THE NATURAL HISTORY OF TYPE VII ALL INTRA-EPIPHYSEAL FRACTURES OF THE LATERAL MALLEOLUS

James G. Gamble; Michelle T. Sugi; Kalie Tileston

摘要

Background: Inversion-type ankle injuries are common in pediatric athletes, often resulting in lateral malleolar fractures (1). Ogden described the Type VII lateral malleolar physeal fracture as an injury in which the fracture line is totally within the secondary ossification center of the distal fibular epiphysis (2). The purpose of this paper is to report on the outcomes of 31 children participating in various types of sports activities who had sustained a Type VII fracture of the lateral malleolus. Methods: Here we report the results of an IRB approved prospective (longitudinal) cohort study carried out at a tertiary care pediatric hospital from March 2012 to December 2017. Eligible patients were those with a type VII (all epiphyseal) fracture of the lateral malleolus, either treated initially or seen in follow-up by the senior author. Exclusion criteria included those patients with all other lateral malleolar injuries and those with negative radiographs. Thirty-one children were enrolled during the study interval. Type VII fractures were classified as either transverse, oblique, or tip avulsion, depending on the trajectory and location of the fracture line within the secondary center of ossification of the lateral malleolus. We recorded the following demographic data: sex of the patient, age at the time of injury, mechanism of injury, sport involved, weight bearing status at the time of injury, treatment of the injury, and time from injury to release to sports activity. Children were permitted to return to sports when they had no discomfort on palpation and an ankle range of motion was equal to the uninvolved side. The primary outcome focus was radiographic status of the fracture at the time of the last clinical evaluation. Results: Thirty-one children with a Type VII fracture of the lateral malleolus were enrolled during the study interval. There were 8 girls and 23 boys. The average age at the time of injury was 107 months (?9 years.) All the children had sustained a supination inversion-type injury while participating in a full spectrum of sports activities. Twenty-five children were initially unable to bear weight, and 6 could walk but with a limp. Twenty-six children were treated with a weight-bearing cast and crutches, and five of those who could bear weight were treated with a cast boot. Four fractures were oblique, 8 were transverse, and 19 were tip avulsions. All the children were asymptomatic and had a negative drawer test when cleared for sports participation at an average time of 3.5 months (range 2.5 to 4) after injury. Eighteen children had radiographs showing uneventful healing of the fractures (Figure 1) when released to full activity, but 13 (31%) healed with formation of a discrete os subfibulare (Figure 2.) The 18 fractures that healed uneventfully were located above the distal third of the fibular epiphysis. All of the 13 that healed with an os subfibulare were located either at the distal tip of the fibula (4) or at the anterior distal aspect of the tip (9) corresponding to the area of attachment of the ATFL. Conclusions: All of children sustaining a Type VII fracture of the lateral malleolus were able to return to full sports activities. Eighteen of the 31 Type VII fractures (58%) healed uneventfully. However, 13 (42%), healed with the formation of an os subfibulare. Since the presence of an os subfibulare has been associated with recurrent ankle instability and pain (3), it may be prudent to observe and even recommend ankle rehabilitation exercises for these children to help prevent long-term problems. Figure 1: 9 y/o boy with a 4.5year f/u of a Type VII fracture showing complete healing. Figure 2: 1.5 year f/u of 8 y/o boy resulting in the formation of a discrete os subfibulare. Su AW, Larson AN. Pediatric Ankle Fractures: Concepts and Treatment Principles. Foot Ankle Clin. 2015;20(4):705-719.26589088. Ogden JA. Injury to the growth mechanisms of the immature skeleton. Skeletal Radiol. 1981;6(4):237-253.7292021. Pill SG, Hatch M, Linton JM, Davidson RS. J Bone Joint Surg Am. 2013;95: e115(1-6) d http://dx.doi.org/10.2106/JBJS.L.00847 .

机译：背景：在儿科运动员中，逆转踝损伤是常见的，通常导致横向畸形骨折（1）。 Ogden描述了VII型横向陈列不良物理骨折作为损伤，其中裂缝线完全在远端腓骨骨骺（2）的次级骨化中心内。本文的目的是报告参与各种类型的体育活动的31名儿童的结果，该活动持续了患有外侧畸形的型号的VII骨折。方法：在此报告2012年3月至2017年12月在第三次护理儿科医院进行的IRB批准的前瞻性（纵向）队列研究结果。符合条件的患者是患有VII型（全部骨骺）骨折的患者，最初治疗或在高级作者的后续行动中进行治疗。排除标准包括那些患有所有其他侧面乳房损伤的患者和具有负射线照片的患者。在学习间隔期间注册了三十一名儿童。根据横向麦芽糖的骨化骨化内部中心内的裂缝线的轨迹和位置，将VII型骨折分类为横向，倾斜或尖端撕脱。我们记录了以下人口统计数据：患者的性别，伤害时的年龄，伤害机制，涉及的体育，重量造成伤害，治疗伤害，伤害治疗，从伤害释放到体育活动。当触诊时没有不适，踝关节运动等于未进入侧，儿童被允许返回运动。主要结果焦点是最后临床评价时骨折的放射线地位。结果：在研究间隔期间纳入了术后畸形的七型骨折的三十一只儿童。有8个女孩和23个男孩。受伤时的平均年龄为107个月（？9年。）所有儿童均持续升级反转型损伤，同时参与全面的体育活动。二十五个孩子最初无法承受体重，6人可以走路，但有跛行。用重轴承的铸造和拐杖处理二十六个儿童，并用铸造靴治疗其中的5个。四个骨折是倾斜的，8例横向，19个是尖端吹扫。所有孩子都无症状，并且在伤害后的平均时间为3.5个月（范围2.5至4）时清除运动参与时，有一个负面抽屉测试。 18名儿童的射线照片显示出裂缝的颈部愈合（图1），但在释放到全部活性时，但13（31％）愈合，形成了离散的OS亚面线（图2.）18个骨折，愈合不平整的骨折位于远端之上三分之一的腓骨骨骺。用OS子比图愈合的所有13位于腓腓（4）的远端尖端或在尖端（9）的前远端方面，对应于ATFL的附接区域。结论：所有儿童均持续乳房型骨折骨折能够恢复全面体育活动。 31型VII骨折（58％）的十八型愈合不平衡。然而，13（42％），用OS亚比里的形成愈合。由于OS亚面比的存在与复发性踝关节不稳定和疼痛有关，因此可以谨慎地观察，甚至推荐这些儿童的踝关节康复练习，以帮助防止长期问题。图1：9 y / o男孩4.5year f / u的vii骨折，显示完全愈合。图2：1.5年F / U的8 y / o男孩，导致形成离散的OS子面比。苏武，Larson An。小儿踝关节骨折：概念和治疗原则。脚踝诊所。 2015; 20（4）：705-719.26589088。奥格登贾。未成熟骨架的生长机制损伤。骨骼放射性。 1981; 6（4）：237-253.7292021。丸SG，舱口米，林顿JM，戴维森卢比。 j骨关节素。 2013; 95：E115（1-6）D http://dx.doi.org/10.2106/jbjs.l.00847。

THE NATURAL HISTORY OF TYPE VII ALL INTRA-EPIPHYSEAL FRACTURES OF THE LATERAL MALLEOLUS

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