Ankle Fractures in Children

Ankle fractures are painful and cause short-term disability for people of all ages. But in children, long-term recovery can be complicated if thereis associated damage to special tissues.

A child's bone grows at open "growth plates." Located at each end of a bone wherever it meets other bones to form a joint (such as the ankle, wrist or knee), these plates eventually close once a person has reached adulthood (that is, when they stop growing).

Whenever a bone fracture includes a portion of a growth plate (also called the "physis"), special care must be taken in order to ensure that the bone keeps growing properly. Growth arrest – when a bone partially or completely stops growing – is a risk factor in any child who fractures an ankle.

The following are examples of broken ankle injuries that require extra attention and possible treatment.

Types of ankle fractures

Distal tibial fracture

This type occurs in two varieties:

• Nondisplaced – in which the fractured bone fragments are aligned
• Displaced – in which the fractured bone fragments are misaligned or separated

A nondisplaced distal tibial fracture at the ankle can look like an ankle sprain, with mild swelling accompanied by pain when the child stands or tries to walk. X-rays will show very subtle signs that a fracture is present. A physical exam by a specialist is critical in order to make the diagnosis. Treatment usually requires that the child wear a cast and/or a brace or "walking boot" for 3 to 4 weeks. Growth arrest in this type of fracture is uncommon.

A typical brace or "walking boot" worn to allow a nondisplaced distal tibial fracture to heal.

An accurate assessment of any ankle fracture is essential, because most displaced ankle fractures in children require surgery to correct the anatomic alignment of the bone. In displaced fractures, it is common for the bones to stop growing properly (partial growth arrest). In order to monitor for and detect any permanent damage to the growth plate and optimize healing, any child or teenager who has a displaced ankle fracture must have follow-up clinical exams and radiographic imaging (X-rays) for 1 to 2 years.

Displaced distal tibial fractures at the ankle joint range from mild fractures that can be treated with casting to more serious fractures (Tillaux fractures, triplane fractures) that require more detailed radiological imaging – including CT or MRI – and may require eventual surgery.

Anterior X-ray (image 1) and cross-sectional CT scan (image 2) of a minimally displaced distal tibial fracture that affected the growth plate and ankle joint.

X-rays showing surgical correction of the tibia with screws (image 3) and the tibia after the fracture has healed and the screw has been removed (image 4).

Distal fibula fracture

This type of ankle fracture also occur in nondisplaced and displaced varieties.

Nondisplaced fractures of the distal fibula can look a lot like ankle sprains. Generally they are treated the same way as non-displaced tibia fractures, with three weeks of a functional brace or cast. Patients with non-displaced distal fibula fractures should have follow-up for up to two years to watch for any growth disturbances.

Displaced distal fibula fractures are usually treated with surgery if the fracture extends into the ankle joint. In these cases, the most common goal of surgery is to restore a smooth, properly aligned, joint surface. If the displacement does not extend into the joint, a pediatric orthopedic surgeon can often realign the bone fragments and hold them with a cast.

Pediatric orthopedists are specialists in pediatric skeletal abnormalities and fractures and therefore can diagnose, treat, and provide follow-up care to minimize future growth problems. For a consultation with our Pediatric Orthopedic Department at Hospital for Special Surgery, contact our Physician Referral Department.

Updated: 10/26/2018

Diagnostic imaging courtesy of the HSS Department of Radiology and Imaging.

Authors

Julia Munn Hale, PA-C, MHS
Physician Assistant, Pediatric Orthopedics
Hospital for Special Surgery

Shevaun Mackie Doyle, MD
Associate Attending Orthopedic Surgeon, Hospital for Special Surgery
Associate Professor of Orthopedic Surgery, Weill Cornell Medical College