Pediatric Fractures

  • Brian B. Carpenter
  • Mitzi L. Williams


Fractures in the foot and ankle region represent greater than 10% of all pediatric fractures. As in the adult population, fractures occur when the skeletal system is exposed to more force than it can withstand. There are differences in the skeletal structure of a child and an adult. This chapter addresses those fractures that are different and treatment recommendations. Due to growth plates, the pediatric skeleton is much more complicated in regard to fractures especially those involving the growth plate. The pediatric skeletal fractures can occur with different/additional mechanisms to that of the adult skeleton secondary to this. Many of the issues with pediatric fractures do not become apparent for months and sometimes years later as they grow and mature. Careful attention must be paid to the immature skeleton in fracture management. Management of the pediatric skeleton is complex, and careful attention must be paid to make an appropriate diagnosis and to provide the appropriate treatment regimen. Inadequate treatment may result in lifelong issues for the patient and affect foot and ankle function. Technical advances have increased the expected levels of outcome in surgical management of pediatric fractures of the foot and ankle.


Salter-Harris Transitional fractures Transitional ankle fractures Pediatric ankle fracture Pediatric foot fracture 


  1. 1.
    Goldring MB. Chondrogenesis, chondrocyte differentiation, and articular cartilage metabolism in health and osteoarthritis. Ther Adv Musculoskelet Dis. 2012;4:269–85.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Löfgren M, Ekman S, Svala E, Lindahl A, Ley C, Skiöldebrand E. Cell and matrix modulation in prenatal and postnatal equine growth cartilage, zones of Ranvier and articular cartilage. J Anat. 2014;225(5):548–68. Scholar
  3. 3.
    Shapiro F, Holtrop ME, Glimcher MJ. Organization and cellular biology of the perichondrial ossification groove of Ranvier: a morphological study in rabbits. J Bone Joint Surg Am. 1977;59:703–23.PubMedCrossRefGoogle Scholar
  4. 4.
    Makarov MR, Dunn SH, Singer DE, Rathjen KE, Ramo BA, Chukwunyerenwa CK, Birch JG. Complications associated with epiphysiodesis for management of leg length discrepancy. J Pediatr Orthop. 2018;38(7):370–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Candela ME, Yasuhara R, Iwamoto M, Enomoto-Iwamoto M. Resident mesenchymal progenitors of articular cartilage. Matrix Biol. 2014;39:44–9. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Schneidmueller D, Bühren V. Verletzungen des Jugendlichen – die Übergangsfraktur Nomenklatur, Diagnostik und Therapie. Trauma Berufskrankh. 2016;18(Suppl 2):101–4.CrossRefGoogle Scholar
  7. 7.
    Lavelle WH, Uhl R, Krieves M, Drvaric DM. Management of open fractures in pediatric patients: current teaching in Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs. J Pediatr Orthop B. 2008;17(1):1–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Crawford AH. Triplane and Tillaux fractures: is a 2 mm residual gap acceptable? J Pediatr Orthop. 2012;32(Suppl 1):S69–73.PubMedCrossRefGoogle Scholar
  9. 9.
    Olgun ZD, Maestre S. Management of pediatric ankle fractures. Curr Rev Musculoskeletal Med. 2018;11(3):475–84.CrossRefGoogle Scholar
  10. 10.
    Landin LA, Danielsson LG. Children’s ankle fractures. Classification and epidemiology. Acta Orthop Scand. 1983;54:634–40.PubMedCrossRefGoogle Scholar
  11. 11.
    Peterson HA, Madhok R, Benson JT, et al. Physeal fractures: part 1. Epidemiology in Olmsted County, Minnesota, 1979–1988. J Pediatr Orthop. 1994;14:423–30.PubMedCrossRefGoogle Scholar
  12. 12.
    Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972;12:275–81.PubMedCrossRefGoogle Scholar
  13. 13.
    Mizuta T, Benson WM, Foster BK, et al. Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop. 1987;7:518–23.PubMedCrossRefGoogle Scholar
  14. 14.
