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Journal of the American Academy of Orthopaedic Surgeons
268
Ankle fractures are distal tibial and
fibular fractures that occur at or dis-
tal to the level of the metaphysis.
Defining the cutoff between a pedi-
atric and an adult fracture is some-
what arbitrary; the upper age limit
of 18 years is often used. Alterna-
tively, pediatric fractures may be de-
fined as those that occur in individ-
uals with open physes regardless of
chronologic age.
Ankle fractures account for ap-
proximately 5% of pediatric frac-
tures and 15% of physeal injuries.
1-4
Such fractures occur twice as fre-
quently in boys.
1-4
Peak incidence
is in the age range of 8 to 15 years.
The annual incidence of ankle frac-
tures in the pediatric population is
approximately 0.1%.
Ligamentous injuries in the
growing child are unusual. Due to
the fact that ligaments are generally
stronger than open physes, low-
energy trauma (such as an inversion
injury) that might result in a liga-

mentous injury in an adult often
results in a physeal fracture in a
skeletally immature individual.
During the evaluation of children, it
is important to correlate physical
and radiographic findings, because
accessory ossification centers may
be misread as fractures.
There are two important goals
when treating children with ankle
fractures: achieving a satisfactory
reduction and avoiding physeal
arrest so as to minimize the risks of
angular deformity, early arthrosis,
leg-length inequality, and joint stiff-
ness. The amount of physeal dam-
age incurred at the time of injury is
beyond the physician’s control;
however, the amount of additional
damage can be minimized by limit-
ing the number of reduction at-
tempts (ideally, only one will be
necessary). For fractures crossing
the physis, open reduction and in-
ternal fixation is frequently used to
minimize the risk of physeal arrest
as well as to enhance articular con-
gruity. Understanding the anatomy
of the foot and ankle aids in the as-
sessment and treatment of these

fractures.
Anatomy
The ankle is a true hinge joint and is
stable due to its inherent articular
congruity and the surrounding liga-
mentous structures. Because the
dome of the talus is wider anteriorly
than posteriorly, there is potentially
more translation and rotation when
the ankle is plantar-flexed. There-
fore, plantar-flexion places the an-
kle at a higher risk for injury.
The medial and lateral collateral
ligaments support the ankle. The
medial superficial deltoid ligament
originates on the distal tibia and in-
serts onto the talus, the calcaneus,
and the navicular. The deep portion
of the deltoid ligament inserts onto
the talus. There are three lateral lig-
aments: the anterior talofibular liga-
Dr. Kay is Assistant Professor of Orthopaedic
Surgery, University of Southern California
School of Medicine, Los Angeles, and
Attending Surgeon, Childrens Hospital Los
Angeles, Los Angeles, Calif. Dr. Matthys is
Resident in Orthopaedic Surgery, University of
Southern California School of Medicine.
Reprint requests: Dr. Kay, Pediatric Ortho-
paedics, Childrens Hospital Los Angeles, 4650

Sunset Boulevard, Mailstop 69, Los Angeles,
CA 90027.
Copyright 2001 by the American Academy of
Orthopaedic Surgeons.
Abstract
Pediatric ankle fractures account for approximately 5% of pediatric fractures
and 15% of physeal injuries. The biomechanical differences between mature
and immature bones, as well as the differing forces applied to those bones, help
explain the differences between adult and pediatric fractures. The potential
complications associated with pediatric ankle fractures include those seen with
adult fractures (such as posttraumatic arthritis, stiffness, and reflex sympathet-
ic dystrophy) as well as those that result from physeal damage (including leg-
length discrepancy, angular deformity, or a combination thereof). The goals of
treatment are to achieve and maintain a satisfactory reduction and to avoid
physeal arrest. A knowledge of common pediatric ankle fracture patterns and
the pitfalls associated with their evaluation and treatment will aid the clinician
in the effective management of these injuries.
J Am Acad Orthop Surg 2001;9:268-278
Pediatric Ankle Fractures: Evaluation and Treatment
Robert M. Kay, MD, and Gary A. Matthys, MD
Robert M. Kay, MD, and Gary A. Matthys, MD
Vol 9, No 4, July/August 2001
269
ment, the calcaneofibular ligament,
and the posterior talofibular liga-
ment. Three structures between the
tibia and the fibula further support
the ankle mortise: the distal contin-
uation of the interosseous mem-
brane and the anterior and posterior

