Pediatric ankle injuries: utilizing the Dias-Tachdjian classification.

Pediatric ankle injuries require timely diagnosis due to their involvement of the distal tibial physis and subsequent impact on long bone growth. These injuries occur in a predictable pattern based on ankle position, direction of force, and degree of closure of the distal tibial physis. The Dias-Tachdjian classification describes possible ankle injury patterns for the completely open physis, and we present a simplified algorithm for applying this system in routine radiographic interpretation. Similar to the Lauge-Hansen classification in adults, the Dias-Tachdjian system is based on the position of the foot and direction of force at the time of injury with four major patterns: supination-inversion, pronation-eversion external rotation, supination-plantar flexion, and supination-external rotation. In addition, we examine the effect that the closing distal tibial physis has on adolescent fracture patterns (specifically, Tillaux and triplane fractures). Awareness of these injury patterns helps the radiologist to identify nondisplaced fractures and subtle physeal injuries with implications for surgical and/or conservative management.

Premature physeal closure following 13-cis-retinoic acid and prolonged fenretinide administration in neuroblastoma.

Retinoid therapy has contributed to improved outcomes in neuroblastoma. Clinical trials of fenretinide report favorable toxicity and disease stabilization in patients with high risk (HR) neuroblastoma. Skeletal effects have been described with other retinoids, but not with fenretinide to date. Two patients with HR, metastatic, refractory neuroblastoma received protracted courses of oral fenretinide for more than 5 years' duration. Both developed premature long bone physeal closure, causing limb length discrepancies; their neuroblastoma remains in remission. The radiographic and clinical findings reported suggest these skeletal abnormalities may be a consequence of treatment with 13-cis-retinoic acid (13cisRA) followed by prolonged oral fenretinide exposure.

Delayed Presentation of Displaced Salter-Harris III Distal Tibia Fracture: Does Transfracture Reduction Yield Satisfactory Outcomes?

LEVELS OF EVIDENCE: Level V.

Traumatic physeal fractures in cats: a review of 36 cases (2010-2020).

OBJECTIVES: The aim of this study was to describe the demography, aetiology, location and classification of physeal fractures in cats, and to describe their management and outcomes. METHODS: Clinical records and radiographs of cats referred for management of physeal fractures were retrospectively reviewed. Fractures of the proximal femoral physis were excluded. Descriptive statistics were used to describe signalment, cause of injury, presence of concurrent injuries, fracture description, treatment modality, complications, follow-up, physeal closure, implant removal and outcome. RESULTS: Thirty-four cats with 36 fractures were included, of which 17 affected the distal femur, 11 the distal tibia and fibula, five the distal radius and ulna, two the proximal tibia and one the distal humerus. Salter-Harris classification was type I in 14, type II in 16, type III in two and type IV in four fractures. Thirty-four fractures were treated with primary fixation, and the most common method was crossed Kirschner wires (24/34 fractures). Complications were observed in 14 fractures, of which 12 were minor. At radiographic follow-up, physeal closure was reported in 23 fractures, of which 15 were considered premature. Implant removal was performed in three fractures. Outcome was good in 28, fair in four and poor in two fractures. CONCLUSIONS AND RELEVANCE: Fracture of the distal femoral physis was the most common physeal fracture seen. Cats presenting with physeal fractures may be skeletally immature or mature with delayed physeal closure. The rate of physeal closure after fracture repair was relatively high but without apparent impact. The frequency of implant removal was very low, indicating that despite having a physeal fracture repair, most cats did not require a second procedure to remove implants. Overall, internal fixation provided a good outcome in most fractures.

Combining Salter-Harris and Dias-Tachdjian could be better at determining the prognosis of distal tibial physeal fractures.

OBJECTIVES: The aim of this study is determining the factors that affect prognosis of distal tibial physeal fractures (DTPF) and analyzing whether Salter-Harris (SH) or Dias-Tachdjian (DT) classification is more predictive for outcomes. METHODS: Patients treated for DTPF were retrospectively analyzed. Fracture patterns were classified according to SH and DT. Treatment methods and fracture characteristics were noted. Distal tibial angles and joint irregularities were analyzed on patient's final ankle radiographs followed by American Orthopedic Foot and Ankle Score questionnaire. RESULTS: 75 patients followed-up between 6 and 96 months meeting the inclusion criteria were evaluated. Joint irregularity was observed in 41.3% and partial premature physeal closure (PPC) in 34.7% of the patients. Lateral distal tibial angle (LDTA) and talocrural angle related deformity were detected in 20% and 14.7% of the patients, respectively. Partial PPC and joint irregularities that have been developed in pronation-eversion-external rotation and supination-inversion injuries (SH type 3, 4) were 62% and 50%, and 42% and 75%, respectively. On follow-ups of supination-external rotation injuries (SH type 2) joint irregularity has never been observed. Following supination-external rotation and supination-plantar flexion injuries, a low rate of partial PPC have been developed; LDTA related deformity was revealed at a high rate of 39.1% after supination-inversion injuries. There weren't any differences observed between the initial displacement, residual displacement or surgical technique and PPC, joint irregularity and angular deformities. Patients treated by ORIF technique had lower AOFAS scores than patients treated by other surgical techniques. CONCLUSIONS: In this study it was revealed that SH classification system is not sufficient alone to determine the prognosis of DTPF, the injury mechanisms causing SH types might be also significant in prediction of the prognosis of DTPF.

