Paediatric Acute care Guidelines PMH Emergency Department

Background

  • Ankle injuries are common and usually involve a twisting or inversion mechanism
  • Before growth plates are fused, physeal injuries are more likely than ligamentous injuries
  • The distal tibia physis is the most common growth plate injured

General

  • Ankle injuries are common and include ankle sprains, avulsion injuries and physeal injuries
  • In children, ligaments are stronger than bone and a fracture is more likely than ankle sprains
  • Ligamentous injuries are more likely in older adolescents once the growth plate has fused

Assessment

  • An X-Ray should be performed if unable to weight bear
  • Assess neurovascular status especially if there is clinical deformity

History

  • The most common mechanism of injury is adduction and inversion of the foot

Examination

  • There is usually localised swelling and tenderness over one or both malleoli
  • There may be clinical deformity of the ankle joint
  • Assess the child’s ability to weight bear
  • Assess passive and active movement of the ankle joint
  • Assess for neurovascular compromise

Investigations

Radiology:

Management

  • Ankle sprains should be treated with Rest, Ice, Compression and Elevation (RICE)
  • Displaced physeal fractures often need internal fixation

Initial management

  • Analgesia
  • Examination for neurovascular injury (if deficits evident manage immediately) – urgent Orthopaedic Team referral
  • Ice and elevation of affected limb
  • Immobilise suspected fracture before X-Rays (e.g. splint, board)
  • Antibiotics for compound fractures and tetanus if not up to date
  • Patients being referred urgently to the Orthopaedic Team should be fasting

Further management

Ankle Sprains

  • Ankle sprains are more common in older adolescents once their growth plates have fused
  • The most common ligament injury is the anterior talofibular ligament – clinically there is maximal tenderness just anterior to the distal fibula
  • Ankle sprains/ligamentous injuries can be managed with simple analgesia, rest, ice, compression and elevation
  • Crutches can be used until the patient can weight bear without a limp
  • Patients who are unable to weight bear with no apparent radiological fracture may be managed in a below knee plaster backslab or a cam boot with a follow up with GP in 7-10 days

Isolated Distal Fibula Fractures

Salter Harris I Fractures

  • Salter-Harris I fractures of the distal fibula are commonly missed fractures
  • If undisplaced, there may only be evidence of soft tissue swelling over the lateral malleolus on X-Ray
  • Clinically there is maximal tenderness over the lateral malleolus
  • Isolated undisplaced Salter-Harris I fractures of the distal fibula are managed in a CAM boot for 3-4 weeks with weight bearing as tolerated.
  • No formal follow up is required.

Salter Harris II Fractures

  • Undisplaced Salter-Harris II fractures of the distal fibula are managed in a CAM boot for 3-4 weeks with weight bearing as tolerated.
  • They should be followed up by GP with a repeat Xray in 7-10 days to ensure no displacement.
  • Displaced fractures should be put in below knee plaster backslab and followed up in fracture clinic. 
minimally displaced Salter Harris 2 fracture of distal fibula - note the significant soft tissue swellingMinimally displaced Salter-Harris II fracture of distal fibula – note the significant soft tissue swelling
 

Avulsion Fractures of Distal Fibula

  • Manage in a CAM boot for 3-4 weeks with weight bearing as tolerated.
  • No formal follow up is required
Avulsion of distal fibula

Avulsion of distal fibula

 Epiphyseal Fracture of Distal Fibula

  • Manage in a CAM boot for 3-4 weeks with weight bearing as tolerated.
  • They should be followed up by GP with a repeat Xray in 7-10 days to ensure no displacement.
  • Displaced fractures should be put in a below knee plaster backslab and followed up in fracture clinic. 
Undisplaced epiphyseal fracture of fibula

Undisplaced epiphyseal fracture of fibula

 Distal Tibia Physeal Fractures

  • Salter-Harris II fractures of the distal tibia often occur in combination with a greenstick fracture of the fibula
  • Undisplaced Salter-Harris II fractures of the distal tibia are managed in a non weight bearing below knee plaster backslab and followed up in the Orthopaedic Fracture clinic in 7 days
  • Displaced Salter-Harris II fractures will need reduction – urgent Orthopaedic Team referral
Minimally displaced Salter Harris 2 fracture of distal tibia
Minimally displaced Salter-Harris II fracture of the distal tibia

 

  • Salter-Harris III and IV fractures of the distal tibia will involve the articular surface of the ankle
  • Any displacement may require internal fixation and urgent Orthopaedic team referral is required
Salter Harris 3 fracture of medial malleolus - required internal fixation

Salter-Harris III fracture of medial malleolus – required internal fixation

  • Tilleaux fracture is a lateral Salter-Harris III fracture of the distal tibia (as the medial part of the growth plate fuses first)
Minimally displaced Tilleaux fracture

Minimally displaced Tilleaux fracture

  • Triplane fracture is a combination Salter-Harris II and Tilleaux fracture of the distal tibia which occurs in 3 planes
  • Fractures involving the articular surface will often need a CT scan to evaluate the extent of the fracture and displacement
Triplane fracture of distal tibia

Triplane fracture of distal tibia

Fractures of Ankle Requiring Urgent Orthopaedic Referral

  • Neurovascular compromise
  • Compound/Open fractures
  • Clinical deformity
  • Displaced Salter-Harris fractures of tibia
  • Displaced Tilleaux fractures
  • Triplane fractures

Referrals and follow-up

  • All children who have a plaster placed should have a plaster check at 24 hours. They can return to the Emergency Department to be assessed by the triage nurse.
  • Ankle sprains and undisplaced fibula fractures can be followed up by the GP
  • All other ankle fractures should be followed up in the Orthopaedic Fracture clinic in 7-10 days. See Outpatient Clinics.

Health information (for carers)

Nursing

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