced SER stage IV injuries with near anatomic alignment after closed reduction can be successfully treated with continued closed management, and have no difference in functional outcomes compared with similar injuries treated with ORIF. Level of Evidence: Level III.

Pediatric Ankle Syndesmosis Injuries

“…41 Another study showed >6 mm tibiofibular clear space and <2 mm tibiofibular overlap were not sensitive and only moderately specific to syndesmotic injury in adolescents. 25 Tibiofibular clear space and medial clear space decrease with age, while tibiofibular overlap appears at 6.1 years in AP and 7.9 years in mortise views and increases with age. 42 Studies support the use of stress radiographs in diagnosis in addition to bilateral ankle radiographs as there is less than 50% difference of ankle measurements in over 90% of uninjured patients.…”

“…[22][23][24] An open physis more often leads to certain fractures found in children and is thought to be a protective factor against syndesmotic injury. 25 As the physes close, transitional fractures and ligamentous injuries become more likely. This is demonstrated in one study where the youngest children had intraarticular tibial fractures and malleolar fractures (mean ages 10.0 to 11.6), the intermediate aged children had epiphyseal fractures (mean ages 12.4 to 12.9), and the oldest children had avulsion fractures such as Tillaux fractures (mean age 13.1).…”

What is New in Pediatric Orthopaedic Foot and Ankle

“…61 Ankle fractures needing surgical intervention have relatively good outcomes in children, especially those with open physes. 62 Paez et al 63 demonstrated that since skeletally immature patients have robust healing potential, lag screw fixation for unstable distal fibular fractures in adolescents without plating can be successful.…”

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

“… 8 - 10 The incidence and natural history of this injury in paediatric and adolescent patients remains unclear, and few studies have examined functional outcomes. 11 , 12 Kramer et al 13 reported a 1% prevalence of syndesmotic injury in all paediatric patients undergoing evaluation for ankle trauma, and Lurie et al 14 found that 36.7% of Weber B and 57.7% of Weber C unstable adolescent ankle fractures required syndesmotic fixation (SF). 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.…”

“…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 …”