SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Review
Article
Foot
and
ankle
fractures
during
childhood:
review
of
the
literature
and
scientific
evidence
for
appropriate
treatment
夽
Stefan
Rammelt
a,
Alexandre
Leme
Godoy-Santos
b,∗,
Wolfgang
Schneiders
a,
Guido
Fitze
a,
Hans
Zwipp
aaUniversitätsklinikumCarlGustavCarus,KlinikfürUnfallundWiederherstellungschirurgie,Dresden,Germany
bUniversidadedeSãoPaulo,FaculdadedeMedicina,DepartamentodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received27October2015 Accepted30October2015
Availableonline13September2016
Keywords: Anklejoint Calcaneus Talus Child
a
b
s
t
r
a
c
t
Footandanklefracturesrepresent12%ofallpediatricfractures.Malleolarfracturesare themostfrequentinjuriesofthelowerlimbs.Hindfootandmidfootfracturesarerare,but inadequatetreatmentforthesefracturesmayresultsincompartmentsyndrome, three-dimensionaldeformities,avascularnecrosisandearlypost-traumaticarthritis,whichhave asignificantimpactonoverallfootandanklefunction.Therefore,thechallengesintreating theseinjuriesinchildrenaretoachieveadequatediagnosisandprecisetreatment,while avoidingcomplications.Theobjectiveofthetreatmentistorestorenormalanatomyand thecorrectarticularrelationshipbetweenthebonesinthisregion.Moreover,thetreatment needstobeplannedaccordingtoarticularinvolvement,lower-limbalignment,ligament stabilityandage.Thisarticleprovidesareviewonthistopicandpresentsthescientific evidenceforappropriatetreatmentoftheselesions.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Fraturas
do
tornozelo
e
do
pé
na
infância:
revisão
da
literatura
e
evidências
científicas
para
o
tratamento
adequado
Palavras-chave:
Articulac¸ãodotornozelo Calcâneo
Tálus Crianc¸a
r
e
s
u
m
o
Asfraturasdotornozeloedopérepresentam12%detodasasfraturaspediátricas. Frat-urasmaleolaressãoaslesõesmaisfrequentesdosmembrosinferiores;fraturasdoretropée mediopésãoraras,masoseutratamentoinadequadopoderesultaremsíndromede compar-timento,deformidadestridimensionais,necroseavasculareosteoartrosepós-traumática precoce,asquaisapresentamimpactosignificativo nafunc¸ãoglobaldotornozeloe pé.
夽
StudyconductedattheDepartmentofOrthopedics,UniversitätsklinikumCarlGustavCarusDresden,Germany,andattheDepartment ofOrthopedicsandTraumatology,FacultyofMedicine,UniversityofSãoPaulo,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:alexandrelemegodoy@gmail.com.br(A.L.Godoy-Santos).
http://dx.doi.org/10.1016/j.rboe.2016.09.001
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Ankle and foot fractures account for 12% of all pediatric fractures.They usuallyrequire investigation through care-fulimagingexams forproperdiagnosis.1Inrecentdecades, asignificant increasehasbeenobservedinincidencerates, includingthoserelatedtocomplextraumaofthisanatomical topography.2 Inappropriatetherapeuticdecisionscan result
inserious complications, suchas compartmentsyndrome,
three-dimensional deformity, avascular necrosis, and early post-traumatic osteoarthritis,with negative impact on the overallfunctionoftheankleand foot.3 Thisarticleaimsto presentthescientificevidenceforthetreatmentofthese trau-maticinjuries.
Malleolar
fractures
Injuriesoftheepiphysealplatesaroundtheanklerepresent 10–25%ofall growth plateinjuries. Therefore,theyare the most prevalent physeal injuries in the lower limbs.1 Such tibia and distal fibula injuries can lead to post-traumatic bonegrowthdisorders.Fracturesofthemedialmalleolusare particularly critical and are underdiagnosedin incomplete radiographicinvestigation.2
Thetypicalfracturepatternsatanklelevelperageare:
1. Impactionfracturewithdistalflexionofthetibia(under10 yearsofage)
2. Fractureofthemedialmalleolus(around10year-old) 3. Epiphysealandmetaphysealfractures(prepubertalperiod) 4. Transitionfracturesinthephysealregion(12–14yearsof
age).