inferior tibiofibular ligaments. The
anterior inferior tibiofibular liga-
ment attaches to the lateral aspect of
the distal tibial epiphysis and is
important in the pathomechanics of
transitional (Tillaux and triplane)
fractures. The tibiofibular syndes-
mosis is a mobile articulation that
allows fibular motion during dorsi-
flexion and plantar-flexion.
The anatomy of the distal tibial
physis has been extensively studied.
The initial contour of the physis is
transverse. An anteromedial undu-
lation appears within the first 2
years, which essentially separates
the physis into medial and lateral
halves. This is important in under-
standing the anatomy of certain
fracture patterns. Closure of the
distal tibial physis progresses from
central to medial and then lateral
over the course of approximately 18
months.
The secondary ossific nucleus of
the distal tibial epiphysis generally
appears between the ages of 6 and 24
months. The medial malleolus, which
begins to ossify between 7 and 8
years of life, forms most commonly

from an elongation of the main ossific
nucleus of the distal tibia. However,
it originates from a separate ossifica-
tion center, the os subtibiale, in as
many as 20% of cases and may be
mistaken for a fracture.
5
The distal
tibial physis provides 3 to 4 mm of
growth annually and contributes
approximately 15% to 20% of the
length of the lower extremity and
35% to 40% of tibial length. Distal
tibial physeal closure is generally
completed by age 14 years in girls
and age 16 years in boys, although
there is minimal longitudinal growth
of the distal tibia after age 12 years in
girls and age 14 years in boys.
The ossific nucleus of the distal
fibula typically begins to ossify be-
tween 18 and 20 months of life, al-
though ossification may be delayed
until age 3 years. The lateral malle-
olus may also have an accessory
ossification center, the os fibulare.
Ogden and Lee
6
have shown that
the medial and lateral malleolar

accessory ossification centers are
actually a portion of the cartilage
anlage of the malleolus and are sep-
arated from the secondary ossifica-
tion center by epiphyseal cartilage.
Classification
Pediatric ankle fractures can be clas-
sified by using either an anatomic
(radiographic) or a mechanism-of-
injury scheme. The Salter-Harris
classification of physeal fractures
(Fig. 1) is the most commonly used
anatomic system, because of its sim-
plicity and the prognostic signifi-
cance of each injury type. Type I
and II injuries have lower risks of
physeal arrest than injuries classi-
fied as types III, IV, and V. Types III
and IV generally require open re-
duction and internal fixation to min-
imize articular incongruity as well
as to decrease the risk of physeal
arrest by enhancing the reduction of
the physis. The increased risk of
growth arrest in type IV injuries
stems from the fact that all levels of
the physis are disrupted. In type V
Figure 1 Salter-Harris classification of fractures. Type I is characterized by physeal separation; type II, by a fracture line that extends
transversely through the physis and exits through the metaphysis; type III, by a fracture that traverses the physis and exits through the
epiphysis; type IV, by a fracture line that passes through the epiphysis, across the physis, and out the metaphysis. Type V is a crush injury

to the physis.
Type I Type II Type III Type IV Type V
Pediatric Ankle Fractures
Journal of the American Academy of Orthopaedic Surgeons
270
injuries, the increased risk of
growth disturbance is due to the
local crush injury to the physis.
Type V fractures cannot generally
be classified accurately at the time
of injury, thus precluding a correct
initial prognosis. However, type V
fractures account for only 1% of
physeal injuries about the ankle.
Rang added a sixth type, compris-
ing perichondral ring injuries that
result from direct open injuries (e.g.,
those due to lawnmower accidents)
or from the trauma of surgical dis-
section.
7
In 1950, Lauge-Hansen, on the ba-
sis of a series of experimental studies
and clinical observations, proposed a
classification for ankle fractures in
adults. Combining the mechanistic
principles of Lauge-Hansen and the
Salter-Harris classification, Dias and
Tachdjian devised a classification
of pediatric ankle fractures using

four basic mechanisms: supination-
inversion, supination–plantar-flexion,
supination–external rotation, and
pronation/eversion–external rota-
tion.
7,8
In the description of each
mechanism, the first term refers to
the position of the foot, and the sec-
ond term refers to the direction of
the applied force at the time of in-
jury. Two additional fracture pat-
terns were included, the juvenile
Tillaux fracture and the triplane frac-
ture. These are termed transitional
fractures to indicate their occurrence
during the time of physeal closure.
Dias subsequently added a ver-
tical compression–type fracture,
which has the same implications as
a Salter-Harris V injury.
7
Such a
mechanistic classification scheme
theoretically has the advantages of
being both precise and useful in
selecting the appropriate method to
reduce the fracture. The fracture
type serves as a guide to the direc-
tion of force and the position of the

