Pelvic Avulsion Fractures in Adolescent Athletes: Analyzing the Effect of Delay in Diagnosis.

OBJECTIVE: To evaluate whether delay in the diagnosis of pelvic avulsion fractures in young athletes leads to prolonged treatment and prolonged return toward sport activities, whether fractures at certain locations are associated with a greater risk of diagnostic delay, and what reasons may exist for delay in diagnosis. DESIGN: Retrospective chart review of young patients who presented with pelvic region avulsion fracture to a community-based sports medicine clinic over a 19-year period. SETTING: Private practice, primary care sports medicine clinic. PATIENTS: Patients younger than 20 years diagnosed with pelvic region avulsion fracture. INTERVENTIONS: None, this was a retrospective study. MAIN OUTCOME MEASURES: Clearance for return toward sport activities. RESULTS: Two hundred twenty-five cases were reviewed for reasons for delay in diagnosis; 208 cases met criteria for the duration of treatment and return to play activities portions of the study. The mean time from date of injury diagnosis was 19.59 days, and the mean duration from date of injury to clearance for return to play advancement was 67.20 days. Duration of treatment varied slightly depending on timing of diagnosis, whereas duration from date of injury to clearance for return to play advancement varied greatly depending on diagnostic delay. Those who did not sense a "pop" at the time of injury were more likely to experience diagnostic delay, as were athletes with ischial tuberosity fractures. The most common cause of diagnostic delay was patient/family decision on when to seek care; misdiagnosis as a muscle strain was also common. CONCLUSIONS: Diagnostic delay of adolescent pelvic avulsion fractures may unnecessarily prevent athletes from returning to play within an optimal time frame. Our observations highlight a need for educating athletes and their families on when to seek initial or follow-up medical care as well as educating medical providers regarding the diagnosis of pelvic avulsion fractures.

Avulsion fractures of the ischial tuberosity in the pediatric athlete: a systematic review and return to sport analysis.

Apophyseal avulsion fractures of the ischial tuberosity (AFIT) in pediatric athletes are relatively uncommon injuries with treatment and return to sport (RTS) outcomes being largely unknown. The purpose of this review is to perform a systematic review analyzing RTS and predictors of successful RTS for pediatric athletes sustaining AFIT. Studies reporting on athletes strictly under the age of 18 years sustaining an AFIT with reported RTS status were included. RTS was analyzed based on injury acuity, mechanism, and management, whereas the incidence of any complications was recorded. A total of 33 studies comprising 90 cases of AFIT were identified. The mean age of athletes sustaining injuries was 14.7 + 1.4 years (range, 9-17 years), most commonly participating in soccer ( n = 25), sprinting ( n = 21), and gymnastics ( n = 7). Acute trauma during sporting activities was responsible for 74.4% ( n = 77/90) of injuries. A total of 82% ( n = 74/90) of athletes reported successful RTS at an average of 7.0 + 5.0 months. Athletes undergoing surgery had a significantly higher RTS rate ( n = 36/38, 94.7%) compared with athletes treated nonoperatively (n = 38/52, 73.08%; P = 0.008). When reported, a high rate of misdiagnosis was reported (39.4%, n = 28/71). Complications were reported in 15.8% ( n = 7/38) and 32.7% ( n = 17/52) of athletes managed surgically and conservatively, respectively. As such, the high rate of misdiagnosis and subsequent high rate of complications and poor rate of RTS highlight the importance of accurate diagnosis and treatment. Future prospective studies evaluating patient outcomes based on fracture displacement, sporting activity, and management strategies are warranted to better treat pediatric athletes. Study design: Level IV, systematic review.

Pelvic Region Avulsion Fractures in Adolescent Athletes: A Series of 242 Cases.

OBJECTIVE: The objective of this descriptive study was to evaluate pelvic region avulsion fractures in adolescents, including age of injury, location of injury, activity and mechanism at time of injury, treatments used, duration of treatment, and outcomes. DESIGN: This was a retrospective chart review of patients who presented with pelvic region avulsion fracture over a 19-year period. SETTING: Private practice, primary care sports medicine clinic. PATIENTS: All patients younger than 20 years of age diagnosed with an acute pelvic region avulsion fracture. INTERVENTIONS: There was no set intervention protocol. A variety of interventions and combination of interventions were used and determined by the treating physician on a case-by-case basis. MAIN OUTCOME MEASURES: Clearance for return toward sport activities. RESULTS: Of the 242 cases, 162 were male. Soccer was the most common sport at the time of injury, and running/sprinting was the most common mechanism. Males were generally older at presentation and were more likely than females to have anterior inferior iliac spine injuries, whereas females were more likely to have iliac crest avulsions. Conservative treatment was effective in all cases. Males were treated for a shorter duration than females, but this difference was not statistically significant. CONCLUSIONS: Pelvic avulsion fractures are a rare injury in adolescent athletes. Males are twice as likely to experience these injuries and are older at presentation compared to females. Conservative management leads to successful outcomes in most cases.