Malleolarfracturesresultfromindirecttraumamechanism byadduction, abduction, and externalrotation of the foot againstthe lower leg. Thefracture line is alsodetermined bythe position ofthe foot atthe time ofthe accident. In aboutthree-quartersofcases,thefootisinsupineposition (inversion),whileinone-quarter,thefootisinproneposition (eversion).3
The classification system developed by Lauge-Hansen4
consistsofthesecomponentsandcanbeusedforchildren
andadolescents,accordingly.1DiasandTachdjian5modified this classification for children and introduced the plantar supination-flexiontype.
Theclassificationsystemsproposed byAitken6 orSalter and Harris7 are related to growth plate injuries. They are dividedasfollows:
1. Pureinjuryofthegrowthplate
2. Epiphysealinjurywithwedgefractureofthemetaphysis (AitkenII)
3. Epiphyseal injury with wedge fracture of the epiphysis
(AitkenII)
4. Meta-epiphyseal fracture that crosses the physeal line
(AitkenIII)
5. Compressionfractureofthegrowthplate
6. Physeallesionwithgrowthplatedefect(addedposteriorly byPeterson8)
Thephysealplateofthedistaltibiaisresponsiblefor45% ofthegrowthinlengthoftheleg;ossificationofthisregion occursbetween12and14yearsofage,overaperiodof1year and6months.Thisprocessbeginsinthemedialportion, mov-ingtowardthecentralthirdoftheepiphysis,andposteriorly advancing tothe lateralregion; thus,the lastportiontobe calcifiedistheanterolateral(Chaput’stubercle).Fracturesof the distaltibia atthis stage(transitional)representa sepa-rateentity.Theenergyoftraumacanleadtohorizontalor perpendicular(sagittal)lines,andsometimesinathirdplane (frontal),withtheformationofadorsalwedge,whichresults inbiplanarortriplanarinjuries.9Suspected“transitional” frac-turesinadolescentsrequireaninvestigationthroughaccurate
imaging, preferably with the aid ofcomputed tomography
(Fig.1).
Therapeuticevidence
Fracture-dislocations are ideally treated after intravenous analgesia,withanesthesiologistmonitoringforpatientsafety; thejointisreducedandthefractureisalignedwiththelower limbtopreventfurtherdamagetosofttissuesandchondral tissue.
Theemergencyindicationforimmediatesurgeryoccursin casesofopenfractureorcasesofclosedfracturewithsevere softtissuedamage,suchasextensivesubcutaneous detach-ment,massiveinternalpressurefromthebonefragments,or
compartmentalsyndrome.3
Minimallydisplacedornon-displacedfracturesmaybetreated
conservativelywith immobilizationwithout weightbearing
Fig.1–(A)Profileradiographyofatriaxialfractureoftherightankle.(B–D)Sagittal,coronal,andaxialsectionsofcomputed tomographyoftherightankle.(EandF)Anteroposteriorandprofilepostoperativeradiographsshowingthefixationwith
compressionscrews.
Initiallydivertedfractures,particularlySalter–HarristypeI physealdetachment,maybesuccessfullytreatedafterclosed
reduction and immobilization without weight bearing for
threetofourweeks.
