Injury mechanisms of ankle fractures with dislocation and analysis of differences on functional outcome.

BACKGROUND: In the existing classifications, no importance is given to dislocations accompanying ankle fractures. The present study aims to investigate differences in injury mechanisms of ankle fractures with concomitant dislocation injury in respect of functional outcomes and complications. METHODS: A retrospective evaluation was carried out of 285 patients who underwent surgery in our clinic for an ankle fracture between January 2012 and December 2018. A comparison was made of functional scores and complications between the patients with ankle fracture with dislocation (AF-D group) and patients with ankle fracture without dislocation (AF-WD). The correlation of dislocation with current classifications (Lauge-Hansen and Danis-Weber) and the effects on functional outcomes were also evaluated. In addition to functional scores, a record was also made for each patient of infection during follow-up, soft-tissue defect, malalignment, non-union, arthrosis and Reflex Sympathetic Dystrophy Syndrome (RSD). RESULTS: The mean age of the patients was 44.7±12.04 years (range, 18-72 years) and the mean follow-up period was 3.2 years. Ankle fracture with dislocation was observed in 88 (30.8%). Similar functional results were determined in the AF-WD and AF-D groups with mean AOFAS 84.05±10.5, and 80.33±9.47, respectively (p=0.379), and mean VAS scores of 1±0.5 and 1.23±0.48, respectively (p=0.117). When the AOFAS values of the dislocation function results were evaluated according to the Lauge-Hansen and Danis-Weber subgroups, no significant difference was observed (p=0.562, 0.723). Arthrosis was seen in two of the AF-WD group and seven of the AF-D group (p=0.004). RSD was determined in two of the AF-WD group and in 10 of the AF-D group (p=0.000). From a medico-legal perspective, patients should be informed about arthrosis, and RSD is another significant problem encountered in this patient group. CONCLUSION: Although dislocation accompanying ankle fracture was not seen to worsen functional results, arthrosis and RSD were determined more often in these patients.

Relationship between fracture morphology of lateral malleolus and syndesmotic stability after supination-external rotation type ankle fractures.

BACKGROUND: Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT). METHODS: All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative Cotton test, stable and unstable groups of the ankle factures were divided. RESULTS: A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors. The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively. CONCLUSIONS: CT was superior to simple radiography in predicting syndesmotic injury at the preoperative period in SER-type III and IV. Medial space widening and fragment angle of the fibular posterior cortex, as predictive factors, showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.

Evaluation and Significance of Mortise Instability in Supination External Rotation Fibula Fractures: A Review Article.

Evaluation and management of ankle fractures has progressed in parallel to an evolving understanding of ankle stability. While stability of the mortise had historically been attributed to the lateral malleolus, Lauge-Hansen's contributions followed by multiple other investigations increased the emphasis on the significance of medial-sided injury in destabilizing the mortise. As the importance of the deltoid ligament has been elucidated, the means of assessing ligamentous incompetence and the prognostic significance of an unstable mortise continue to be defined. LEVEL OF EVIDENCE: Level V, expert opinion.

[Anterior dislocation of the fibula resulting from surgical malreduction: a case report].

Ankle joint fracture is one of the most common types of fracture. There are many researches on the injury mechanism, treatment principles and surgical techniques. A type of injury which combines posterior dislocation of fibula, known as the Bosworth injury, is relatively rare. In 1947, Bosworth first described this type of injury as an unusual ankle fracture dislocation with fixed posterior fracture dislocation of the distal part of the fibula. In this type of fracture, the proximal fibular shaft fragment locks behind the tibialis posterior tubercle. This rare ankle fracture variant is often not recognized in initial radiographs and requires a computed tomographic (CT) scan for verification. But there are already many reports, discussing the injury mechanism, treatment principles and surgical techniques. However, there are few reports of anterior dislocation of the fibula, caused by either injury or surgery. The mechanism of the injury is still not clear. This article reports a case of anterior dislocation of the fibula. We report a patient with left ankle open fracture (Lauge-Hansen pronation-external rotation stage III, Gustilo IIIA). Open reduction and internal fixation was done in the initial surgery, but ended up with poor reduction, resulting in fibula anterior dislocation, anterior dislocation of talus and tibia fibular dislocation. The fibula was dislocated anteriorly of the tibia, which rarely happened. The patient suffered severe ankle joint dysfunction. The second operation took out the original internal fixation, reduced the fracture, and reset the internal fixation. The function of ankle joint was improved obviously after operation. But because of the initial injury and the two operations, the soft tissue around the fracture was greatly damaged. 6 months after the second operation, and the fracture still not healed, so the bone graft was carried out in the third surgery. Two months after the third surgery, the function of the ankle was significantly better than before, but the fracture healing was poor, which needed further review. Through this case, we understand the rare type of ankle fracture with anterior dislocation of the fibula, and recognize that the timing and quality of initial surgery has a great impact on the patient's prognosis and rehabilitation period.