foot at the time of injury. The direc-
tion of the force is usually reversed
during closed or open reduction.
However, the interobserver repro-
ducibility of this classification sys-
tem is low, and it is, therefore, of
limited value.
Diagnosis
A lower-extremity injury must ini-
tially be considered in the context of
the patient’s overall condition. In
the polytrauma patient, concomitant
orthopaedic injuries are common,
9
but stabilization of airway, breath-
ing, and circulation always takes
precedence.
A careful neurovascular exami-
nation of the extremity should be
performed, although a precise motor
and sensory examination may be
difficult in a frightened child. Cap-
illary refill should be assessed.
Pulses may not be palpable in the
child who has had marked blood
loss and has low or low-normal
blood pressure. If pulses are not
palpable, a Doppler study may aid
in the assessment of arterial inflow.
If the child cannot cooperate with

the examination of light-touch sen-
sation distal to the injury, the physi-
cian may need to check whether the
child responds to painful stimuli,
such as needle sticks.
Many pediatric ankle injuries
occur in patients without injuries to
other organ systems. Despite this, a
complete history is extremely im-
portant. Child abuse and pathologic
lesions should be considered if the
reported mechanism of injury does
not appear to match the fracture
type present. Approximately 1% of
all children are abused annually,
and approximately 2 million reports
of child abuse are filed each year in
the United States.
10,11
The incidence
of physical abuse has been reported
as 0.5%, and 1 of every 1,000 abused
children will die as a result of the
inflicted trauma.
12
Classic radio-
graphic findings, such as corner
fractures and multiple fractures in
different stages of healing, may be
seen in child abuse; however, isolated

fractures are seen in 50% of child
abuse cases, and the fracture patterns
are often unremarkable.
13
Any sus-
picion of child abuse warrants im-
mediate referral to the local child
protective services agency.
Pathologic fractures may be due
to systemic or local disease. A care-
ful patient and family history may
alert the orthopaedist to an underly-
ing metabolic bone disease. Sys-
temic signs and symptoms or pain
preceding the fracture should raise
the treating physician’s index of
suspicion of a pathologic fracture.
Bone pain is the presenting com-
plaint in approximately 25% of cases
of childhood leukemia.
14
Radio-
graphs may demonstrate a focal le-
sion. Fibrous cortical defects have
been reported in 27% of pediatric
patients, with the distal tibia being
the most common site of pathologic
fracture.
15-17
Although lesions mea-

suring more than approximately 3.3
cm in diameter or occupying more
than 50% of the diameter of a bone
appear to carry an increased risk of
pathologic fracture, the need for pro-
phylactic treatment remains contro-
versial.
15,16,18,19
Three radiographic views should
be obtained in the evaluation of
pediatric ankle injuries. Tillaux
fractures and other subtle injuries
may be easily missed if only two
views are obtained. For some inju-
ries (such as Salter-Harris I fractures),
the only radiographic abnormality
visible may be soft-tissue swelling
adjacent to the physis or slight
widening of the physis. Numerous
anatomic variations may be present
around the ankle, and interpretation
of the radiographs must be corre-
lated with the physical examination.
Medial accessory ossicles (ossa sub-
tibiale) are found in as many as 20%
of patients and lateral ossicles (ossa
fibulare) in about 1%.
6
Tenderness
in these areas may indicate an acute

fracture of the ossicle.
Stress radiographs are rarely
needed to evaluate pediatric ankle
Robert M. Kay, MD, and Gary A. Matthys, MD
Vol 9, No 4, July/August 2001
271
injuries. Although some authors
have recommended stress views
for the diagnosis of nondisplaced
Salter-Harris I fractures, they are
probably unnecessary and may
result in iatrogenic physeal dam-
age. Appropriate indications are to
rule out ligamentous injuries and
to differentiate an acute fracture
from an accessory ossicle.
Computed tomography is a use-
ful diagnostic aid, especially for the
evaluation of intra-articular frac-
tures, including transitional frac-
tures. If there is unexpected stiffness
after treatment, magnetic resonance
(MR) imaging may be indicated to
look for intra-articular cartilaginous
fragments.
A thorough evaluation can pro-
vide insight into the mechanism of
injury and can aid in planning the
reduction. Urgent reduction may
be required to restore neurovascular

function or to relieve skin tenting
over a displaced fracture.
Treatment of Distal
Tibial Fractures
Salter-Harris I and II Fractures
Salter-Harris I and II fractures
have a low incidence of physeal
arrest and are generally treated in
similar fashion. Type I fractures
account for approximately 15% of
distal tibial physeal fractures
1-3,20
and generally disrupt the physis
through the zone of hypertrophy.
Salter-Harris II fractures account for
approximately 40% of distal tibial
fractures.
1-3,20
In type II fractures,
the fracture line extends through
the zone of hypertrophy but then
exits through the metaphysis, creat-
ing a triangular Thurston-Holland
fragment. The periosteum is typi-
cally torn on the side opposite to
the Thurston-Holland fragment and
may be interposed in the fracture
site.
Salter-Harris I and II fractures
should be reduced so as to minimize