Theanatomical reductionofdisplaced Salter–Harris type II–IVfracturesinchildrenandadolescentsisusuallydifficult duetothetough,thickperiosteum.Often,theinterpositionof thattissueorevenoftheneurovascularbundleatthefracture sitepreventsclosedreduction.10
There is insufficient evidence in the literature indicat-ing the exact tolerable point for opting for conservative
treatment. However, thereare many indicationsthat open
reductionandinternalfixationofdeviatedfracturesgreatly
reducetheriskofprematureclosureswhencomparedwith
conservative therapy.11–13 Many studies have shown
bet-terlong-termoutcomesinpatientstreatedwithanatomical reduction.14–16
Atfirst,openreductionshouldbemadeinextra-articular fractures (Salter–Harris type II) with fragment deviations
greaterthan3mm,orincaseswhererepositioningis impos-sibledue tointerposition. Inintra-articular fractures,open
reduction is recommended for those with a displacement
measuring2mmormore14;however,someauthorsarguethat thisprocedureshouldbeperformedinfracturesgreaterthan 1mm.17,18
Osteosynthesisshouldbemadewithscrewsparalleltothe epiphysisand,wherepossible,perpendiculartothefracture line, forinterfragmentarycompression. When instability is present,whichrequires implantstobepassedthroughthe growthplates,thisshouldbemadewithKirschnerwiresonly temporarily.14,17,18
Usually,afterstabilizationofthetibia,thefibulapresents alignedandstable;otherwise,stabilizationofthefibulacanbe sufficientlyachievedwithintramedullaryKirschnerwires.19
The typical biplane fracture is a bone avulsion of the anterior and lateral edge of the tibia in the frontal plane (Tillaux-Chaputfragment),representingaligamentinjuryof the anterior syndesmosis; fragments should be anatomically reduced,andthestabilizationshouldbemadewithasmall screw.3
The triplane fracture is also articulate and presents an additional fracture perpendicular to the medial malleolus, resultinginametaphysealwedge.Afteranatomicalreduction, stabilizationoftheseadditionalpiecesismadewith compres-sionscrewsparalleltotheepiphysis.20
Theoperatedlimbisimmobilizedwithasural-podalsplint duringtheperiodofhealingofsurgicalincisionswounds,for 7–10days.Afterthisperiod,weightbearingisauthorized,with theuseofaprotectiveimmobilizationbootuntiltheendofthe fourthpostoperativeweek.Fullunprotectedweightbearing isauthorizedbasedonpatientcomplaintsandradiographic control.3
Talus
fractures
These areextremelyrare, duetothehigh elasticresilience
of this bone, which is mostly consisted of cartilage in
childhood.21Publishedstudiesindicateanannualprevalence from0.01%to0.08%inchildren.22,23Talusneckfracturesare themostcommon,beingsimilartothoseofadults,as clas-sified byHawkins24; followed bytalar body fractures,with hightraumamechanism.Finally,fracturesofthetalarhead are usuallysecondary to dislocationofthe midtarsal joint (Chopart).25
Inturn,peripheraltalarfractures(lateralandposterior pro-cesses)areveryrareanddifficulttodiagnoseinthisagegroup, requiringinvestigationthroughpreciseimagingexamswith theaidofcomputedtomography;whenuntreated,theyresult infootpainandlimitationofthesubtalarjointinadulthood.23 Centralandperipheralfracturesofthetaluswereclassified bytheMarti26uniformclassificationsystem,whichwaslater adoptedforadults:
1. peripheral fractures (lateral process, posterior process, head)
2. centralfractureswithoutdisplacement(neckandbody) 3. centralfractureswithdisplacementordislocationofa
cen-traljoint(mainlysubtalar)
4. multifragmentarycentralfracturesorfracture-dislocations withdisplacementofatleasttwojoints
Withincreasingpatientage(about12years),thenumberof high-energyinjuriesandthereforetheseverityofthefracture clearlyincrease.27,28
Fig.2–(A)Medialaccessrouteforsurgicaltreatmentoftalusfracture.(B)Lateralaccessrouteforsurgicaltreatmentoftalus fracture.