Bilateral anterior superior iliac spine apophysis avulsion fractures in a skeletally mature patient: case report and literature review.

We present a case of bilateral anterior superior iliac spine avulsion fractures in an adult patient who was involved in a road traffic collision. Her injuries were managed conservatively and she has had an uncomplicated recovery with a good outcome. This is, to our knowledge, the only reported case of bilateral simultaneous anterior superior iliac spine apophyseal avulsion fractures in an adult.

BET 2: Tubular bandage, plaster or aircast boot for avulsion fractures of the base of the fifth metatarsal?

A shortcut review was carried out to investigate whether avulsion fractures of the base of the fifth metatarsal were best treated with tubular bandage, a walking boot or a short leg plaster cast. One paper presented the only evidence to answer one of the clinical questions (plaster cast or walking boot) but no evidence was found comparing tubular bandage and a walking boot. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this paper are tabulated. It is concluded that while the only evidence available shows marginal benefit of walking boot over short plaster cast during recovery, there is no benefit to final outcome. Further research comparing tubular bandage and walking boot is required.

Hard-Soled Shoe Versus Short Leg Cast for a Fifth Metatarsal Base Avulsion Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial.

BACKGROUND: The purpose of this study was to determine whether tolerated weight-bearing in a hard-soled shoe was noninferior to the use of a short leg cast for the treatment of a fifth metatarsal base avulsion fracture, as assessed with use of a 100-mm visual analog scale (VAS) for pain at 6 months after the fracture. METHODS: A total of 145 patients were assessed for eligibility. Of these, 96 patients were randomly assigned to either the hard-soled shoe group (46 patients) or the cast group (50 patients). The primary outcome measure was the mean difference on the 100-mm VAS between groups at 6 months after the fracture. Secondary outcome measures included the time to return to preinjury activity and patient-reported satisfaction. Analysis was performed according to both an intention-to-treat basis (i.e., patients were included in the assessment of their assigned treatment arm, even if they crossed over to the other treatment arm prior to completing the 6-month follow-up) and a per-protocol basis (i.e., patients who completed the 6-month follow-up were analyzed according to the treatment they received). RESULTS: At 6 months after the fracture, the mean 100-mm VAS was 8.6 ± 7.0 mm in the hard-soled shoe group and 9.8 ± 7.3 mm in the cast group (p = 0.41) according to intention-to-treat analysis. The mean difference in 100-mm VAS between the 2 groups was -1.3 mm (95% confidence interval, -4.3 to 1.8 mm). The upper limit of the 95% confidence interval did not exceed the noninferiority margin of 10 mm, indicating that treatment with the hard-soled shoe was noninferior to treatment with the short leg cast. The proportion of patients who reported satisfaction with their treatment was similar between the hard-soled shoe and cast groups (89.5% compared with 87.5%, respectively; p = 0.79), but the time to return to preinjury activity was significantly shorter in the hard-soled shoe group (37.2 ± 14.4 days compared with 43.0 ± 11.1 days in the cast group; p = 0.04). There were no cases of nonunion in either group. CONCLUSIONS: Weight-bearing as tolerated in a hard-soled shoe for a fifth metatarsal base avulsion fracture was noninferior to the use of a short leg cast as assessed with use of a 100-mm VAS at 6 months after the fracture. Patient-reported satisfaction was similar between groups, but the time to return to preinjury activity was shorter in the hard-soled shoe group. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Nonoperative Management of Minimally Displaced Patellar Sleeve Fractures.

