Epiphyseal injuries of the foot and ankle

A thorough knowledge of functional growth plate anatomy and physiology is essential to proper management of epiphyseal foot and ankle injuries. The ability to classify foot and ankle fractures according to the Salter-Harris anatomic and radiographic classification provides useful prognostic information that may affect treatment. The Dias-Tachdjian mechanistic classification system for pediatric ankle fractures provides useful information about the extent of osseous and soft tissue injury and the best method of closed reduction and correlates well with the Lauge-Hansen system, which is widely used for adult ankle fractures. Most epiphyseal foot fractures involve the metatarsals or phalanges and can usually be managed with closed reduction. Considerable spontaneous correction of deformity can be expected in the younger child (under age 10 years), but one should be aware that sagittal plane and rotational malalignment of the metatarsal heads may cause significant problems. Salter-Harris type I and II fractures of the ankle can usually be managed with closed reduction. Salter-Harris type III and IV ankle fractures with greater than 2 mm of displacement require open reduction and internal fixation. One must also have a high index of suspicion for juvenile Tillaux and triplane transitional fractures that may not be obvious on plain radiographs. Although these fractures usually do not produce significant limb-length discrepancies, they are intra-articular fractures and ankle joint arthritis can result. Finally, younger children (under age 10 years) have a better prognosis for spontaneous correction of nongrowth arrest-induced deformities but a much poorer prognosis with growth arrest injuries than do older children, in whom growth arrest does not usually cause a significant problem. All children with growth plate injuries should be followed at regular intervals for at least 2 years or to skeletal maturity in the case of physeal disturbance. Treatment of epiphyseal fractures of the foot and ankle must be individualized but should always be based upon a thorough knowledge of anatomy, bone growth physiology, classification, potential pitfalls, and prognosis.