footfunction,inbetween27%and38%ofcases,anobservation thathasbeenwelldescribedintheliterature.29–35
Thegreatestproblemsarisemainlyduetojoint misalign-mentsoraxialdisplacements,typicallywithvarusdeformity
ofthe talarneckand consequent shorteningofthe medial
columnofthefoot.35
Therapeuticevidence
Nonsurgicaltreatmentisrecommendedonlyinminimally dis-placedorundisplacedfractures.21Thetreatmentofchoicefor alldisplacedtalarfracturesisanatomicreductionandstable internalfixation;forasufficientviewoftherepositioningof theanatomicalaxes,twoaccessroutesareusuallyrequired (medialandlateral;Fig.2).36
Thefixationshouldbemadewithscrews,whichbalance themechanicalefficiencyandminimizedamagetothe car-tilagesurfaces;inyoungerchildren,crossingKirschnerwires allowforadequatestability.3
Osteochondral fragments are fixed with fibrin glue or
absorbablepins.
Theadditionalpresenceofasituationofinstabilityisdue
toacapsuloligamentous injury orbonecomminution; in a
criticaltissuesituation,itmaybeduetotheexternalfixator.21 The risk of avascular necrosis associated with central fracturesinvolveshigh-energytraumaandthedegreeof dis-placement,withanincidenceof16%ofobservedcases.27,37 Childrenunder6yearsofagearethemostaffected,especially whenlate-diagnosed.37
Thespontaneouscourseoftalarbodynecrosisinchildhood isgenerallygood,withagradualremodelingofthetalusinthe courseoftwoyears;therefore,itisnotnecessarytoprevent weightbearingintheaffectedlegforalongperiodoftime.3
When timely, corrective joint preservation surgery can improveprognosis.Osteoarthritissignsarereportedon aver-agetwoyearsafterthe fractureinupto17% ofpatients.38 Meieretal.39observedlong-termneedforanklearthrodesis in25%ofcases,atameanof11yearsaftertheinjury.
Calcaneal
fractures
They represent merely 0.05% to 0.15% of all fractures in
childhood. Only 5% of all calcaneal fractures occur in
childhood.Thepeakageisbetween8and12years,andthe
mostprevalenttraumamechanismsarefallsfromheightor
trafficaccidents.40,41
Whencomparedwithadults,thereisahigherproportion ofextra-articularfractures.42–44Extra-articularfracturesaffect thecalcanealtuberosityandsometimesshowanarticularline withoutdeviationoftheposteriorfacet.45Computed tomogra-phyisthebestimagingmethodtoconfirmdiagnosisandrule outintra-articularinvolvement.
Wileyand Profitt46reportedlatediagnosis in43%ofthe extra-articularcalcanealfractures.
Stressfracturesininfantsaredescribedatthebeginningof gait(toddler’sfracture).Inthisscenario,thechildrenrefuseto walk;twoweeksthereafter,radiographyshowsbonesclerosis inthecalcanealtuberositywithspontaneousrecovery.47
Theapophysisofthecalcanealtuberosityisvisiblein pro-fileradiographyingirlsbetween5and13yearsandinboys between7and 15years.Occasionally,acutefracture ofthe apophysisisdescribedandshouldbetreatedwithsuture.48 Thisisdifferentfromosteochondrosisofthecalcaneal apoph-ysis(Sever’sdisease),whichissecondarytoaninflammatory oroverloadprocess.45
Inadolescentswhopracticesports,aspecialformofinjury istheavulsionfractureofthecalcaneustendoninthe pos-terosuperioredgeofthecalcanealtuberosity,presentingthe duck-beaksigninradiography.Duetotheconsiderable pres-sureoftheskinovertheAchillestendon,thisisanorthopedic emergency that requiresreductionand fixation inthe first hoursaftertheinjury.42
Asasignofplasticity,Clintetal.49analyzed227calcanei andobservedasignificantchangeintheBöhlerangle,
depend-ing on the age. Upto 5years ofage, the mean value was
15◦;between5and10years,asignificantincreaseto55◦was observed,reachingupto37◦at13,whichisverysimilartothe adultvalue.Tworetrospectiveseriesindicatedgoodlong-term resultsfromconservativetreatmentofdeviatedintra-articular fractures.50,51 However,degenerative changes in the subta-lar joint and significant shortening of the calcaneus were observedafter12years.47
Fig.3–(AandB)Lateralradiographofthefootandaxialradiographofthecalcaneus.(CandD)Coronalandobliqueaxialcut ofthefoot.(EandF)Anteroposteriorandprofilepostoperativeradiographsshowingthefixationwithplateandcompression screws.(GandH)Lateralradiographofthefootandaxialradiographofthecalcaneusinthelatepostoperativeperiod.