    McHugh MP. Oversized young athletes: a weighty concern. Br J Sports Med. 2010;44:45–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Zonfrillo MR, Seiden JA, House EM, et al. The association of overweight and ankle injuries in children. Ambul Pediatr. 2008;8:66–9.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0–16 years. J Pediatr Orthop. 1990;10:713–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Ertyl JP, Barrack RL, Alexander AH, et al. Triplane fracture of the distal tibial epiphysis. Long term follow up. J Bone Joint Surg Am. 1988;70:967–76.CrossRefGoogle Scholar
  18. 18.
    Eismann EA, Stephan ZA, Mehlman CT, Denning J, Mehlman T, Parikh SN, Tamai J, Zbojniewicz A. Pediatric triplane ankle fractures: impact of radiographs and computed tomography on fracture classification and treatment planning. J Bone Joint Surg Am. 2015;97:995–1002.PubMedCrossRefGoogle Scholar
  19. 19.
    Rapariz JM, Ocete G, González-Herranz P, López-Mondejar JA, Domenech J, Burgos J, Amaya S. Distal triplane fractures: long term follow –up. J Pediatr Orthop. 1996;16(1):113–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Hadad MJ, Sullivan BT, Sponseller PD. Surgically relevant patterns in triplane fractures. J Bone Joint Surg Am. 2018;100:1039–46.PubMedCrossRefGoogle Scholar
  21. 21.
    Cooperman DR, Spiegal PG, Laros GS. Tibial fractures involving the ankle in children. The so called triplane epiphyseal fractures. J Bone Joint Surg Am. 1978;60(8):1040–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Marmor L. An unusual fracture of the tibial epiphysis. Clin Orthop Relat Res. 1970;73:132–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Kärrhom J, Hansson LI, Laurin S. Computed tomography of intraarticular supination-eversion fractures of the ankle in adolescents. J Pediatr Orthop. 1981;1(2):181–7.CrossRefGoogle Scholar
  24. 24.
    Smekal V, Kadletz R, Rangger C, Gföller P. A new type of triplane fracture in 19-year- old snowboarder. J Trauma. 2001;50(1):155–7.PubMedCrossRefGoogle Scholar
  25. 25.
    von Laer L. Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia. J Bone Joint Surg Am. 1985;67(5):687–98.CrossRefGoogle Scholar
  26. 26.
    Denton JR, Fischer SJ. The medial triplane fracture: report of an unusual injury. J Trauma. 1981;21(11):991–5.PubMedCrossRefGoogle Scholar
  27. 27.
    El-Karef E, Sadek HI, Nairn DS, Aldam CH, Allen PW. Triplane fracture of the distal tibia. Injury. 2000;31(9):729–36.PubMedCrossRefGoogle Scholar
  28. 28.
    Peiró A, Aracil J, Martos F, Mut T. Triplane distal tibial epiphyseal fracture. Clin Orthop Relat Res. 1981;(160):196–200.Google Scholar
  29. 29.
    van Laarhoven CJ, van der Werken C. ‘Quadriplane’ fracture of the distal tibia: a triplane fracture with a double metaphyseal fragment. Injury. 1992;23(7):497–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Salter R, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963;45(3):587–622.CrossRefGoogle Scholar
  31. 31.
    Ogden JA. Skeletal growth mechanism injury patterns. J Pediatr Orthop. 1982;2(4):371–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Mubarak SJ. Extensor retinaculum syndrome of the ankle after injury to the distal tibial physis. J Bone Joint Surg Br. 2002;84:11–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Haumont T, Gauchard GC, Zabee L, Arnoux J-M, Journeau P, Lascombes P. Extensor retinaculum syndrome after distal tibial fractures: anatomical basis. Surg Radiol Anat. 2007;29:303–11.PubMedCrossRefGoogle Scholar
  34. 34.
    Stefanich RJ, Lozman J. The juvenile fracture of Tillaux. Clin Orthop Relat Res. 1986;210:219–27.Google Scholar
  35. 35.
    Manderson EL, Ollivierre CO. Closed anatomic reduction of a juvenile Tillaux fracture by dorsiflexion of the ankle. A case report. Clin Orthop Relat Res. 1992;276:262–6.Google Scholar
  36. 36.
    Kärrhom J, Hansson LI, Selvik G. Changes in tibiofibular relationships due to growth disturbances after ankle fractures in children. J Bone Joint Surg Am. 1984;66:1198–210.CrossRefGoogle Scholar
  37. 37.