Patellar sleeve fractures primarily occur in the adolescent population from a rapid contraction of the quadriceps with the knee in a flexed position. Several small case reports describe operative reduction and fixation for displaced fractures. However, there is sparse literature on nonoperative management of these injuries. Retrospective review and prospective follow-up of all patients diagnosed with patellar sleeve fracture between 1991 and 2014 at a single institution. Patients with superior pole avulsion fractures, history of prior knee surgery, and fractures managed operatively were excluded. Patients with a clinical diagnosis without support of advanced imaging were also excluded. Radiographs and magnetic resonance imaging (MRI) were reviewed for initial fracture displacement, time until fracture union, and the presence of patellar tendon ossification. Outcome was assessed using the Tegner's activity scale, Kujala's Score and the International Knee Documentation Committee (IKDC) subjective knee evaluation score at final follow-up. Eighteen nonoperatively treated distal patellar pole sleeve fractures were identified, while five patients had advanced imaging to support their diagnosis. All were males with a mean age of 15.1 (range: 12-18). Traumatic and sport-related injuries were noted in the majority of patients. Only one patient had any appreciable displacement, but still < 2 mm. Final radiographic evaluation revealed fracture healing without patellar tendon ossification in all patients. All five patients had full terminal knee extension and symmetric range of motion. Mean IKDC score was 96.4 (range: 82-100) mean Tegner's activity score was 60 (range: 5-8), and mean Kujala's score was 89.7 (range: 63-100) at final follow-up. Of the five cases, three patients presented in a delayed fashion, and all went on to have surgical treatment. Two required arthroscopic loose body removal, while the other had an open patellar debridement and platelet-rich plasma (PRP) injection. Minimally displaced patellar sleeve fractures can be successfully managed nonoperatively with excellent clinical outcomes. However, delayed in presentation may be associated with worse outcome. This study of case series reflects level of evidence IV.

The amount of displacement can determine non-operative treatment in posterior cruciate ligament avulsion fracture.

PURPOSE: It is generally agreed that surgical treatment is warranted for acute posterior cruciate ligament (PCL) avulsion fracture with displacement. However, the amount of displacement that warrants surgical treatment has not been defined. The purpose of this study was to determine the optimal cut-off value for displacement of posterior cruciate ligament avulsion fracture in determining non-operative treatment and to compare the results of non-operative treatment in acute isolated PCL avulsion fractures with non-operative treatment of acute PCL injury. METHODS: Between 2007 and 2017, 30 consecutive patients with acute isolated PCL avulsion fractures and 70 consecutive patients with acute isolated PCL injuries, all of whom underwent non-operative treatment (cast immobilization with > 2 years of follow-up) were retrospectively analyzed. Clinical scores including the International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score, as well as side-to-side differences on stress radiographs, were compared between the PCL avulsion fracture and PCL injury groups at the final follow-up. The failure rates of non-operative treatment were also compared. The predictive value of the amount of fracture displacement for successful non-operative treatment was calculated using area under the receiver operating characteristic curve (AUROC). The optimal cut-off of the amount of fracture displacement to determine non-operative treatment was based on the maximal sum of sensitivity and specificity. RESULTS: The two groups exhibited comparable clinical scores and mean side-to-side differences on stress radiographs. There were 5 (16.6%) failures of non-operative treatment in the PCL avulsion fracture group and 19 (27.1%) failures in the PCL injury group. (n.s) There was a significant positive correlation between the amount of initial avulsion fracture displacement and side-to-side difference in posterior stress radiographs at final follow up (P < 0.001). The optimal cut-off value for the amount of fracture displacement in PCL avulsion fracture to predict failure of non-operative treatment was 6.7 mm (AUROC = 1.0). CONCLUSION: The outcomes of non-operative treatment of acute isolated PCL avulsion fractures were comparable to those of patients with acute isolated PCL injuries. Acute PCL avulsion injuries with displacement of less than 6.7 mm should be considered for non-operative treatment. LEVEL OF EVIDENCE: IV.

Satisfactory clinical outcome of operative and non-operative treatment of avulsion fracture of the hamstring origin with treatment selection based on extent of displacement: a systematic review.