physeal injury. The patient should
be well sedated or anesthetized, and
reduction should be attempted only
once or twice. Closed reduction is
used for displaced fractures (Fig. 2).
Generally, reduction within a few
millimeters is possible, and cast
treatment for 4 to 6 weeks results in
a successful outcome. Adult cadaver
studies have shown that distal-third
tibial fractures that heal in 10 de-
grees of angulation can markedly
decrease the tibiotalar contact area
and increase tibiotalar contact pres-
sure
21,22
; however, comparable data
are not available for children.
If closed reduction is not success-
ful, open reduction should be per-
formed. Failure of closed reduction
is often due to interposed soft tis-
sue, such as periosteum, tendons,
and neurovascular structures. After
removal of these impediments, the
fracture can be reduced and will
Figure 2 Plain radiographs of a 13-year-old boy with a Salter-Harris II distal tibial fracture
and a Salter-Harris I fibular fracture. A and B, AP and lateral preoperative films obtained
in the emergency department. C and D, Films obtained 3 months after a single closed
reduction attempt.

C D
A B
Pediatric Ankle Fractures
Journal of the American Academy of Orthopaedic Surgeons
272
generally be stable. Internal fixation
is rarely necessary. If fixation is re-
quired for an unstable fracture and
the metaphyseal fragment is large
and accessible, a 3.5- or 4.0-mm can-
nulated lag screw parallel to the
physis is effective. If the physis
must be crossed with hardware,
smooth wires should be used.
The child should be followed up
for signs of healing as well as for
evidence of growth arrest after a
physeal fracture. Leg-length dis-
crepancy and sagittal- or coronal-
plane deformity may be seen clini-
cally. Growth disturbance lines are
common radiographic findings after
a fractured bone resumes normal
longitudinal growth. These lines
should be parallel to the physis; if
they are absent or not parallel to the
physis, growth arrest has occurred.
Although complete growth arrest
will result in leg-length discrepancy,
it may not necessitate intervention if

the child is nearing skeletal matu-
rity. In contrast, partial arrest will
lead to a progressive angular defor-
mity in addition to the leg-length
discrepancy and generally necessi-
tates intervention. Medial growth
arrest causes varus angulation, leg-
length discrepancy, and relative
fibular overgrowth with resultant
lateral impingement (Fig. 3). Com-
plete distal tibial growth arrest does
not lead to angular deformity, but
relative fibular overgrowth and lat-
eral impingement are potential con-
sequences.
Salter-Harris III Fractures
Salter-Harris III fractures account
for approximately 25% of distal tib-
ial fractures.
1-3,20
Because these
fractures traverse the physis and
exit through the epiphysis, there is
often an intra-articular step-off, as
well as injury to the subarticular
physis. These are commonly seen
with medial malleolus fractures as
well as with Tillaux fractures. Me-
dial malleolus fractures frequently
have a large cartilage component,

and the fracture fragment is often
much larger than the ossified por-
tion that is apparent radiographi-
cally.
Risks following Salter-Harris III
fractures are joint incongruity and
growth disturbance. Closed reduc-
tion under sedation may be at-
tempted. Open reduction and inter-
nal fixation is recommended for all
such fractures with more than 2 mm
of residual displacement. In one
series,
23
growth disturbance devel-
oped in only 1 of 20 patients with
Salter-Harris III or IV fractures
treated with open reduction and
internal fixation, but 5 of 9 patients
with such fractures who were treated
with casting subsequently had radio-
graphic evidence of a bone bridge
crossing the physis.
If possible, fixation devices
should be placed parallel to (and
avoiding) the physis. Screw fixation
is preferable, but smooth wires may
be used. If smooth wires are inserted
parallel to the physis, the two wires
should not be exactly parallel in all

planes, as postoperative displace-
ment may occur after such fixation.
Screws or threaded wires should
never be placed across an open
physis. Smooth pins may cross a
physis if necessary for fracture fixa-
tion. Pins traversing physes should
be removed when the fracture
becomes stable, generally within
several weeks.
Tillaux Fractures
Tillaux fractures are Salter-
Harris III fractures of the anterolat-
eral portion of the distal tibia, and
result from an epiphyseal avulsion
at the site of attachment of the ante-
rior inferior tibiofibular ligament
(Fig. 4). These fractures are most
commonly seen in children nearing
skeletal maturity (generally 12 to 14
years old) during the approximately
18-month period during which the
distal tibial physis is closing. Tillaux
fractures account for 3% to 5% of
pediatric ankle fractures.
20,24
The
anterolateral location is due to the
order of closure of the distal tibial
physis (initially centrally, then medi-