Open reduction and internal fixation for displaced Salter-Harris type II fractures of the distal tibia: a retrospective study of sixty-five cases in children.

BACKGROUND: The treatment for displaced Salter-Harris II (S-H II) distal tibia fractures remains controversial. The purpose of this study was to review S-H II distal tibia fractures and evaluate the rate of premature physeal closure (PPC) treated by open reduction and internal fixation (ORIF). METHODS: We reviewed the charts and radiographs of S-H II fractures of the distal tibia with displacement > 3 mm between 2012 and 2019 treated by ORIF. Patients were followed up for a minimum of 6 months. CT scans of injured side or contralateral ankle radiograph were obtained if there was any evidence of PPC. Any angular deformity or shortening of the involved leg was documented. Multivariable logistic regression was performed to identify risk factors for the occurrence of PPC. RESULTS: A total of 65 patients with a mean age of 11.8 years were included in this study. The mean initial displacement was 8.0 mm. All patients but one were treated within 7 days after injury and the mean interval was 3.7 days. Supination-external rotation injuries occurred in 50 patients, pronation-eversion external rotation in 13, and supination-plantar flexion in two. The residual gap was less than 1 mm in all patients following ORIF and all fractures healed within 4-6 weeks. Superficial skin infection developed in one patient. Ten patients complained of the cosmetic scar. The rate of PPC was 29.2% and two patients with PPC developed a varus deformity of the ankle. Patients with associated fibular fracture had 7 times greater odds of developing PPC. Age, gender, injured side, mechanism of injury, amount of initial displacement, interval from injury to surgery, or energy of injury did not significantly affect the rate of PPC. CONCLUSIONS: ORIF was an effective choice of treatment for S-H II distal tibia fractures with displacement > 3 mm to obtain a satisfactory reduction. PPC is a common complication following ORIF. The presence of concomitant fibula fracture was associated with PPC.

Outcome of distal tibia physeal fractures: a review of cases as related to risk factors.

INTRODUCTION: The physeal fractures represent the 20-30% of all fractures of the child. The distal tibial physis is the third most frequently injured. The most important complication is the premature physeal closure (PPC). Aim of this study is to evaluate risk factors that can influence the outcome like fracture pattern, fracture displacement, mechanism of injury and treatment method. MATERIAL AND METHODS: The records of 46 patients treated for distal tibia physeal fractures between 2003 and 2013 were reviewed. Initial injury radiographs were categorized according to Salter-Harris and Dias-Tachdjian classifications and the initial and post-treatment fracture displacementwas measured. Any complex fractures had preoperative CT for additional assessment. Three different types of treatment were compared: closed reduction and casting versus closed reduction and percutaneous pinning versus ORIF. RESULTS: Therewas significantly less residual displacement in patients who had ORIF versus those who had closed reduction and percutaneous Kirschner wires or plaster only. In fractures with an intact fibula, we found significantly less initial and residual displacement. The Dias-Tachdjian classification is significantly correlated with the displacement. Patients studied with CT show a less degree of post reduction displacement. At the final follow-up we found only one PPC as complication. CONCLUSION: The physeal fractures are very common in children and the main goal is to avoid any complications. It is clear that the development of complications after distal tibial fractures is due to multiple contributing factors like skeletal maturity, severity of injury, fracture type, degree of comminution and displacement aswell as adequacy of reduction. A premature physeal closure is the most common complication. The fibula fracture can play an important role in initial displacement. The presence of an intact fibula and a good anatomical reduction have a significant positive influence on fracture outcome.

Complications of Pediatric Foot and Ankle Fractures.

Ankle fractures account for 5% and foot fractures account for approximately 8% of fractures in children. Some complications are evident early in the treatment or natural history of foot and ankle fractures. Other complications do not become apparent until weeks, months, or years after the original fracture. The incidence of long-term sequelae like posttraumatic arthritis from childhood foot and ankle fractures is poorly studied because decades or lifelong follow-up has frequently not been accomplished. This article discusses a variety of complications associated with foot and ankle fractures in children or the treatment of these injuries.