[EFFECTIVENESS OF SURGERY IN TREATMENT OF ANKLE FRACTURES ASSOCIATED WITH DELTOID LIGAMENT INJURY].

OBJECTIVE: To evaluate the effectiveness of repairing the deltoid ligament with ankle fracture. METHODS: Between January 2010 and January 2013, 11 patients with ankle fractures associated with deltoid ligament injury were treated. There were 7 males and 4 females, with an average age of 38.2 years (range, 18-72 years). The interval between injury and operation was 6 hours to 7 days (mean, 4 days). According to Lauge-Hansen classification, ankle fracture was rated as pronation-external rotation type in 5 cases, as supination-external rotation type in 4 cases, and as pronation-abduction type in 2 cases. The MRI and color Doppler ultrasound showed deltoid ligament rupture. The results of valgus stress test, talus valgus tilt test, and anterior drawer test after anesthesia were all positive. Fracture was treated by open reduction and internal fixation, and deltoid injury was repaired. RESULTS: All incisions healed primarily. All patients were followed up 12-18 months (mean, 13.3 months). The X-ray films showed anatomical reduction, good position of internal fixation and stable distal tibiofibular syndesmosis. The mean fracture union time was 7.6 weeks (range, 6-8 weeks). MRI at 3 months after operation showed normal shape of the deltoid ligament. According to American Orthopaedic Foot and Ankle Society (AOFAS) score, the results were excellent in 6 cases, good in 3 cases, fair in 1 case, and poor in 1 case, with an excellent and good rate of 81.8%. CONCLUSION: It is an effective method to treat ankle fracture with deltoid ligament injury by open reduction and internal fixation of ankle fracture and repair of the deltoid ligament injury, which can effectively rebuild medial instability and has satisfactory effectiveness.

Weight bearing or non-weight bearing after surgically fixed ankle fractures, the WOW! Study: study protocol for a randomized controlled trial.

BACKGROUND: The optimal post-operative care regimen after surgically fixed Lauge Hansen supination exorotation injuries remains to be established. This study compares whether unprotected weight bearing as tolerated is superior to protected weight bearing and unprotected non-weight bearing in terms of functional outcome and safety. METHODS/DESIGN: The WOW! Study is a prospective multicenter clinical trial. Patients between 18 and 65 years of age with a Lauge Hansen supination exorotation type 2, 3 or 4 ankle fractures requiring surgical treatment are eligible for inclusion. An expert panel validates the classification and inclusion eligibility. After surgery, patients are randomized to either the 1) unprotected non-weight-bearing, 2) protected weight-bearing, or 3) unprotected weight-bearing group. The primary outcome measure is ankle-specific disability measured by the Olerud-Molander ankle score. Secondary outcomes are 1) quality of life (e.g., return to work and resumption of sport), 2) complications, 3) range of motion, 4) calf wasting, and 5) maximum pressure load after 3 months and 1 year. DISCUSSION: This trial is designed to compare the effectiveness and safety of unprotected weight bearing with two commonly used post-operative treatment regimens after internal fixation of specified, intrinsically stable but displaced ankle fractures. An expert panel has been established to evaluate every potential subject, which ensures that every patient is strictly screened according to the inclusion and exclusion criteria and that there is a clear indication for surgical fixation. TRIAL REGISTRATION: The WOW! Study is registered in the Dutch Trial Register ( NTR3727 ). Date of registration: 28-11-2012.

