Figure 22b. 2, Radiologic Clinics of North America, Vol. Study these images. Because the midtarsal talonavicular and calcaneocuboid joints act in unison, they are often injured together (10). The supinationplantar flexion mechanism (Fig 10) is the least common of the Dias-Tachdjian ankle fracture patterns and involves a displaced physeal fracture of the distal tibia without any associated fibular fracture. The case shows superior extensor retinaculum injury, grade I injuries of lateral ankle ligaments, and avulsion fracture of the anterior calcaneal process. If the force is high enough, the medial malleolus can be pushed away as it were (= vertical fracture) by the rotating talus (stage II) (fig. There is no associated syndesmotic widening. The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops (stage I). More recently, such fractures have been described in association with trampoline activity, especially multioccupant trampoline use (32). Unable to process the form. Lateral. With this classification, each injury type is assigned a prognostic significance. 2, Radiologic Clinics of North America, Vol. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails An associated spiral fracture of the fibular shaft (arrowhead) also is present. Juvenile Tillaux fracture caused by a wrestling injury in a 15-year-old boy. Up to 22% of all MT fractures involve the base of the MT bone, and 90% of these injuries occur in children older than 10 years (33). 3. Figure 10b. Although the mean age at which the tibiofibular overlap appeared on the AP view was 5 years in both boys and girls, this overlap appeared on the mortise view in girls at a mean age of 10 years and in boys at a mean age of 16 years (15). Small bone fragment at the inferior portion of the lateral malleolus is consistent with an avulsed fracture. No other fractures were seen. Figure 20. Schmidt and Weiner (49) modified the Essex-Lopresti (52) classification of calcaneal fractures for use in children and included compound fractures secondary to lawn mower injuries (4,33). Enter your email address below and we will send you the reset instructions. Weber B is the most common ankle fracture accounting for 60-70% of all ankle fractures. The normal anatomy of the distal tibia (A), as well as type I (B), type II (C), type III (D), type IV (E), and type V (F) Salter-Harris fractures, are depicted. The fracture line then propagates horizontally along the patent physis until it meets the fused physis; at this point, it proceeds through the epiphysis into the joint. Below is an example of a supination-exorotation trauma (fig. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. Weber B and Weber C fractures are very different in the type of fibula fracture. It can occur at numerous sites in the body, but some areas are more sensitive to these types of fractures than others, such as at the ankle which mostly occurs at the lateral aspect of the medial malleolus or in the foot where avulsion fractures are common at the base of the fifth metatarsal, but also at the talus and calcaneus. II. Since they are generally the result of external rotation and abduction, they are almost always seen in association with other fractures and ligamentous injuries at the ankle joint. This type of injury is termed Chopart fracture-dislocation and usually occurs after a fall from a height, motor vehicle accident, or severe twisting sports injury, with fractures of the navicular, cuboid, and calcaneus bones and/or dislocation of the talonavicular joint. This is a normal developmental variant; there is no associated soft-tissue swelling. Figure 12. Figure 21. Associated neurovascular compromise may be present. In the same study (75), fractures of the second, third, and fourth MT bones were frequently found to be associated with fractures of another MT bone (Fig 22), whereas the majority of the first and fifth MT bone fractures were isolated. Tibiotalar dislocation in a 14-year-old girl that occurred after a trampoline injury. (b) Volume-rendered CT image in a different patient with a similar injury pattern more clearly depicts a posterior fracture fragment. The right image shows a vertical fracture of the medial malleolus (arrow). This fracture configuration is characteristic of nonaccidental trauma. And just like in a Weber B, you can get injury to the anterior syndesmosis, fibula and finally the posterior syndesmosis. https://radiopaedia.org/articles/weber-classification-of-ankle-fractures Among these rare injuries, fractures to the talar neck, as classified by Hawkins (Table 4) (57,58), are the most common. Figure 14c. In their classification system, type