Boutis Kathy, Narayanan Unni G, Dong Frederik F T, Mackenzie Heather, Yan Hanmu, Chew Derek, Babyn Paul
Division of Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
Injury. 2010 Aug;41(8):852-6. doi: 10.1016/j.injury.2010.04.015. Epub 2010 May 21.
In skeletally immature children, isolated lateral ankle injuries without radiograph-visible fractures are often diagnosed with Salter-Harris I fractures of the distal fibula (SH1DF). However, recent magnetic resonance imaging (MRI) evidence in children suggests that sprains may be more common than previously thought. Thus, the main objective of this study was to determine the rate of MRI-confirmed SH1DF among cases where this diagnosis was made presumptively, based on clinical findings. In ankle injuries where there is no MRI evidence of SH1DF, another aim is to detect the pathology which gives rise to this clinical scenario.
This was a prospective cohort study performed at a tertiary care paediatric centre. Eligible patients included skeletally immature children with acute ankle injuries presenting with difficulty weight bearing and maximal tenderness and swelling over the distal fibular growth plate (lateral malleolus). Enrolled patients had ankle radiographs at the Emergency Department (ED) visit, MRI within 1 week of the injury, and repeat ankle X-rays at 4 weeks. All images were reviewed by two radiologists and an orthopaedic surgeon. Discrepancies between reading physicians were resolved by consensus agreement.
Eighteen patients were enrolled into the study from September 2008 to August 2009. Mean (SD) age of participants was 8.7 (2.0) years. None of the 18 patients had evidence of fibular growth plate injury on MR imaging. Patients often had more than one abnormal finding on MRI. Fourteen (78%) had evidence of ligamentous sprains, 11 (61%) had bony contusions, one patient (6%) had a subtle fibular avulsion fracture, and another was found to have a minor articular cartilage injury. At 4 weeks, only one patient's radiographs demonstrated a healing fracture, which corresponded with the avulsion fracture case. All patients had returned to full weight bearing by 4 weeks.
In this series, the clinical diagnosis of SH1DF was incorrect in 100% of cases. Instead, in almost 90% of these patients, MRI identified ligamentous sprains and/or bony contusions. These results may influence the way children who present with this common clinical scenario are managed since the vast majority of children in this study actually had sprain/contusion injuries and none had SH1DF.
在骨骼未成熟的儿童中，无X线可见骨折的单纯外侧踝关节损伤常被诊断为远端腓骨的Salter-Harris I型骨折（SH1DF）。然而，近期针对儿童的磁共振成像（MRI）证据表明，扭伤可能比之前认为的更为常见。因此，本研究的主要目的是确定在基于临床发现而初步诊断为SH1DF的病例中，MRI确诊的SH1DF的发生率。在无SH1DF的MRI证据的踝关节损伤中，另一个目的是检测导致此临床情况的病理改变。
这是一项在三级儿科医疗中心进行的前瞻性队列研究。符合条件的患者包括骨骼未成熟、急性踝关节损伤且存在负重困难以及远端腓骨生长板（外踝）处有最大压痛和肿胀的儿童。入选患者在急诊科就诊时进行踝关节X线检查，受伤后1周内进行MRI检查，并在4周时复查踝关节X线。所有图像由两名放射科医生和一名骨科医生进行评估。阅片医生之间的分歧通过达成共识来解决。
2008年9月至2009年8月期间，18名患者纳入本研究。参与者的平均（标准差）年龄为8.7（2.0）岁。18名患者中，没有一人在MRI上有腓骨生长板损伤的证据。患者在MRI上常常有不止一项异常发现。14例（78%）有韧带扭伤的证据，11例（61%）有骨挫伤，1例患者（6%）有轻微的腓骨撕脱骨折，另有1例被发现有轻微的关节软骨损伤。在4周时，只有1例患者的X线片显示骨折愈合，这与撕脱骨折病例相符。所有患者在4周时均恢复了完全负重。
在本系列研究中，SH1DF的临床诊断在所有病例中均不正确。相反，在几乎90%的这些患者中，MRI发现了韧带扭伤和/或骨挫伤。这些结果可能会影响对此常见临床情况的儿童的处理方式，因为本研究中的绝大多数儿童实际上患有扭伤/挫伤，而无人患有SH1DF。