ally, and finally laterally). Depend-
ing on the severity of trauma, there
may be an associated distal fibular
fracture. The mechanism of injury is
typically supination–external rota-
tion.
Treatment is directed at obtain-
ing and maintaining reduction of
the intra-articular surface of the dis-
tal tibia. Nondisplaced fractures are
immobilized with a long leg cast for
4 weeks. A short leg cast may be
used for an additional 2 weeks if
physeal tenderness is present on
removal of the long leg cast. Com-
puted tomographic (CT) scans are
used to rule out intra-articular in-
congruity.
Patients with displaced fractures
are treated with closed reduction
under sedation. The mechanism of
injury (supination–external rotation)
is reversed, and direct pressure may
also be applied to the anterolateral
fragment. After reduction, plain
Figure 3 AP radiograph of a 14-year-old
girl approximately 4 years after a distal tib-
ial fracture complicated by medial growth
arrest. There is a 1.7-cm leg-length dispari-
ty and a 15-degree varus deformity of the

ankle. Growth-disturbance lines (arrow)
converge medially due to the medial
growth arrest.
Robert M. Kay, MD, and Gary A. Matthys, MD
Vol 9, No 4, July/August 2001
273
radiographs and CT scans will con-
firm the adequacy of reduction. If
the intra-articular step-off measures
2 mm or more, reduction and inter-
nal fixation is warranted.
In the operating room, closed
reduction may first be attempted. If
an essentially anatomic reduction
can be obtained, percutaneous fixa-
tion with cannulated screws or
wires may be used. However, if
such a reduction is not possible,
open reduction should be per-
formed through an anterolateral
approach to the ankle, so that direct
visualization of the fracture frag-
ments and the intra-articular surface
can be obtained. Schlesinger and
Wedge
25
have described percuta-
neous manipulation of a displaced
Tillaux fracture with a Steinmann
pin followed by percutaneous frac-

ture fixation.
Fracture fixation may cross the
physis in the patient with a Tillaux
fracture who is nearing skeletal
maturity, as the distal tibial physis
is in the process of closing and
crossing the physis will not, there-
fore, result in clinically important
growth arrest. If the child has con-
siderable growth remaining, the
physis should not be violated with
screws.
Salter-Harris IV Fractures
Salter-Harris IV fractures traverse
the metaphysis, physis, and epiph-
ysis to enter the ankle joint, and
appear to account for as many as
25% of distal tibial fractures.
1,3
Type
IV fractures are seen with triplane
fractures and with shearing injuries
to the medial malleolus. Patients
with nondisplaced fractures should
be treated in a non-weight-bearing
long leg cast for 4 weeks, which may
be followed by a short leg walking
cast for another 2 weeks.
If there is more than 2 mm of
residual displacement, treatment is

open reduction and internal fixa-
tion to minimize articular incon-
gruity and the risk of physeal bar
formation (Fig. 5). The fracture and
the articular surface of the distal
tibia should be visualized to ensure
anatomic reduction. The perichon-
dral ring should not be elevated
from the physis, and screw fixation
should be parallel to the physis.
Fibular fractures accompanying
Salter-Harris IV distal tibial frac-
tures are most commonly Salter-
Harris I and II injuries. The fibular
fracture is usually stable after reduc-
Tibia
Ligament
Fibula
A B
Figure 4 A, Tillaux fracture. (Adapted with permission from Weber BG, Sussenbach F:
Malleolar fractures, in Weber BG, Brunner C, Freuler F [ed]: Treatment of Fractures in
Children and Adolescents. New York: Springer-Verlag, 1980.) B, As visualized from below,
the Tillaux fragment is seen to be avulsed by the anterior inferior tibiofibular ligament.
Figure 5 A, AP radiograph demonstrates a displaced Salter-Harris IV fracture of the distal
tibia and a Salter-Harris I fracture of the distal fibula. B, Radiograph obtained 3 months
after open reduction and internal fixation of the tibial fracture and closed reduction of the
fibular fracture demonstrates good alignment and fixation parallel to the physis. The dis-
tal fibular physis has closed, and the distal tibial physis is in the process of closing.
A B
Pediatric Ankle Fractures

