SLR - December 2020 - Aseem Saini

Functional Outcomes of Unstable Ankle Fractures in Adolescents

Reference: Lurie, Benjamin M. BA*; Bomar, James D. MPH†; Edmonds, Eric W. MD, FAOA†; Pennock, Andrew T. MD†; Upasani, Vidyadhar V. MD† J Pediatr Orthop 2020 Aug;40(7):e572-e578. 

Level of Evidence: Level III

Scientific Literature Review 

Reviewed By: Aseem Saini, DPM
Residency Program: John Peter Smith Hospital – Fort Worth, TX

Podiatric Relevance: Currently, there is a substantial amount of published literature that has investigated the differences in functional outcomes of adult ankle fractures treated with open reduction and internal fixation (ORIF) versus closed reduction with casting. Despite this, there remains little literature regarding the functional outcomes of similar ankle fractures in the pediatric population. As so, there is no current consensus regarding optimal treatment for pediatric ankle fractures.

Methods: A retrospective review was used to review pediatric patients who had sustained Lauge-Hansen SER 4 and PER 3/ 4 ankle fractures. A total of 67 patients were reviewed in this study. If a patient was determined to have anatomic reduction of the fracture and syndesmosis after initial closed reduction, surgery was not pursued. Small avulsion fractures of the posterior malleolus were not fixated in any patients. Repair of the deltoid ligament was not a part of the treatment protocol for any patient in this study. The syndesmosis was fixated with either a suture button or syndesmotic screw as determined by lateral translation of the fibula during intraoperative hook/Cotton testing. Two millimeters of displacement of the fibula during intraoperative stress testing was an indication to pursue syndesmotic repair. Functional outcomes were determined by ADL and FAAM scores. Only patients who had data one year after initiation of treatment were included in this study.

Results: A total of 67 adolescents were included in the study. The mean follow up time in this study was 52.3 ± 24.8 months. 56 patients were treated operatively with ORIF, while 11 patients (all of whom had SER fractures) were managed by closed reduction and serial castings. No major surgical complications were appreciated. Both SER and PER fractures had similar FAAM and ADL scores, without any statistically significant differences noted. Fractures that required syndesmotic repair had similar FAAM and ADL scores as fractures that did not necessitate syndesmotic repair. With respect to the outcomes of surgically and non-surgically treated SER fractures, both groups were found to have similar FAAM and ADL scores.

Conclusions: There is scant literature currently published on the functional outcomes of surgically and non-surgically treated SER and PER fractures in the pediatric population. The findings of this study suggest that there are similar functional outcomes in pediatric patients who are treated with ORIF versus casting after initial closed anatomic reduction of SER ankle fractures. The paper also suggests that there is no functional difference in patients who sustain medial malleolus fractures and frank ruptures of the deltoid ligament. Pediatric fracture dislocations of the ankle joint had similar functional outcomes to pediatric fractures without dislocation, which is in stark contrast to data that has been published in adult populations. In adults, several studies have demonstrated that ankle fracture dislocations tend to have less favorable functional outcomes than ankle fractures without dislocations. Future larger scale studies with greater stratification of fracture types would be helpful in guiding management of pediatric ankle fractures.

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