[Minimally invasive percutaneous osteosynthesis for the treatment of 53 patients with complex ankle fractures].

OBJECTIVE: To explore the surgical method and its clinical effects of minimally invasive osteosynthesis on the treatment of complex ankle fractures. METHODS: From January 2007 to December 2011, 53 patients with complex ankle fractures were treated with minimally invasive osteosynthesis. There were 31 males and 22 females, with an average age of 38.2 years old (ranged, 18 to 65). According to the system of Lauge-Hansen, 32 fractures were supination external rotation injury (grade WV), 13 fractures were pronation external rotation (grade III or IV), 5 fractures were pronation abduction (grade III); and 3 fractures can not be classified due to serious comminution fracture of fibula. According to the system of Denis-Weber, there were 4 cases with type A, 34 cases with type B and 15 cases with type C. Seven cases were open fractures. The duration from injuries to operation ranged from 2 hours to 14 days with an average of 5 days. The sequence of reduction and fixation of ankle fractures was firstly posterior malleolus, then medial malleolus and lateral malleolus, and inferior tibiofibular syndesmosis lastly. The fractures of posterior malleolus were reduced and fixed through anterior ankle approaches; the fractures of medial and lateral malleolus were percutaneously fixed with bolts or blade plate or tensile force band; and inferior tibiofibular syndesmosis were firmly fixed if necessary. Baird-Jackson scoring system was used to evaluate clinical effects. RESULTS: Forty-eight patients were followed up from 10 to 36 months with an average of 13 months. The fractures got healing with an average time of 12 weeks (ranged, 10 to 18). According to the Baird-Jackson scoring system, the mean score of ankle function was 94.7 +/- 4.2, and 28 cases obtained excellent results, 15 good, 3 fair and 2 poor. One case experienced superficial infections and was cured by changing dressings, 2 cases experienced fixed syndesmosis screw breakage. CONCLUSION: The surgical method of minimally invasive osteosynthesis can ensure the anatomical join restoration, protect the blood supply of fracture end, rebuild the function of ankle joint, obtain satisfactory clinical results in treating complex ankle fractures.

Correlation of weightbearing radiographs and stability of stress positive ankle fractures.

BACKGROUND: A positive external rotation stress test has been used as an indication for operative treatment of fractures of the lateral malleolus. The objective of the current study was to ascertain the results of a protocol initially treating stress positive ankle fractures nonoperatively and utilizing weightbearing radiographs in surgical decision making. METHODS: We performed a prospective study of lateral malleolar fractures with an associated medial ligamentous injury. All patients with fractures of the lateral malleolus with medial sided symptoms and/or signs, and an intact ankle mortise underwent an external rotation stress test to confirm injury to the deltoid ligament (stress positive). Patients with a positive stress test were placed in a short-leg walking cast and seen in 7 days where weightbearing radiographs of the ankle were obtained. If the radiographs demonstrated an intact mortise, then nonoperative treatment was continued. If the weightbearing radiographs demonstrated medial clear space widening, then the patient was offered operative treatment to restore the congruency of the ankle mortise. Patients were assessed for conversion to operative treatment, complications, and functional outcome. Thirty-eight patients were enrolled in the study. Using Lauge-Hansen classification 36 (95%) were stress positive supination-external rotation fractures and 2 (5%) were stress positive pronation-external rotation fractures. Followup assessment was performed at a minimum of 6 months and averaged 12 months. RESULTS: Weightbearing radiographs at the first post-injury clinic visit had an average medial clear space of 2.9 ±0.9 mm. Three (8%) patients met our criteria for medial clear space widening and underwent operative treatment. Of these three patients, two were pronation-external rotation fracture patterns. Therefore, 3% of the supination-external rotation IV fractures, and all of the pronation-external III/IV rotation fractures ultimately required operative treatment. At final followup, the average AOFAS hindfoot score was 92 ±8.1. CONCLUSION: Ligamentous supination-external rotation Stage IV fractures with an intact mortise on static radiographs can be initially treated nonoperatively. Weightbearing radiographs should be utilized to assess congruency of the ankle mortise during an early post-injury visit. Utilizing this approach, a significant number of surgeries were avoided, and good to excellent results were obtained. From our early experience, nonoperative treatment of pronation-external rotation III/IV injuries using this protocol is not recommended.