Journal of the American Academy of Orthopaedic Surgeons
274
tion of the tibial fracture. If the fib-
ula remains unstable after reduction
of the tibial fracture, internal fixa-
tion is indicated, often with an intra-
medullary Kirschner wire.
Triplane Fractures
Triplane fractures are Salter-Harris
IV fractures that challenge the
orthopaedist’s three-dimensional per-
ception. Triplane fractures have com-
ponents in the sagittal, coronal, and
transverse planes and may be two-,
three-, or four-part fractures. They
account for 5% to 7% of pediatric
ankle fractures.
20,24
These fractures
are also considered transitional frac-
tures, but may occur in younger chil-
dren than Tillaux fractures do. The
average age of patients with triplane
fractures is approximately 13 years,
although they have been reported in
children as young as 10.
20,24,26,27
Triplane fractures involve both a
metaphyseal fragment posteriorly
and an epiphyseal fragment, which is

generally lateral. Lateral triplane frac-
tures are more common than medial
triplane fractures. Lateral fractures
appear similar to Tillaux fractures on
anteroposterior (AP) plain radio-
graphs of the ankle, but can be distin-
guished from them on the basis of
evidence of a Salter-Harris II or IV
fracture line on the lateral view.
Medial triplane fractures are distin-
guished from lateral triplane fractures
radiographically by the more medial
location of the epiphyseal and me-
taphyseal fractures, as well as by the
fact that the metaphyseal fracture
occurs in the sagittal plane in medial
triplane fractures and in the coronal
plane in lateral triplane fractures.
The epiphyseal fragment is usu-
ally connected to the metaphyseal
fragment (two-part fracture), al-
though they may be separate frag-
ments. In two-part lateral triplane
fractures, one fragment is composed
of the anterolateral and posterior
portions of the epiphysis joined to
the posterior metaphyseal fragment.
The other part consists of the ante-
romedial epiphysis connected to the
remainder of the distal tibia (Fig. 6).

Three-part lateral fractures differ
from two-part lateral fractures in
that an additional fracture line sepa-
rates the anterolateral epiphyseal
fragment from the fragment con-
taining the posterior metaphyseal
fragment and posterior epiphysis
(Fig. 7). The distinction between
three- and four-part fractures often
can be demonstrated only on CT
scans. Four-part fractures are com-
minuted variants.
As with Tillaux fractures, nondis-
placed triplane fractures may be
treated with immobilization in a long
leg cast for 4 weeks, followed by use
of a short leg walking cast for an addi-
tional 2 weeks. Also as with Tillaux
fractures, CT scans are imperative for
assessing fracture alignment.
Performed with the patient under
conscious sedation, closed reduction
of two-part triplane fractures (with
internal rotation of the distal frag-
ment for lateral triplane fractures
and with eversion for medial tri-
plane fractures) may be successful.
Such reduction is less commonly
Figure 6 A, Two-part lateral triplane fracture. One fragment is composed of the anterolateral and posterior portions of the epiphysis
joined to the posterior metaphyseal fragment. The other part consists of the anteromedial epiphysis connected to the remainder of the dis-

tal tibia. (Adapted with permission from Jarvis JG: Tibial triplane fractures, in Letts RM [ed]: Management of Pediatric Fractures.
Philadelphia: Churchill Livingstone, 1994, p 739.) B, Two-plane medial triplane fracture. (Adapted with permission from Rockwood CA
Jr, Wilkins KE, King RE: Fractures in Children. Philadelphia: JB Lippincott, 1984, p 933.)
A B
Robert M. Kay, MD, and Gary A. Matthys, MD
Vol 9, No 4, July/August 2001
275
successful with three- or four-part
fractures. Postreduction CT scan-
ning is imperative to assess the re-
duction. Ertl et al
27
have shown that
residual intra-articular displacement
of 2 mm or more compromises treat-
ment results.
Intra-articular displacement of 2
mm or more or displacement at the
level of the physis of more than 2 mm
in a child with more than 2 years of
growth remaining mandates the use
of open reduction and internal fixa-
tion. Open reduction is generally
carried out through an anterolateral
approach for lateral fractures or an
anteromedial approach for medial
fractures in order to visualize the
fracture fragments and joint surface.
Depending on fracture configura-
tion and surgeon preference, either

the metaphyseal or the epiphyseal
fragment may be fixed initially. Ar-
ticular congruity must be restored
to maximize patient outcome.
Triplane fractures can result in
clinically important growth distur-
bance if they occur in children with
at least 2 years of growth remaining.
Growth disturbance appears to occur
in fewer than 10% of patients after
triplane fractures, although Cooper-
man et al
26
reported this complica-
tion in 3 (21%) of 14 patients. If more
than 2 years of growth remains, fixa-
tion traversing the physis should be
avoided if possible.
Cannulated screw systems allow
accurate hardware placement and
appear to minimize incidental phys-
eal damage. Fixation may be neces-
sary when a high-energy injury
results in a comminuted fibular frac-
ture that is likely to shorten (Fig. 8).
Fibular fractures proximal to the
physis are more common in children
nearing skeletal maturity. These
fractures are often spiral fractures,
which are not stable after reduction

