From the Guidelines
The diagnosis for a 14-year-old male with a right lateral ankle injury, suspected of having a Salter-Harris type 1 fracture of the distal fibular physis, with tenderness to palpation on the lateral aspect of the ankle, and involvement of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) is most likely a combination of a growth plate fracture and ligament sprain, requiring careful management to prevent growth disturbances. To confirm the diagnosis, X-rays should be obtained, including three standard views: anteroposterior, lateral, and mortise views to include the base of the fifth metatarsal bone distal to the tuberosity 1. The Ottawa Ankle Rules (OAR) are the current standard clinical imaging guidelines to determine if radiographs are necessary, with a sensitivity of 92% to 99% for detecting ankle fracture 1. Given the patient's age and symptoms, it is essential to consider the possibility of a Salter-Harris type 1 fracture, which occurs in children whose growth plates haven't closed yet, with type 1 indicating the fracture line passes through the growth plate without involving the adjacent bone 1. Treatment typically involves immobilization with a cast or walking boot for 3-4 weeks, followed by gradual return to activities, and follow-up imaging is crucial to ensure proper healing and to monitor for potential growth complications 1. In some cases, comparison views of the uninjured ankle may help identify subtle fractures, and special attention should be given to the lateral process fracture of the talus, also known as a snowboarder's fracture, which may be overlooked on routine radiographs 1. Ultrasound (US) may be useful but is not typically considered the first line of imaging for the evaluation of acute trauma to the ankle with positive OAR 1. The patient's treatment plan should prioritize immobilization, pain management, and gradual return to activities to minimize the risk of growth disturbances and ensure optimal outcomes. Key considerations in the management of this patient include:
- Immobilization with a cast or walking boot for 3-4 weeks
- Gradual return to activities
- Follow-up imaging to ensure proper healing and monitor for potential growth complications
- Pain management and rehabilitation to minimize the risk of chronic pain and immobility.
From the Research
Diagnosis of Ankle Injury
The diagnosis for a 14-year-old male with a right lateral ankle injury, suspected of having a Salter-Harris type 1 fracture of the distal fibular physis, with tenderness to palpation (TTP) on the lateral aspect of the ankle, and involvement of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) can be considered based on the following points:
- The patient's symptoms, such as tenderness to palpation on the lateral aspect of the ankle, are consistent with a Salter-Harris type 1 fracture of the distal fibular physis 2.
- The involvement of the ATFL and CFL suggests a more complex injury, potentially involving a combination of fracture and ligamentous injury 3.
- The diagnosis of a Salter-Harris type 1 fracture can be challenging, and emergency physicians may be more likely to diagnose this condition than orthopedic physicians 4.
Differential Diagnosis
The differential diagnosis for this patient's condition may include:
- Salter-Harris type 1 fracture of the distal fibular physis
- ATFL injury
- Osteochondral avulsion of the distal fibula
- Other fractures or ligamentous injuries of the ankle
Diagnostic Considerations
When evaluating this patient, the following diagnostic considerations should be taken into account:
- Imaging modalities, such as X-rays or MRI, may be necessary to confirm the diagnosis and rule out other potential causes of the patient's symptoms 3.
- The patient's age and the mechanism of injury should be considered when evaluating the potential for a Salter-Harris type 1 fracture or other ankle injuries 2, 5.
- A thorough physical examination, including assessment of tenderness to palpation and ligamentous stability, is essential in evaluating the patient's condition 4, 6.