Foot impairments and limitations in walking activities in people affected by leprosy.

OBJECTIVE: To explore the relationships between perceived limitations in walking-related daily activities, walking ability (capacity), and the amount of daily walking (performance) in persons affected by leprosy and to identify their determinants. DESIGN: A cross-sectional study. SUBJECTS: Thirty-nine persons affected by leprosy. METHODS: Perceived limitations were assessed with the World Health Organization Disability Schedule II, domain "getting around". Walking capacity was assessed as covered distance in 6 min. Walking performance was recorded as mean strides/day with the Stepwatch(TM) 3 Activity Monitor. Potential determinants were sensory function, foot deformities, joint mobility, ankle muscle strength and co-morbidity. RESULTS: Perceived limitations in walking-related activities were significantly correlated with walking capacity (r = -0.47; p < 0.01) but not with walking performance, although walking capacity significantly correlated with walking performance (r = 0.38; p < 0.05). Various foot impairments independently contributed to reduced walking capacity and, to a lower degree, to perceived limitations in activities and performance. CONCLUSION: People affected by leprosy perceive limitations in walking-related activities that are determined by a reduced walking ability and the severity of foot impairments. Since perceived limitations in walking-related activities were not related to walking performance, perceived limitations are apparently weighted against the individual's needs.

Early active motion versus immobilization after tendon transfer for foot drop deformity: a randomized clinical trial.

BACKGROUND: Immobilization after tendon transfers has been the conventional postoperative management. Several recent studies suggest early mobilization does not increase tendon pullout. QUESTIONS/PURPOSES: To confirm those studies we determined whether when compared with immobilization early active mobilization after a tendon transfer for foot-drop correction would (1) have a similar low rate of tendon insertion pullout, (2) reduce rehabilitation time, and (3) result in similar functional outcomes (active ankle dorsiflexion, plantar flexion, ROM, walking ability, Stanmore score, and resolution of functional problems. METHODS: We randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. Rehabilitation time was defined as the time from surgery until discharge from rehabilitation with independent walking. The minimum followup was 16 months (mean, 19 months; range, 16-38 months) in both groups. RESULTS: We observed no case of tendon pullout in either group. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups. CONCLUSION: In patients with Hansen's disease, an early active mobilization protocol for foot-drop correction has no added risk of tendon pullout and provides similar functional outcomes compared with immobilization. Early mobilization had the advantage of earlier restoration of independent walking. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The use of weightbearing radiographs to assess the stability of supination-external rotation fractures of the ankle.

BACKGROUND: Isolated lateral malleolar fractures usually result from a supination-external rotation (SER) injury and may include a deltoid ligament rupture. The necessity of operative treatment is based on the recognition of a relevant medial soft-tissue disruption. Currently used tests to assess ankle stability include manual stress radiographs and gravity stress radiographs, but seem to overestimate the need for fracture fixation. METHODS: We investigated the use of weightbearing radiographs to distinguish stable and unstable isolated lateral malleolar fractures induced by the SER mechanism in 57 patients. Patients with stable fractures (SER type II according to the Lauge-Hansen classification) were treated non-operatively with varying external support. Forty-seven patients were evaluated by questionnaire and AOFAS ankle-hindfoot score. Follow-up was 18-120 months (mean 62). RESULTS: Fifty-one of fifty-seven (90%) patients were found to have stable fractures (SER type II) and were treated nonoperatively. The AOFAS score was 96.1 points on average (range 85-100) at latest follow-up. Four patients reported minor complaints. A "moderate" correlation of risk factors (i.e. smoking) to delayed bone healing was found while the correlation of varying external support (i.e. bandage, cast) to the AOFAS score and delayed bone healing was "poor". CONCLUSION: The use of weightbearing radiographs is an easy, pain-free, safe and reliable method to exclude the need for operative treatment, with excellent clinical outcome in the majority of the patients seen at latest follow-up. The delay of 3-10 days until the decision about surgical treatment is well accepted by the patients.

