From the Guidelines
The primary concern for a lateral ankle injury with a Salter-Harris fracture, involvement of the dorsal, fibular physis, and potential damage to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) is to prevent long-term morbidity and mortality by ensuring proper healing and minimizing the risk of growth disturbances, particularly in growing children. The injury involves the fibular physis (growth plate) with tenderness to palpation over the lateral malleolus, and the diffuse pain and involvement of the ATFL and CFL suggest a combination of ligament sprain and possible growth plate injury.
Key Considerations
- The Ottawa Ankle Rule (OAR) should be used to determine the need for radiographs, as it has a high sensitivity and specificity for detecting ankle fractures 1.
- Treatment should include the RICE protocol (Rest, Ice, Compression, Elevation) for the first 48-72 hours, followed by protected weight-bearing with crutches or a walking boot for 2-4 weeks depending on severity.
- Non-steroidal anti-inflammatory medications like ibuprofen (400-600mg three times daily with food) can help manage pain and inflammation, but their use should be cautious due to potential complications 2.
- Physical therapy should begin after the acute phase to restore range of motion, strength, and proprioception.
- Follow-up imaging may be necessary to ensure proper healing of the growth plate, and MRI or MR arthrography may be useful for evaluating ligamentous integrity and associated injuries 3.
Management
- Functional treatment with an ankle brace or tape is preferred over immobilization, as it allows for protected loading of the damaged tissues and promotes recovery of functional joint stability 4, 5.
- Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment 2.
- The aim of treatment is to reduce long-term injury-associated symptoms and prevent recurrent ankle sprains, and ankle braces should be considered as an efficacious option for prevention 2.
From the Research
Concerns for Lateral Ankle Injuries
The concern for a lateral ankle injury, specifically a Salter-Harris (fracture involving the growth plate) fracture, with involvement of the dorsal, fibular physis, and potential damage to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) includes:
- Premature physeal closure, which can lead to growth disturbances and long-term consequences 6, 7
- Intra-articular incongruence and subsequent degenerative changes 7
- Syndesmotic instability and medial (deltoid ligament) injury 6
- Fibular growth disturbance 6
Diagnosis and Treatment
Diagnosis of lateral ankle injuries in children can be challenging, and the use of magnetic resonance imaging (MRI) can help confirm the presence of a Salter-Harris type I fracture or ligament injuries 8, 9. Treatment variability exists among pediatric orthopaedic surgeons, with some using examination only to distinguish between ankle sprain and Salter-Harris type 1 fracture, while others perform serial radiography or use immobilization techniques such as controlled ankle motion boots or casting 10.
Complications
Complications from lateral ankle injuries can include:
- Distal fibular growth arrest 10
- Infection 10
- Nonunion 10
- Late fracture displacement 10
- Recurrent fracture 10
- Cast complications, such as skin irritation or pressure sores 10
Ligament Injuries
Ligament injuries, such as ATFL and CFL sprains, are common in pediatric lateral ankle injuries and can be associated with radiographically occult fibular avulsion fractures 8, 9. The incidence of ATFL sprains and osteochondral avulsions in patients with suspected Salter-Harris type I fractures of the distal fibula is significant, and these injuries should be taken into consideration in daily practice when ordering radiological examinations and deciding on treatment modalities 9.