PURPOSE: To compare outcome of operative and non-operative treatment of avulsion fractures of the hamstring origin, with minor (< 1.5 cm) and major (≥ 1.5 cm) displacement, and early (≤ 4 weeks) and delayed (> 4 weeks) surgery. METHODS: A systematic literature search was performed using PubMed, Cochrane, Embase, CINAHL and SPORTDiscus. A quality assessment was performed using the Physiotherapy Evidence Database (PEDro) scale. RESULTS: Eight studies with 90 patients (mean age: 16 years) were included. All studies had low methodological quality (PEDro score ≤ 5). Operative treatment yielded a return to preinjury activity rate (RTPA) of 87% (95% CI: 68-95), return to sports (RTS) rate of 100% (95% CI: 82-100), Harris hip score (HHS) of 99 (range 96-100) and a University of California Los Angeles activity scale (UCLA) score of 100%. Non-operative treatment yielded a RTPA rate of 100% (95% CI:68-100), RTS rate of 86% (95% CI: 69-94), HHS score of 99 (range 96-100), and non-union rate of 18% (95% CI: 9-34). All patients with minor displacement were treated non-operatively (RTPA: 100% [95% CI: 21-100], RTS: 100% [95% CI: 51-100]). For major displacement, operative treatment led to RTPA and RTS rates of 86% (95% CI: 65-95) and 100% (95% CI: 84-100), and 0% (0/1, 95% CI: 0-79) and 100% (95% CI: 51-100) for non-operative treatment. Early surgery yielded RTPA and RTS rates of 100% (95% CI: 34-100 & 57-100) compared to 100 (95% CI: 72-100) and 90% (95% CI: 60-98) for delayed repair. CONCLUSION: All included studies have high risk of bias. There is only low level of evidence with a limited number of included patients to compare outcome of operative and non-operative treatment. Overall outcome was satisfactory. There is a treatment selection phenomenon based on displacement, with acceptable outcome in both groups. There is insufficient data to draw conclusions regarding timing of surgery. LEVEL OF EVIDENCE: IV.

Surgical versus conservative management of fifth metatarsal fractures in adults: A protocol of retrospective study.

BACKGROUND: At present, the treatment of base fractures of the fifth metatarsal, especially the area I fractures, is still a controversial topic. The objective of our work was to assess the radiological and clinical outcomes of displaced avulsion fractures of the fifth metatarsal base after treated with conservative treatment or intramedullary screw. METHODS: All of the fifth metatarsal fractures patients underwent surgery by the senior authors in our hospital from January 2017 to December 2019 were reviewed. Institutional Review Board in the Subsidiary Hospital of Guizhou Medical University approved this study. Patients with the following conditions can be included:Patients with the following conditions will be excluded: follow-up less than 6 months; open fracture; pathological fracture; osteoporotic fracture; patients have the history of ankle or foot surgery. Radiographs were taken at 1, 3, 6 and 12 months in outpatient follow-up. The following outcomes were assessed in the follow-up: functional outcomes, the score of patient satisfaction, as well as the motion range, and complications. All the statistical analyses were implemented via applying the software of SPSS Version 12 (SPSS Inc, Chicago, IL). RESULTS: We hypothesized that there was no remarkable difference between two groups in the outcomes after operation. TRIAL REGISTRATION: This study protocol was registered in Research Registry (researchregistry6024).

Factors Related to Failure of Conservative Treatment in Volar Plate Avulsion Fractures of the Proximal Interphalangeal Joint.

BACKGROUD: Volar plate avulsion fractures of the proximal interphalangeal (PIP) joint are a common hand injury and have been treated conservatively with favorable results. We assumed that conservative treatment of volar plate avulsion fractures of the PIP joint would be unsuccessful if the fracture fragment, even if small, was much displaced or rotated and that delayed excision of the avulsion fractures would result in good outcomes. We report clinical and radiological outcomes of conservative treatment of volar plate avulsion fractures of the PIP joint and risk factors for failure of conservative treatment. METHODS: We retrospectively reviewed the clinical and radiological outcomes of 88 volar plate avulsion fractures (85 patients) treated conservatively at first. In 18 of these fractures, delayed excision of the fracture fragment was required after an average of 75 days of conservative treatment for limited motion or pain of the joint. We compared parameters between failed cases and successful cases after conservative treatment. RESULTS: Compared to the successful cases, the failed cases had a higher prevalence of joint dislocation at the time of injury and greater pain, larger flexion contracture, and less further flexion after conservative treatment. The shape, comminution, and size of the fracture fragments were not related with the need for operation, but the operative cases had greater displacement and rotation of the fracture fragments than the conservative cases. After fragment excision, postoperative protection of the joint was not necessary, pain was reduced, and the mean range of motion increased. CONCLUSIONS: The presence of joint dislocation and greater displacement and rotation of the fragments may be associated with the failure of conservative treatment of volar plate avulsion fractures. Failed cases after conservative treatment could be resolved by delayed fragment excision with favorable results. Therefore, it might be appropriate to consider conservative treatment at first in almost all volar plate avulsion fractures of stable PIP joints.

Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents.