    Chung T, Jaramillo D. Normal maturing distal tibia and fibula: changes with age at MR imaging. Radiology. 1995;194:227–32.CrossRefGoogle Scholar
  38. 38.
    Anderson M, Green W, Messner M. Growth and predictions of growth in the lower extremities. J Bone Joint Surg. 1963;45A:1–14.CrossRefGoogle Scholar
  39. 39.
    Menelaus MB. Correction of leg length discrepancy by epiphyseal arrest. J Bone Joint Surg. 1966;48-B:336–9.CrossRefGoogle Scholar
  40. 40.
    Moseley CF. A straight- line graph for leg length discrepancies. J Bone Joint Surg. 1977;59-A:174–9.CrossRefGoogle Scholar
  41. 41.
    Paley D, Bhave A, Herzenberg JE, et al. Multiplier method for predicting limb length discrepancy. J Bone Joint Surg. 2000;82-A:1432–46.CrossRefGoogle Scholar
  42. 42.
    Kling TF, Bright RW, Hesinger RN. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. 1984;66:647–57.PubMedCrossRefGoogle Scholar
  43. 43.
    Luhmann SJ, Oda JE, O’Donnell J, Keeler KA, Schoenecker PL, Dobbs MB, et al. An analysis of suboptimal outcomes of medial malleolus fractures in skeletally immature children. Am J Orthop. 2012;41:113–6.PubMedGoogle Scholar
  44. 44.
    Caterini R, Farsetti P, Ippolito E. Long term follow up of physeal injury to the ankle. Foot Ankle. 1991;11:372–83.PubMedCrossRefGoogle Scholar
  45. 45.
    Leary JT, Handling M, Talerico M, Yong L, Bowe JA. Physeal fractures if the distal tibia predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop. 2009;29:356–61.CrossRefPubMedGoogle Scholar
  46. 46.
    Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of the two hundred and thirty-seven cases in children. J Bone Joint Surg Am. 1978;60:1046–50.PubMedCrossRefGoogle Scholar
  47. 47.
    Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23:733–9.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Choudhry IK, Wall EJ, Eismann EA, Crawford AH, Wilson L. Functional outcome analysis of triplane and Tilleaux fractures after closed reduction and percutaneous fixation. J Pediatr Orthop. 2014;34:139–43.PubMedCrossRefGoogle Scholar
  49. 49.
    Peterson HA. Metallic implant removal in children. J Pediatr Orthop. 2005;25(1):107–15.PubMedGoogle Scholar
  50. 50.
    Bransby-Zachary MA, MacDonald DA, Singh I, et al. Late fracture associated with retained internal fixation. J Bone Joint Surg Br. 1989;71:539.PubMedCrossRefGoogle Scholar
  51. 51.
    Kahle WK. The case against routine metal removal. J Pediatr Orthop. 1994;14:229–37.PubMedCrossRefGoogle Scholar
  52. 52.
    Labosky DA, Cermak MB, Waggy CA. Forearm fracture plates: to remove or not to remove. J Hand Surg Am. 1990;15:294–301.PubMedCrossRefGoogle Scholar
  53. 53.
    Müller ME, Allgöwer M, Schneider R, et al. Manual of internal fixation techniques recommended by the AO Group. 2nd ed. (English translation by J Schaatzker). Berlin: Springer; 1979. p. 148–53.CrossRefGoogle Scholar
  54. 54.
    Rosson JW, Petley GW, Shearer JR. Bone structure after removal of internal fixation plates. J Bone Joint Surg Br. 1991;73:65–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Charlton M, Costello R, Mooney JF III, et al. Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia. J Pediatr Orthop. 2005;25(5):635–40.PubMedCrossRefGoogle Scholar
  56. 56.
    Keles-Celik N, Kose O, Sekerci R, Aytac G, Turan A, Güler F. Accessory ossicles of the foot and ankle: disorders and a review of the literature. Cureus. 2017;9(11):e1881. Published 2017 Nov 26. Scholar
  57. 57.
    Kruppa C, Snoap T, Sietsema DL, Schildhauer TA, Dudda M, Jones CB. Is the midterm Progress of pediatric and adolescent talus fractures stratified by age? J Foot Ankle Surg. 2018;57(3):471–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Smith JT, Curtis TA, Spencer S, Kasser JR, Mahan ST. Complications of Talus fractures in children. J Pediatr Orthop. 2010;30(8):779–84.PubMedCrossRefGoogle Scholar
  59. 59.