of the tibia. The portion of the fibula
distal to the fracture site may be
reflected distally to enhance expo-
sure for tibial fracture reduction.
Ertl et al
27
reported marked dete-
rioration in the results of treatment
of triplane fractures at a follow-up
interval of 3 to 13 years compared
with the results at 1.5 to 3 years.
This deterioration was seen even in
those patients who had undergone
accurate open reduction and inter-
nal fixation.
Salter-Harris V Fractures
Salter-Harris V injuries account
for 1% of distal tibial physeal inju-
ries and involve a compressive force
across the germinal layer of the phy-
sis.
1-3,20
Displacement of the epiphy-
sis is rare. If the fracture is accu-
rately identified as a type V injury
initially, excision of the damaged
portion of the physis and placement
of a fat graft may prevent the devel-
opment of growth arrest. However,
these fractures are generally catego-

rized as type V injuries when a pa-
tient is noted to have a leg-length
discrepancy or angular deformity
months or years after a suspected
type I physeal injury. The prognosis
of this injury is poor due to the
sequelae of physeal arrest. With late
diagnosis, treatment is directed
toward addressing the leg-length
discrepancy or angular deformity.
Treatment of Distal Fibular
Fractures
Isolated Fractures
Salter-Harris I and II injuries
account for approximately 90% of
isolated distal fibular fractures, and
frequently result from low-energy
trauma. An isolated Salter-Harris I
fracture can be distinguished from a
lateral ankle sprain by the presence
of local tenderness over the distal
fibular physis rather than over the
anterior talofibular, calcaneofibular,
and posterior talofibular ligaments.
Such isolated injuries generally heal
2
3
2
3
1

1
Talus
Figure 7 A, Lateral view of a three-part lateral triplane fracture, which differs from a two-
part lateral fracture in that a coronal fracture line separates the anterolateral epiphyseal
fragment from the fragment containing the posterior epiphyseal and metaphyseal frag-
ments (1 = anterolateral epiphyseal fragment; 2 = fragment containing the posterior metaph-
yseal fragment and posterior epiphysis; 3 = tibia). B, View from below shows relationship
of the fracture components. (Adapted with permission from Marmor L: An unusual frac-
ture of the tibial epiphysis. Clin Orthop 1970;73:132-135.)
A B
Pediatric Ankle Fractures
Journal of the American Academy of Orthopaedic Surgeons
276
well within 3 weeks in a short leg
walking cast. Salter-Harris III and
IV injuries are rare and must be
distinguished from an accessory
ossification center (os fibulare). Re-
duction is rarely necessary, but
may be required for the rare distal
fibular Salter-Harris III or IV frac-
ture with marked residual dis-
placement.
Avulsion of accessory ossifica-
tion centers of the distal fibula may
be symptomatic. Ogden and Lee
6
noted that these avulsion fractures
are analogous to Salter-Harris II
fractures if the accessory ossification

center is considered an epiphysis.
They recommended immobilization
in a short leg walking cast for 2 to 3
weeks. They also reported that non-
operative treatment sometimes fails
and surgical treatment becomes nec-
essary, although this seems to be
quite rare.
Fractures Combined With Distal
Tibial Fractures
Fibular fractures seen in con-
junction with distal tibial fractures
are routinely reduced with re-
duction of the tibial fracture.
These fibular fractures tend to be
stable after reduction and rarely re-
quire fixation in the skeletally im-
mature individual. Fixation may
be indicated for the child nearing
skeletal maturity with a severely
A B
D E
C
Figure 8 A and B, AP and lateral radio-
graphs of a 90-kg 14-year-old boy reveal a
two-part lateral triplane fracture and a
comminuted distal fibular fracture.
Arrows indicate the apparent gap between
the fracture fragments. C, CT scan shows
the marked external rotation of the lateral

portion of the distal tibia, the marked frac-
ture displacement, and the mild comminu-
tion of the medial tibia. D and E, Radio-
graphs obtained 1 year after operative
treatment demonstrate healed fractures in
a satisfactory position and closure of the
distal tibial and distal fibular physes.
Robert M. Kay, MD, and Gary A. Matthys, MD
Vol 9, No 4, July/August 2001
277
comminuted fracture at risk for
shortening.
Complications of Ankle
Fractures
Growth Arrest
Growth arrest is most common
after distal tibial Salter-Harris III and
IV fractures, and often leads to both
a leg-length discrepancy and an
angular deformity of the ankle. Leg-
length discrepancy is related to the
child’s age at the time of fracture and
usually is between 1 and 2 cm.
23,28
In one series, growth disturbance
developed in only 1 (5%) of 20
patients with Salter-Harris III or IV
fractures treated with accurate open
reduction and internal fixation, in
contrast to 5 (56%) of 9 patients with