I fractures are characterized by a narrow fracture line and no intramedullary sclerosis, type II fractures have a wider fracture line with evidence of intramedullary sclerosis, and type III fractures are characterized by complete obliteration of the medullary cavity by sclerotic bone. CT is useful for assessment of comminuted fractures and small fractures of the anterior process, and for surgical planning. Anatomic variants and developmental phenomena can mimic or obscure the diagnosis of osseous and ligamentous trauma in skeletally immature patients (Fig 25). The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. Fractures of the posterior tibial tubercle should not be confused with fractures of the posterior articular margin (posterior malleolus), which have a worse prognosis. A group of distal tibial metaphyseal fractures in very young children are pathognomonic for nonaccidental trauma. Associated injury to the peroneus longus tendon may be present. A Salter-Harris type I physeal fracture passes along the width of the physis and may be visible at radiography if the growth plate is widened or the epiphyseal and metaphyseal components are malaligned. These articulations act in unison and thus are often injured together. Drawings illustrate various calcaneal fracture patterns in children. Bony avulsion from anterior calcaneal process at the bifurcate ligament attachment site. Tibiotalar Dislocation.Pure ankle dislocation without fracture (Fig 14) is a rare injury in skeletally immature children due to the vulnerability of the physes, which fail before the more robust surrounding ligamentous structures do (44). Intra-articular displacement (double-headed arrow) of 3 mm is seen. Stage III: rupture of interosseous membrane + high fibular fracture. The patients skeletal maturity must be considered in treatment decisions. https://www.physio-pedia.com/Avulsion_Fractures_of_the_Ankle Findings on standard nonweight-bearing radiographs of the foot (not shown) were unremarkable. Better predictor of damage to the syndesmosis. 22): Note: this trauma mechanism is also seen in Weber B fractures. A Salter-Harris type IV fracture extends from the metaphysis to the epiphysis. 15). Swelling and ecchymosis over the cuboid should raise suspicion of this injury and when other midfoot injuries are present , the cuboid articulations should be carefully inspected for subtle injury. Toe Fractures.Phalangeal fractures account for up to 18% of all foot fractures and are most commonly Salter-Harris type I or type II injuries. This complication has been found to correlate positively with high-energy mechanisms of trauma (83), significant initial displacement, and multiple attempts at closed reduction (24). AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. 1950;60(5):957-85. Post-traumatic arthritis has been reported in ~15% of patients despite an anatomic reduction, likely due to chondral injury 7. In this lecture we present a simple algoritm that helps you to find: The algoritm is based on the Weber-classification, because it is simple and everybody knows it. The fracture was not detected on the antero-posterior (AP) view of ankle (Fig. The two differences between Weber B and C are: Sometimes we are lucky, because the fibula fracture is visible on the x-rays of the ankle.Then we know we are looking at an unstable stage 3 weber C fracture. (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). This information is intended to supplement radiologists understanding of developmental phenomena, anatomic variants, fracture patterns, and associated complications that affect the pediatric foot and ankle. The Lisfranc ligament connects the plantar base of the second MT bone to the plantar surface of the medial cuneiform bone (8). Table 6: Fractures Amenable to Conservative Treatment, Table 7: Indications for Surgical Management of Fractures. Stage I: rupture of medial collateral ligament and/or fracture of medial malleolus. Fracture immobilization can also cause hyperemia and disuse subchondral lucency. Swelling. Ossification of the lateral distal tibial metaphysis leads to the creation of two separate lines on the AP and mortise views. ADVERTISEMENT: Supporters see fewer/no ads. Most (86%) ankle ligament tears are midsubstance; thus, only 14% are avulsion injuries. Unable to process the form. Due to the pronation there is enormous stress on the medial collateral bands and thats where the injury will start with either a band rupture or an avulsion of the medial malleolus (stage 1). (a) Axial radiograph of the right calcaneus bone in a 16-year-old boy who jumped from a 1015-fthigh window shows an obliquely