[The role of the tibiofibular syndesmotic and the deltoid ligaments in stabilizing Weber B type ankle joint fractures--an experimental investigation]. / Beitrag der Syndesmosen und des Deltabandes zur Stabilität der Aussenknöchelfraktur Typ Weber B. Eine experimentelle Untersuchung.

The purpose of the present biomechanical investigation was to check the functional importance of the syndesmosis ligaments and of the deltoid ligament for ankle fracture type B according to the AO-Weber classification. We constructed a special fixation clamp, with 12 fresh and unembalmed lower legs being tested for lateral shift (mm) and ten for tibiotalar rotation. All specimens were exposed in the same neutral position. Transverse loads (F(y)) varied between 0 and 150 N, axial loads (F(z)) between 0, 300, 600 and 1,000 N and rotational loads (F(r)) between 2.4 and 4.9 Nm. All series were repeated according to supination-eversion (SE) injury patterns of the Lauge-Hansen classification. Syndesmotic ligaments and the fibula were incrementally sectioned from anterior to posterior. Type SE I consisted of an isolated incision of the anterior syndesmosis ligament. Type SE II had an additional oblique fracture of the fibula at the height of the tibiofibular syndesmosis. In type SE III injuries, in addition to the fibular fracture, a complete rupture of the syndesmosis ligaments was present, and for type SE IV lesions the deltoid ligaments were incised. The transverse load-displacement curve was s-shaped in all uninjured joints,with the highest gradient between 10 and 20 N with no axial compression. Without axial compression in cases of F(y)=25 N transverse loads, the mean talus translation was 0.51 mm. Following type II injuries, the average talus translation was 0.68 mm (not significant) and rose to an average of 0.95 mm ( P <0.01) in type III injuries. After additional incision of the deltoid ligaments, the ankle joint subluxed permanently when more than 5-10 N transverse loads were applied. Axial loads of 300 N or more resulted in a considerable reduction in talus translations, indicating increased stability and congruency within the joint complex. In this way, the vertical loading of the ankle joints always contributed to joint stability. The average internal tibiotalar rotation reached with a torque of 2.4 Nm was 3.52 degrees and with 4.9 Nm 5.15 degrees when no axial compression was applied. External rotation measured -6.36 degrees and -8.62 degrees, respectively. Following the experimental protocol, significant increases were noted for external rotation at SE II degrees injuries ( P =0.003) and for internal rotation at SE III degrees ( P =0.03) injuries. Our data support the proposition that the deltoid ligaments and the posterior syndesmosis play a key role in the stability of ankle fractures for supination-eversion injuries. If these structures remain intact, conservative and early functional treatment are recommended in patients with minimal (<2 mm) or no fracture displacement. This concept is confirmed by the literature dealing with clinical mid- and long-term follow-up studies.

Motion of the ankle in a simulated supination-external rotation fracture model.

