Pediatric Ankle Fractures: When to Operate and When to Leave Alone?

Ankle fractures are a common pediatric orthopaedic injury and are the second most common site of physeal injury after the distal radius. Concerns regarding these injuries include the risk of premature physeal closure and intra-articular incongruence with subsequent degenerative changes. Salter-Harris type I and II injuries have high rates of premature physeal closure especially in those with a physeal gap greater than 3 mm and pronation-abduction injuries. The authors of this chapter recommend surgical management if acceptable alignment cannot be obtained with closed reduction. A residual physeal gap is not an appropriate sole indicator for surgical management. Salter-Harris type III and IV injuries also have high rates of premature physeal closure and can result in articular incongruence given their intra-articular nature. The authors of this chapter recommend surgical management of these fractures when intra-articular displacement is greater than 2 mm. Transitional fractures (ie, Tillaux and triplane) occur in older patients during distal tibial physeal closure. Fracture lines travel through the relatively weaker lateral tibial physis, which is the last to close in the transitional period. These intra-articular fractures with displacement greater than 2 mm should be managed surgically to anatomically reduce the articular surface and prevent early degenerative changes.