oriented linear fracture extending through the calcaneus bone (arrows). (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. The injury mechanism is generally categorized as plantar flexion with inversion. This is always stage 2 and is unstable, whether you see a fracture of the lateral malleolus or not. Tibiofibular syndesmosis is intact/partial rupture. It means that there already is stage 1, because the trauma mechanism always follows this strict order, first stage 1 and then stage 2. Lateral Ankle Sprain may be associated with: ankle dislocation, distal lateral malleolar avulsion or spiral fracture, medial malleolar fracture, talar neck or medial compression fractures. No other fractures were seen. Drawing illustrates the Salter-Harris classification of growth plate fractures at the distal tibia. {"url":"/signup-modal-props.json?lang=gb\u0026email="}, Patel M, Ankle extensor retinaculum and lateral ligaments injuries - ultrasound. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, All ankle fractures, even the ones that are not visible on the X-rays, Predict rupture of ligaments even if you cant see them on the images, Determine whether the ankle is stable or unstable, just by looking at the radiographs. These classification systems aid in diagnosis and treatment planning, facilitate communication, and help standardize documentation and research. An x-ray does not exclude ligament damage. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-97259. Dias-Tachdjian pronationexternal rotation ankle fracture in a 13-year-old boy who was involved in an all-terrain vehicle accident. (a) Lateral radiograph of the ankle of a 14-year-old boy after a twisting injury to the right ankle shows a subtly widened anterior physis at the distal tibia with a posteriorly based Thurston-Holland fragment (arrow). Both the tibiofibular overlap on AP and mortise views and the relative fibular width on AP views increase with age. Since the fibula fracture is already stage 3, we wanna look for: The mechanism of a Weber C is a result of a position of the foot in pronation with an exorotation force applied by the foot and that is why Lauge-Hansen calls it pronation exorotation (PER). This is a stage 2 - unstable bimalleolar Weber A fracture. And finally in stage 4 there will be a rupture of the posterior syndesmosis or tertius avulsion (stage 4). An approach to reading an ankle radiograph can be read here. (a) AP weight-bearing radiograph of the foot shows a very subtle step-off (arrow) between the intermediate cuneiform bone and second MT bone, which was not visible on the nonweight-bearing views. Calcaneal fractures observed on CT images have been divided into intra- and extra-articular fractures on the basis of the involvement of the posterior facet of the subtalar joint (Fig 15) (48). Stage I supination-adduction fracture. Fixation of distal fibula using plate osteosynthesis. (b) Accompanying lateral radiograph shows the dislocation at the tibiotalar joint to be posterior. Ogden (53) modified the Rowe et al (54) calcaneal fracture classification system, and Sanders et al (55) classified calcaneal fractures on the basis of their CT appearances. This phenomenon results in muscle weakness and diminished sensation in the first web space (85). Closed reduction should be attempted for displaced fractures. MT Fractures.MT fractures are common. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. Other toe fracture types include shaft and tuft fractures. As in each 1, The Journal of Foot and Ankle Surgery, Vol. Since the Weber-classification is a simplification of the Lauge-Hansen classification, it will help you to understand the different stages of Lauge-Hansen. Fractures of the body tend to occur in the sagittal and horizontal planes after major trauma such as a motor vehicle collision. Most other physeal closures start centrally and expand peripherally. Below is an example of a pronation-exorotation fracture (fig. Any pain or soft tissue swelling on the medial side can be a first indication that we are dealing with a Weber C fracture. Ligament damage may be inferred by an abnormal configuration of the ankle fork. (b) Mortise radiograph of the ankle in an 11-year-old boy shows a slight decrease in the medial clear space (black arrow), a narrowed tibiofibular interval (single-headed white arrow) with no overlap yet seen, and a slightly widened distal fibula (double-headed arrow). A conservative approach involves appropriate immobilization and protected weight bearing, with serial follow-up radiographs obtained to exclude late displacement in the cast. After sudden, severe pain, the most common symptoms of avulsion fractures include: Bruising. Provides insight into the trauma mechanism. Foot radiograph findings were unremarkable. Figure 21. Although calcaneocuboid dislocation is generally less severe compared with talonavicular dislocation, it typically involves severe lateral joint space widening and comminuted calcaneus and cuboid fractures (64). 