UNLABELLED: An experimental study was undertaken with use of axially loaded, unconstrained cadaver ankles to determine the motion patterns seen with progressive stages of the supination-external rotation type of fracture. As described by Lauge-Hansen, these fractures were modeled by transection of the anterior aspect of the capsule and the anterior tibiofibular ligament (stage I), followed by oblique fibular osteotomy ending at the level of the ankle joint (stage II), transection of the posterior aspect of the capsule (stage III), and sequential sectioning of the superficial and deep fibers of the deltoid ligament (stage IV). Thirteen specimens were tested on an apparatus that allowed for controlled loading while the ankle was passed through a physiological range of dorsiflexion and plantar flexion. The ankles were unconstrained about the axial (internal and external rotation) and coronal (varus and valgus angulation) axes. Measurements were made throughout the range of motion in these axes in order to define the kinematic behavior. In the intact specimens, maximum plantar flexion was associated with a mean (and standard deviation) of 1.9 +/- 4.12 degrees of internal rotation of the talus and maximum dorsiflexion, with a mean of 7.2 +/- 3.88 degrees of external rotation. Varus angulation increased slightly with plantar flexion compared with the value in dorsiflexion (2.4 +/- 2.40 compared with 0.3 +/- 1.96 degrees). Internal and external rotation was not affected by fibular osteotomy or by transection of the superficial fibers of the deltoid ligament. Transection of the deep fibers of the deltoid ligament caused a significant (p < 0.02) increase in external rotation of the talus at maximum plantar flexion; this was corrected incompletely by insertion of an anatomical fibular plate. With the numbers available for study, we could not show that varus or valgus angulation was significantly affected by any combination of sectioning of the deltoid ligament and fibular osteotomy. These experiments were repeated with the addition of fixation of the subtalar joint with a talocalcaneal screw. With the number of specimens available, we could detect no significant difference, with respect to axial rotation, due to fixation of the subtalar joint. However, along the coronal axis, increased valgus angulation (p < 0.02) was seen during plantar flexion when either the deep or the superficial fibers of the deltoid ligament had been cut. CLINICAL SIGNIFICANCE: These results indicate that stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. Complete fibular osteotomy did not cause abnormal motion of the ankle in the absence of a medial injury. In the presence of a complete injury, lateral reconstruction only partially restored the mechanical integrity of the ankle. The results provide justification for the non-operative treatment of isolated fractures of the lateral malleolus. The data also suggest that a lateral fracture associated with a major injury of the deltoid ligament should be treated with anatomical lateral fixation followed by immobilization without early motion, to allow adequate healing of the deltoid ligament at its resting length.

Fracture fixation with biodegradable rods. Forty-one cases of severe ankle fractures.

In a prospective study of 41 patients, severe ankle fractures of Lauge-Hansen types SE III-IV, PA III, and PE III-IV were treated by open reduction and internal fixation using biodegradable self-reinforced polyglycolide cylinder-shaped rods. Disruption of the distal tibiofibular syndesmosis and/or fracture of the posterior tibial margin requiring reduction and fixation were the inclusion criteria for the study. The mean follow-up time after operation was 16 (12-32) months. Two failures of fixation necessitated reoperation. A secondary displacement of 1-2 mm of the lateral malleolus occurred in 3 cases. Transient accumulation of soluble polyglycolide mass complicated the course in 3 cases, but did not influence the radiographic or the functional result. Function became good in 30 patients. The advantage of the biodegradable implants is that they do not need to be removed at secondary operations.

Epiphyseal injuries of the foot and ankle.

A thorough knowledge of functional growth plate anatomy and physiology is essential to proper management of epiphyseal foot and ankle injuries. The ability to classify foot and ankle fractures according to the Salter-Harris anatomic and radiographic classification provides useful prognostic information that may affect treatment. The Dias-Tachdjian mechanistic classification system for pediatric ankle fractures provides useful information about the extent of osseous and soft tissue injury and the best method of closed reduction and correlates well with the Lauge-Hansen system, which is widely used for adult ankle fractures. Most epiphyseal foot fractures involve the metatarsals or phalanges and can usually be managed with closed reduction. Considerable spontaneous correction of deformity can be expected in the younger child (under age 10 years), but one should be aware that sagittal plane and rotational malalignment of the metatarsal heads may cause significant problems. Salter-Harris type I and II fractures of the ankle can usually be managed with closed reduction. Salter-Harris type III and IV ankle fractures with greater than 2 mm of displacement require open reduction and internal fixation. One must also have a high index of suspicion for juvenile Tillaux and triplane transitional fractures that may not be obvious on plain radiographs. Although these fractures usually do not produce significant limb-length discrepancies, they are intra-articular fractures and ankle joint arthritis can result. Finally, younger children (under age 10 years) have a better prognosis for spontaneous correction of nongrowth arrest-induced deformities but a much poorer prognosis with growth arrest injuries than do older children, in whom growth arrest does not usually cause a significant problem. All children with growth plate injuries should be followed at regular intervals for at least 2 years or to skeletal maturity in the case of physeal disturbance. Treatment of epiphyseal fractures of the foot and ankle must be individualized but should always be based upon a thorough knowledge of anatomy, bone growth physiology, classification, potential pitfalls, and prognosis.