Therapeuticevidence
Sincetheexactextentofspontaneouscorrectionandthe clin-icalrelevanceofresidualmisalignmentsincalcanealfractures atthepediatricagearenotknown,openreductionand inter-nalfixationareusuallyrecommended.2,30,33,52
Inadolescentsover15years,theadultcriteriaareapplied: jointdeviation>1mm,andenlargementorlossofheightof morethan20%whencomparedwiththeoppositeside.53
Insinglelinefractures,closedreductionandpercutaneous fixationwithKirschnerwiresorscrewsareoptions.
Whentheimplantsinterferewithphysisgrowth,theuse oflow-profileplatesonthelateralwall(Fig.3)hasshownboth goodandexcellentresultsinrecentstudies.2,30,52,54
Loadontheaffectedlimbmustbeforbiddenforsixweeks.
Chopart
and
Lisfranc
fracture-dislocations
Themostprevalentmechanismisdirecttrauma,suchascrush injuries,fallingobjects,andtrafficaccidents.44
A careful clinical evaluation (plantar ecchymosis) is an indispensableprerequisitefortheidentificationoftheserare
lesions.Compartmentsyndromemustberuledoutthrough
directpressure measurements, particularly in unconscious
patients.
Radiographicinvestigation includesthe followingviews: profile, dorsoplantar at 30◦ cephalic (midtarsal) tilt or 20◦ cephalic(Lisfranc)tilt,andobliquewithplantarinclinationat 45◦.3
Astheselesionsarestilloftenunderestimated,additional computedtomographyexamsareusefulforcorrectdiagnosis andappropriatesurgicalplanning.20,29,48
Cuboidfracturesarerareinadultsandveryunusualin chil-dren.Publishedstudiesindicatethatthesefracturesrepresent upto5%ofalltarsalfractures.21
Theexperiencewithdeviatedcuboidfracturesinthe pedi-atric population is limited tocase reports.10,14,15,21,24,27,29,42 These injuries oftenresult insubluxation or Chopart joint dislocation, as they are usually associated withother foot fractures.4,12,14,20,27
The cuboid plays an importantrole in maintaining the
lengthandflexibilityofthelateralcolumnofthefoot. There-fore, surgical treatmentof diverted fractures ofthe cuboid isusuallyperformedtopreventtheshorteningofthelateral column, jointincongruity,abductiondeformities,and post-traumaticarthritis.27,42,51
Zwipp et al.33 reporteda combined Chopart dislocation (transtalar/transcuboidal)inachildaged8years,treatedinthe early1990s.Inanotherreport,onlythetalarneckfracturewas identified andstabilized withKirschnerwires. Thispatient developedpost-traumaticosteoarthritis,bothin talonavicu-larand inthecuboid-calcaneal joint,and underwent triple arthrodesisthreeyearsaftertheinjury.17
Midtarsal injuries are usually associated with ligament
injuries,55 due to the trauma mechanism in abduction or
Fig.4–(AandB)Three-dimensionalreconstructionofacomputedtomographyshowingfracturewithshiftoftransitionof theneck/headofthetalusandshorteningofthelateralcolumnduetocuboidfracture.(CandD)Anteroposteriorandprofile postoperativeradiographsshowingthefixationwithKirschnerwireofthecuboidandtalusfractures.(E,F,andG)
Anteroposterior,profile,andobliqueradiographsoffootinthelatepostoperativeperiod.