Although rare, tibial tubercle avulsion fracture must be considered in the differential diagnosis for the pediatric patient presenting with acute knee pain. In the adolescent population, tibial tubercle avulsion fracture is a rare injury that is typically seen in boys who engage in sporting activities that involve jumping or sprinting. The proximal tibial physis closes distally in the posteromedial to anterolateral direction, creating an environment that predisposes the tubercle to a potential avulsion injury. Historically, the Ogden classification has guided nonoperative and operative management of this condition. Multiple fracture fixation methods have been described with the overall goal of restoring the extensor mechanism and the joint surface.

Treatment of Zone 1 Fractures of the Proximal Fifth Metatarsal With CAM-Walker Boot vs Hard-Soled Shoes.

BACKGROUND: Zone 1 fractures of the proximal fifth metatarsal are usually treated nonsurgically using some type of immobilization. The aim of this study was to compare clinical and functional outcomes, time to return to prior activity levels, and rate of bone healing when using a hard-soled shoe (HSS) vs a controlled ankle motion (CAM)-walker boot (CWB). METHODS: Seventy-two consecutive patients with zone 1 fractures of the fifth metatarsal base were treated conservatively with either an HSS or CWB by 2 different providers. We included 57 women and 15 men, average age of 41.3 (range, 16-88) years. Radiographic findings, visual analog scale (VAS) for pain, and American Orthopaedic Ankle & Foot Society (AOFAS) midfoot score were assessed. Patients were followed at 4, 8, 10, 12, and 24 weeks or until asymptomatic and able to return to prior level of activities. Statistical analysis was performed using Mann-Whitney U, Fisher exact, and chi-square tests. P values <.05 were considered significant. RESULTS: Age and gender distributions were similar in both groups (P = .23 and P = .57). Patients had similar VAS and AOFAS scores after 8 (P = .34 and P = .83) and 12 (P = .87 and P = .79) weeks. Average time for bone healing was significantly faster using the CWB (7.2 weeks) when compared to the HSS (8.6 weeks) (P < .001). The average time to return to prior level of activities was similar in both groups (8.3 weeks for CWB and 9.7 weeks for HSS) (P = .11). Fracture displacement was equal in both groups, with a mean of 1.9 mm of displacement in patients using the HSS, and a mean of 1.6 mm in those using the CWB (P = .26). CONCLUSION: Zone 1 fractures of the proximal fifth metatarsal can be treated conservatively with either a hard-soled shoe or a CAM-walker boot. Even though patients treated in the CAM-walker boot demonstrated earlier signs of complete healing, similar clinical and functional results were achieved with both treatments. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Tibial tubercle avulsion fractures in children.

PURPOSE OF REVIEW: To summarize and discuss the fundamentals of pediatric tibial tubercle avulsion fractures (TTAFs) including preferred imaging modalities, systems for fracture classification, frequently associated injuries, treatment options, outcomes, and common complications. RECENT FINDINGS: Although TTAFs amount to fewer than 1% of all physeal injuries in children, the incidence is increasing, likely because of greater participation in high-level athletics. SUMMARY: TTAFs tend to occur in adolescents nearing skeletal maturity who engage in sports with repetitive jumping. The most popular classification system was proposed by Ogden, which defines five fracture types based on the fracture pattern and extent of fragment displacement. Treatment can be nonsurgical or surgical, and indications depend on fracture type. Most fractures are surgical candidates and can be repaired with open reduction and internal fixation (ORIF) or arthroscopy. Arthroscopic approaches can reveal associated soft tissue injuries, such as meniscal tears, and confirm articular reduction. The most common postoperative complication is irritation because of hardware. With proper treatment, both nonsurgical and surgical outcomes are excellent. TTAFs have high rates of union and patients typically return to sports.

A Comparison of Conservative and Operative Management of Thumb Ulnar Collateral Ligament Avulsion Fractures in Children.

Background: The optimal management of pediatric thumb ulnar collateral ligament (UCL) avulsion fractures remains poorly defined. The purpose of this study was to elucidate patient outcomes based on initial management and fracture characteristics. Methods: A retrospective study of all patients younger than 18 years of age presenting with a thumb UCL avulsion fracture was performed. Patients were grouped by their initial management. The primary outcome of the study was time to return to full activity. Fractures were characterized by articular surface involvement, displacement, and rotation. Results: Forty-seven patients with thumb UCL avulsion fractures were identified. Ten patients underwent surgery as initial treatment; all healed without complication, with a mean recovery time of 6.2 ± 1.8 weeks. Thirty-seven patients were treated conservatively; although most healed, the recovery time was longer (9.2 ± 8.3 weeks, adjusted hazard ratio = 2.3, 95% confidence interval = 1.0-5.5). Four cases (11%) required conversion to surgery that all healed without complications. Fractures treated with immobilization alone were significantly smaller, less displaced, and less rotated than those initially treated with surgery; however, 19 fractures that would have met criteria for surgery were treated with immobilization and successfully healed within 7.1 ± 2.9 weeks. Fracture characteristics did not predict which patients would fail conservative treatment or have prolonged recovery times. Conclusions: While surgery provided definitive treatment without delay in recovery, immobilization may not be an unreasonable treatment choice even for patients with large or displaced fractures. In cases where patients failed immobilization, surgery as a second-line treatment had good results.