similar fractures treated with closed
reduction.
23
If the growth arrest is
detected before considerable angu-
lar deformity develops, the main
issue is the ultimate leg-length dis-
crepancy predicted. If considerable
angular deformity is already pre-
sent at the time the physeal arrest is
detected, an osteotomy is the only
possible solution to correct the me-
chanical axis. The amount of angu-
lar deformity that is acceptable has
not been established, although an-
gulation in distal tibial fractures has
been shown to markedly increase
contact pressure in the ankle joint in
adult cadaver studies.
21,22
For children nearing skeletal ma-
turity, epiphysiodesis of the part of
the physis that remains open may
be all that is necessary if no angular
deformity is present. For example,
because the distal tibia grows only 3
to 4 mm annually as the child nears
skeletal maturity, a child with 2
years of growth remaining will lose
less than 1 cm of leg length if a com-

plete arrest occurs. Epiphysiodesis
of the distal fibula should be consid-
ered to prevent fibular overgrowth
and lateral impingement. In youn-
ger children, physeal bar resection
may be considered if the bar encom-
passes less than 50% of the physis as
delineated on MR images.
Osteoarthritis
Osteoarthritis may result from
chondral damage at the time of in-
jury or articular incongruity at the
time of fracture healing. In a long-
term study an average of 27 years
after injury, 12% of all 71 patients
with physeal ankle fractures had
radiographic evidence of osteoar-
thritis, compared with 29% of pa-
tients with a Salter-Harris III or IV
fracture.
28
In the same study, the
late results correlated most strongly
with the initial fracture displace-
ment and with the residual dis-
placement after reduction. In a
study of triplane fractures, Ertl et
al
27
concluded that anatomic reduc-

tion of intra-articular fractures may
reduce the incidence of late arthritis.
Ankle Stiffness
Posttraumatic ankle stiffness is
likely due to a combination of inju-
ries to both the soft tissues and the
osseous structures. Caterini et al
28
reported this complication in 4 (6%)
of 71 patients at long-term follow-
up and found that it correlated with
radiographic evidence of osteoar-
thritis in 3 of the 4 patients with
ankle stiffness. Physical therapy
should be used to treat all patients
with severe injuries as well as to
treat those patients with marked
residual ankle stiffness 1 month
after cast removal.
Reflex Sympathetic Dystrophy
As in adults, reflex sympathetic
dystrophy (RSD) in children is char-
acterized by pain out of proportion
to an injury in conjunction with
signs of autonomic dysfunction of
the injured extremity. The condition
is more common in lower-extremity
injuries and often follows trivial
trauma. In the largest reported
series of RSD in children, the au-

thors noted a 1-year delay from the
onset of symptoms to the diagno-
sis.
29
In that series, 84% of the pa-
tients were girls.
The most important aspect of
treatment of RSD is prompt recog-
nition. Potential components of
treatment include physical therapy,
psychological counseling, drug
therapy, and sympathetic blockade.
Wilder et al
29
reported that, at a me-
dian follow-up interval of 3 years,
38 (54%) of 70 patients with RSD
had persistent symptoms despite
aggressive treatment.
Summary
Pediatric ankle fractures are com-
mon injuries. Appropriate treat-
ment is guided by the accurate
assessment of the injury itself, as
well as its potential ramifications.
The goals of treatment are a satisfac-
tory reduction and the avoidance of
growth disturbance. Closed reduc-
tion of physeal injuries should be
carried out a minimal number of

times (preferably once) and should
be done only in well-sedated or
anesthetized patients. It is impor-
tant to recognize that even injuries
that appear benign initially may
have poor long-term results.
Closed treatment and casting of
Salter-Harris I and II distal tibial
fractures generally yield good re-
sults. Salter-Harris III and IV distal
tibial fractures have high incidences
of articular incongruity, physeal
arrest, and late arthritis if treated by
closed means, and require open
reduction and internal fixation if
there is more than 2 mm of residual
displacement. Computed tomo-
graphic scans are more useful in the
evaluation of residual displacement
than plain radiographs, which are
often out of plane with the fracture.
Salter-Harris V injuries account for
only 1% of distal tibial fractures,
and are often recognized only retro-
spectively. Growth disturbance
lines should be carefully monitored,
Pediatric Ankle Fractures
Journal of the American Academy of Orthopaedic Surgeons
278
so that a growth disturbance can be

detected early.
Salter-Harris I and II injuries ac-
count for 90% of isolated distal fibular
fractures and respond well to closed
treatment. These fractures should be
distinguished from accessory ossi-
cles. Salter-Harris III and IV distal
fibular fractures are rare. Surgical
treatment may be required for such a
fracture if there is significant residual
displacement after reduction.
Distal fibular injuries are often
seen in conjunction with distal tibial
fractures. These distal fibular frac-
tures are generally stable after re-
duction of the tibia and rarely re-
quire fixation.
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