2007;458:40-1. Since the fibula fracture in a Weber C is most commonly not visible on the x-rays of the ankle, this can be a tough question to answer.We will have to look for additional findings that lead us to the right answer and that will help us to make the decision to do additional images. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. Results following the anatomic reduction of a displaced ankle fracture are good. Distal tibial physeal closure occurs in a unique eccentric pattern (Fig 1) over a period of 18 months, typically between 12 and 15 years of age in girls and between 14 and 18 years of age in boys. Findings at presentation include pain, swelling, inability to bear weight, and possibly medial plantar ecchymosis. Figure 15a. An avulsion of the fibular attachment is even more rare. Viewer, http://www.cdc.gov/arthritis/basics/risk-factors.htm, Acute Fractures and Dislocations of the Ankle and Foot in Children, Pitfalls in MRI of the Developing Pediatric Ankle, Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings, Imaging Review of Normal and Abnormal Skeletal Maturation, Imaging of Sports-related Injuries of the Lower Extremity in Pediatric Patients, Imaging of Acute Capsuloligamentous Sports Injuries in the Ankle and Foot: Sports Imaging Series, Pediatric Foot and Ankle Fractures: Patterns, Mimics, Complications, and Treatment, Dancing Feet: Biomechanism and Imaging Findings of Foot and Ankle Musculoskeletal Injuries in Dancers, Painful Corners of the Ankle: Keeping an Eye on the Periphery. Open fractures are rare, accounting for just 2% of all ankle fractures. Clin Orthop Relat Res. Foot radiograph findings were unremarkable. Disruption of the tibiofibular joint seen on static radiographs signifies syndesmotic injury. Trauma mechanism of supination-adduction according to Lauge-Hansen. Table 2: Salter-Harris Classification of Physeal Fractures. In Weber C finding a high fibula fracture means unstable stage 3. It allows the website owner to implement or change the website's content in real-time. 2015;205(5):1061-7. A Salter-Harris type IV fracture of the medial distal tibia (arrow) with a medial Thurston-Holland fragment and some associated comminution also is seen. (b) Findings on the sagittal CT image of the left ankle confirm partial physeal fusion at the distal tibia (arrows). Salter-Harris type III fracture of the distal tibia in a 13-year-old boy. References Ng J, Rosenberg Z, Bencardino J, Restrepo-Velez Z, Ciavarra G, Adler R. US and MR Imaging of the Extensor Compartment of the Ankle. The delayed diagnosis of extra-articular calcaneal fractures (50) has been reported. The closure of most physes begins centrally and expands peripherally. Lisfranc injury in a 17-year-old high school football player, which occurred after another player fell on the back of his heel, causing hyperflexion of his midfoot. Subsequent computed tomography (CT) of the foot confirmed the presence of a minimally displaced, predomi-nately coronal oriented avulsion fracture through the APC (Fig. Primary tibial and fibular ossification is present at birth (11). Hawkins type II displaced talar neck fracture in a 15-year-old girl with left ankle deformity, ecchymosis, and swelling after she fell from an aerial cheerleading spin and landed on her left leg. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails to tear during an injury. Since repeated attempts at closed reduction can result in physeal damage, they should be performed with caution. When you see a Weber B fracture, which is always good visible on either the AP- or the lateral view, the only thing you need to check is whether there is an unstable stage 3 with posterior injury or even stage 4 with medial injury. Radiographics. Owing to fracture obliquity, radiography might not enable these fractures to be assessed completely and CT may be required. 27, No. These dislocations are predominantly posteromedial and associated with disruption of the lateral capsular ligamentous complexes and the fibular physis in children (33). Note: in the 2 most severe forms (= stage III and IV), there is ligament damage and/or fracture.PTFL = posterior tibiofibular ligament. Dias-Tachdjian supinationplantar flexion ankle fractures. 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