Therapeuticevidence
The long-term findings in the conservative treatment of
these do not indicate compensation and proper
remodel-ing throughout the child’s growth.44,56,57 In particular, one caseofattemptedclosedreductionandfixationwith percuta-neousKirschnerwiresshowedsubtleresidualmisalignment orincompletereduction,negativelyimpactingthefinalresults duetopainfuldeformities.3,21
Thetreatmentofchoiceistheopenreduction,aimingto rebuildarticularsurfacesandrestoretheshaftand stabiliza-tionratios(Fig.4).
Thefixationofthebonecomponentisindividualized,and dependsonthefracturepatternandtheconcomitant ligamen-tousinstability.
Temporaryjointtransfixionforfourtosixweeksisoften required.19
FixationwithKirschnerwiresappearstobesufficientto stabilizecuboidfracturesinchildren.Incasesofgreat short-eningofthecuboid,abonegraftisusedtomaintainthelength ofthesidecolumn.10,21,24,42
Lisfrancdislocationsshouldalsobeanatomicallyreduced andstabilizedwithtemporarytransarticularKirschnerwires.
The starting point for correct reduction is the second
radius,thebaseofthesecondmetatarsal andintermediate cuneiform.
Fractures
of
the
metatarsals
and
toes
Between70%and90%ofallfootfracturesinchildreninvolve themetatarsalsandtoes,whichgenerallyhavelowratesof complications.1,58,59
Inisolated metatarsal fractures,displacementisusually smallandduetotheactionofthedisplacedinterosseous mus-cleandligamentinsertions;thus,thechoiceforconservative treatmentissafe.
The same applies to fractures of two metatarsals with
little displacement in the same direction, with stable
tarsometatarsal joints; shortening and minimum
devia-tion in the sagittal plane do not negatively impact late
results.3
Complex foot and ankle injuries in children
Radiographic assessment
Open fracture Closed fracture Compartment syndrome
Immediate intervention fasciotomy
Immediate intervention surgical washing
Fracture without deviation
Immobilization Fracture with deviation
and soft tissue lesion
Immediate intervention external fixation
Definitive treatment Definitive
treatment
Definitive treatment
Internal fixation
Non-surgical treatment
Definitive treatment CT CT
CT Definitive treatment
Fig.5–Algorithmfortreatmentofcomplexfootandankleinjuriesinchildren.
Therapeuticevidence
Displacementswithcorticalcontactare,inprinciple,eligible fornonsurgicaltreatment;however,anaxisdeviationofmore than20◦orassociatedinstabilityarebettertreatedwithopen reductionand intramedullary anterograde Kirschnerwires, especiallyinchildrenover12years.
Inturn,avulsionfracturesthataredisplacedfromthebase ofthefifthmetatarsal,unlike Iselinapophysitis,should be reducedwithatensionband.20
Intra-articular or condylar phalangeal fractures are the resultofadirecttraumamechanism.Anatomicalreductions areparticularlyimportantinthefirstandfifthtoes,inorder toavoidstuntingorearlymetatarsophalangealosteoarthritis. Fracturesofthecentraltoesarere-alignedandprotected withsplintsandshoestoavoiddorsiflexionduringgait.
Fracturesofthedistalphalanx,combinedwithskin lacer-ationsorsubungualhematoma,areconsideredtobeexposed fractures;theyshouldbetreated withduecareinorder to avoidosteomyelitis.60
As a rule, fractures of the metatarsals are protected
fromloadforfourweeksandphalangesfractures,forthree weeks.