    Meier R, et al. Fractures of the talus in the pediatric patient. Foot Ankle Surg, [s l]. 2005;11:5–10.CrossRefGoogle Scholar
  60. 60.
    Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. 1970;52(5):991–1002.PubMedCrossRefGoogle Scholar
  61. 61.
    Canale ST, Kelly FB. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg Am. 1978;60(2):143–56.PubMedCrossRefGoogle Scholar
  62. 62.
    Polyzois VD, Vasiliadis E, Zgonis T, Ayazi A, Gkiokas A, Beris AE. Pediatric fractures of the foot and ankle. Clin Podiatr Med Surg. 2006;23:241–55.PubMedCrossRefGoogle Scholar
  63. 63.
    Metzger MJ, Levin JS, Clancy JT. Talar neck fractures and rates of avascular necrosis. J Foot Ankle Surg. 1999;38:154–62. Scholar
  64. 64.
    Mora S, Thordarson DB, Zionts LE, Reynolds RA. Pediatric calcaneal fractures. Foot Ankle Int. 2001;22(6):471–477.CrossRefGoogle Scholar
  65. 65.
    Petit CJ, Lee BM, Kasser JR, Kocher MS. Operative treatment of intraarticular calcaneal fractures in the pediatric population. J Pediatr Orthop. 2007;27(8):856–62.PubMedCrossRefGoogle Scholar
  66. 66.
    Knijnenberg LM, Dingemans SA, Schepers T, Terra MP, Struijs PAA, Schep NWL. Radiographic anatomy of the pediatric lisfranc joint. J Pediatr Orthop. 2018;38(10):510–3.PubMedCrossRefGoogle Scholar
  67. 67.
    Wilson DW. Injuries of the Tarso-metatarsal joints. J Bone Joint Surg. 1972;54-B:677–86.CrossRefGoogle Scholar
  68. 68.
    Buoncristiani AM, Manos RE, Mills WJ. Plantar-flexion tarsometatarsal joint injuries in children. J Pediatr Orthop. 2001;21:324–7.PubMedGoogle Scholar
  69. 69.
    Bloome D, Clanton T. Treatment of Lisfranc injuries in the athlete. Tech Foot Ankle Surg. 2002;1:94–101.CrossRefGoogle Scholar
  70. 70.
    Hill JF, Benton EH, Lierhaus A, Kocher MS, Mahan ST. Lisfranc injuries in children and adolescents. J Pediatr Orthop B. 2017;26:159–63.PubMedCrossRefGoogle Scholar
  71. 71.
    Singer G, Cichocki M, Schalamon J, Eberl R, Höllwarth ME. J Bone Joint Surg A. 2008;90(4):772–6.CrossRefGoogle Scholar
  72. 72.
    Southey ER, Soares-Weiser K, Kleijnen J. Systematic review and meta-analysis of the clinical safety and tolerability of ibuprofen compared with paracetamol in pediatric pain and fever. Curr Med Res Opin. 2009;25(9):2207–22.PubMedCrossRefGoogle Scholar
  73. 73.
    Vetter TR, Heiner EJ. Intravenous Ketorolac as an adjuvant to pediatric patient controlled analgesia with morphine. J Clin Anesth. 1994;6(2):110–3.PubMedCrossRefGoogle Scholar
  74. 74.
    Akbarnia BA, Akbarnia NO. The role of orthopedist in child abuse and neglect. Orthop Clin North Am. 1976;7(3):733–42.PubMedGoogle Scholar
  75. 75.
    Schmitt BD. Current pediatric roles in child abuse and neglect. Am J Dis Child. 1979;133(7):691–6.PubMedGoogle Scholar
  76. 76.
    Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Brian B. Carpenter
    • 1
  • Mitzi L. Williams
    • 2
    • 3
  1. 1.Department of OrthopaedicsThe University of North Texas Health Science CenterFort WorthUSA
  2. 2.Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatric SurgeryKaiser PermanenteOaklandUSA
  3. 3.Pediatry Institute Faculty Member, American Academy of Foot and Ankle, OsteosynthesisOaklandUSA

Personalised recommendations