Avulsion fracture of the medial head of the gastrocnemius muscle associated with multiple ligament injuries before closure of the growth plate: a case report.

BACKGROUND: Avulsion fracture of the medial head of the gastrocnemius muscle is a very rare phenomenon. There are no reports of avulsion fractures associated with multiple ligament injuries before closure of the growth plate. The authors present a case of avulsion fracture of the insertion of the medial head of the gastrocnemius muscle associated with posterior cruciate ligament injury and an avulsion fracture of the medial collateral ligament at the femoral attachment. CASE PRESENTATION: A 15-year-old Japanese boy was injured by contact with another player while playing soccer. He was immediately admitted to the authors' hospital with knee pain. Radiography and computed tomography revealed an avulsion fracture of the medial collateral ligament at the femoral attachment and an avulsion fracture of the medial head of the gastrocnemius muscle. In examination under anesthesia, the Lachman test was negative and posterior drawer test was positive. Fixation of the avulsion fractures of the medial collateral ligament and medial head of the gastrocnemius was performed 9 days after the injury. After fixation, valgus instability at full extension had disappeared. The knee was immobilized in a brace for 2 weeks postoperatively. One year postoperatively, the posterior drawer test was slightly positive; however, our patient was able to ambulate without pain and returned to sports without feeling instability in his knee. CONCLUSION: A rare case of avulsion fracture of the gastrocnemius muscle combined with multiple ligament injuries before closure of the growth plate is described. A satisfactory result was obtained by fixation of the avulsed bone fragments of the gastrocnemius muscle and medial collateral ligament. The authors believe that avulsion fracture of the medial head of the gastrocnemius muscle associated with posterior cruciate ligament injury should be repaired.

Fifth Metatarsal Avulsion Fracture in an Adolescent Tennis Player.

A 17-year-old male tennis player presented to physical therapy via direct access with complaints of intermittent left lateral foot pain. Due to positive fracture testing and application of the Ottawa foot/ankle rules, an orthopaedist was consulted and radiographic imaging was performed. Radiographs revealed a nondisplaced avulsion fracture of the fifth metatarsal. J Orthop Sports Phys Ther 2019;49(8):620. doi:10.2519/jospt.2019.8534.

Management of ankle fractures in children.

Ankle fractures are a common injury in children and adolescents - 1 in 1000 children will sustain an ankle fracture each year. Understanding the diagnosis and management of these injuries is vital for any doctor or clinician working in the emergency department, orthopaedics or providing community care. This review identifies the important features of high- and low-risk ankle fractures, how to prevent the use of unnecessary radiation and the management of these injuries. Fractures may be at high or low risk of instability and are managed accordingly. Many can be treated with conservative management in a cast, including unstable injuries following reduction. However, particular fracture patterns associated with the tibial growth plate need careful assessment of fracture reduction with cross-sectional imaging before committing to conservative management.

Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary?

Fractures of the anterior tibial tubercle are infrequent lesions. They often occur in male adolescent athletes, usually in relation with sports involving powerful jumps. We present a retrospective study of 10 patients, with an average age of 15.1 years, all of them males, and a total of 11 acute avulsions of the anterior tibial tubercle. We analyzed the etiology of the lesion, the type of treatment used as well as non-weight bearing period, protected immobilization period, and time until sports reincorporation. We obtained 11 acute avulsions: one case of type I; three cases of type II; four cases of type III; and three cases of type IV. Five cases were treated conservatively, including the three cases of type IV, and surgery was only performed in six cases since an anatomical reduction was not obtained with closed reduction. The results were satisfactory in all cases, with 100% percentage of sport reincorporation in less de 25 weeks. We registered only one complication, intolerance of material, which did not require additional surgeries. These fractures, although rare, have an excellent prognosis. Even if they are often treated surgically, we have obtained good results with the conservative treatment in patterns previously reported as surgical.