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Ankle Fractures in Children

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

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

Growth occurs in children’s bones near the end of the bone (at the “growth plate” or physis) where there is a joint (such as the ankle, wrist, or knee). When there is a fracture involving the growth plate, special care must be taken in order to avoid future growth problems. The following are examples of ankle fractures requiring vigilance and possible treatment.

Types of ankle fractures:

1. Distal tibial fractures occur in two varieties: non-displaced (when the fracture fragments are in line) and displaced (when the fracture fragments are separated).

An accurate assessment is essential, as most displaced ankle fractures in children require surgical treatment. Commonly, with displaced fractures, partial growth arrest may occur. Clinical and radiographic (X-ray) follow-up are necessary for one to two years after displaced ankle fractures in order to detect or monitor any permanent damage to the growth plate.

Non displaced distal tibial fractures at the ankle can look like an ankle sprain, with mild swelling and pain with attempts to walk. X-rays will show very subtle signs that a fracture is present; physical exam by a specialist is critical in order to make the diagnosis. Treatment usually requires casting for 3-4 weeks. Growth arrest with this type of fracture is uncommon.

Photo of a child wearing a walking boot
A typical brace or "walking boot" worn to allow a non-displaced distal tibial fracture to heal.

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 necessitate a more detailed radiological work-up - including CT or MRI - and may require eventual surgery.

Anterior X-ray

Cross-sectional CT scan
Anterior X-ray (X-ray image 1) and cross-sectional CT scan (X-ray image 2) of a minimally displaced distal tibial fracture involving the growth plate and ankle joint. Surgery is often necessary to correct the anatomic alignment for optimal healing potential.

X-ray showing surgical correction of the tibia with screws

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

2. Distal fibula fractures at the ankle also occur in non-displaced and displaced varieties.

Non-displaced 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 this case, 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 specialist can often reduce (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.

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


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