Complex
lesions
Thetermcomplexankleandfootinjuryisreservedfor frac-turesinvolvingserioussofttissuedamage,includingvascular
and nervedamage,usuallywithjoint involvementofbone
tissueandisassociatedwithahighriskofcomplications.27,55 Themaincausesofinjuriesinchildrenaretrafficaccidents, fallfromheight,andbicycleaccidents.60,61
Inadults,thereisstandardprotocolforthemanagementof complextraumatoachieveoptimalfunctionalresults.In chil-dren,thescenarioisdifferent,mainlyduetolowerfrequency
ofthistypeofinjury,thelargepercentageofradiolucent skele-tons,andthemoreresistantsofttissuecoverage;therefore, theuseofaprecisetreatmentalgorithmisalsooffundamental importanceinthepediatricagegroup(Fig.5).62
Thetreatmentdecisionisbasedonthefullextentofthe
lesions, which are evaluated by the system developed by
Zwippetal.57
Thesystemconsidersthenumberofregionsoftheaffected foot(ankle,talus,calcaneus,Chopartjoint,Lisfrancjoint,and forefoot),aswellasthedegreeofsofttissueinjury(openor closed),accordingtothedescriptionbyTscherneandOestern; eachaffectedtopographicregionreceives1–3pointsforsoft tissueinjury,anddeglovingorpartialtraumaticamputation are assigned4points.Ascoreof5orhigherisadiagnostic criterionforcomplexankleandfoottrauma.57
The reported complication rate is 27.5%,which include
superficial infections, compartment syndrome, soft tissue
necrosis, bone growth disorder, non-union, and
post-traumatic osteoarthritis. In contrast with adults, it is
importanttoreportthatexposed fractures inchildhooddo
notexcludecompartmentsyndrome;around50%ofpatients
withcompartmentsyndromehaveexposedfracture.62 Thefinalfunctionalresultsshowameanof82.3(59–100) pointsintheAOFASscore.62
Therapeuticevidence
Inpolytraumacases,treatmentisstaged:lifesupport
meas-ures in the emergency room, complete debridement, and
extensive washing,combined withstable externalfixation. After the stabilization of the vital functions, the definitive treatmentoffracturesdependsontheindividualpattern.3
Fig.6–(A)Anteroposteriorradiographofthefootshowingtarsometatarsalfracture-dislocation.(BandC)Anteroposterior andprofilepostoperativeradiographsshowingthefixationwithKirschnerwireandaidofanexternalfixator.(DandE) Postoperativeclinicalaspectshowingdamageofskincoverage.(FandG)Lateralandanteroposteriorradiographsofthefoot inthelatepostoperativeperiod.
At12yearsofage,96%ofgirlsand88%ofboysare skele-tallymature.Inyoungerpatientswithalargeproportionof cartilageareaonthearticularsurfaces,theessentialpartof treatmentistherestorationofthelength,width,height,and rotation;under12yearsofage,stabilizationwithKirschner wiresissufficient.Incasesofgreatinstability,theaidprovided bytheexternalfixatoriskey(Fig.6).62Inpatientsoverthisage, restoringtheanatomicjointreductionisalsorequired.57
Duringemergencysurgery,oneshouldnotconsume
sur-gical time with reconstruction challenges; the definitive treatmentisplannedaftersofttissuerecoveryandcomplete diagnosis withtheaid ofcomputed tomography.Joints are reconstructedwithsupportplatesandspecialscrews.62
Adecisivefactorfortheprognosisisasafeandpermanent skincoverage,involving all the resources ofreconstructive microsurgery,includingfreeflaps.62
Evenintotalorsubtotalfootamputations,replantationis justifiedselectedcases,asthefunctionalsuccessobservedin thesmall numberofcasesreported ismorefavorablethan inadults.However,inthis scenario,decisionbetweenlimb salvageorre-implantationisbasedonthesumoflesionsand ontheprinciple“lifebeforelimb”.54
Conclusions
for
clinical
practice
In the last decade, malleolar and foot bone fractures in
pediatricpatientshavepresentedanincreaseinprevalence
andseverity.Diagnosisthroughsophisticatedimagingexams
allows for a more appropriate therapeutic decision.
Cur-renttreatmentprinciplesindicateatendencytowardsurgical treatmentinordertominimizethemostfrequent complica-tions,suchascompartmentsyndrome,bonegrowthdisorders, three-dimensional deformity, avascularnecrosis, and early post-traumaticosteoarthritis.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
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e
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n
c
e
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