High Yield Overview

PAEDIATRIC ANKLE FRACTURES - SALTER-HARRIS ORIF

Direct approach based on fracture pattern: Anterolateral (Tillaux/triplane lateral component), Anteromedial (medial malleolus), Posteromedial (posterior malleolus/triplane posterior component). May require combination of approaches for triplane fractures. | advanced

Critical Danger Zones - 5 Specific Anatomical Structures

Danger 1: Distal Tibial Physis

Location: Horizontal growth plate 1-2cm proximal to ankle joint, thickest anteromedially, closes in predictable pattern (central → medial → anterolateral from age 12-16)

Protection: NEVER place screws perpendicular to open physis - causes physeal bar and arrest. Use K-wires parallel to physis, screws crossing obliquely (greater than 45 degrees), or epiphyseal screws that remain entirely within epiphysis

Danger 2: Distal Fibular Physis

Location: 1cm proximal to tibial physis, closes at 15-17 years (later than tibia). Commonly injured with ankle fractures but often undisplaced

Protection: In children less than 12 years with significant growth remaining, avoid crossing with screws. Use smooth K-wires parallel to physis or accept fibular displacement if ankle mortise is anatomically reduced

Danger 3: Superficial Peroneal Nerve

Location: Emerges from anterior compartment 8-10cm proximal to ankle joint line, crosses anterolateral ankle obliquely toward first web space, directly in path of Tillaux/triplane anterolateral incision

Protection: Make skin incision slightly more anterior, identify nerve in subcutaneous tissue before deeper dissection, retract gently with vessel loop, avoid electrocautery near nerve

Danger 4: Deep Peroneal Nerve & Anterior Tibial Artery

Location: Travel together between EHL (lateral) and tibialis anterior (medial), lie on anterior tibia deep to extensor retinaculum, at risk with all anterior approaches to ankle

Protection: Develop interval between tibialis anterior and EHL, retract EHL laterally with entire neurovascular bundle intact, avoid aggressive medial retraction, use Hohmann retractors carefully on bone not soft tissue

Danger 5: Saphenous Vein & Nerve Complex

Location: Anterior and superior to medial malleolus, nerve provides sensation to medial ankle and foot, vein is often prominent in children, both vulnerable during medial malleolar approach

Protection: Make anteromedial incision anterior to medial malleolus tip, identify and protect both structures in subcutaneous layer, avoid electrocautery near nerve, gentle retraction to prevent neuroma formation

Mnemonic

SALTERSALTER Mnemonic for Physeal Fracture Classification

Memory Hook:In viva, classify the fracture using Salter-Harris FIRST before discussing treatment - shows systematic approach. Emphasize that SH III/IV are intra-articular requiring anatomic reduction, while SH I/II can tolerate some displacement.

Mnemonic

PHYSISPHYSIS Protection Strategy for Fixation

Memory Hook:When examiner asks about fixation technique, demonstrate knowledge of physeal-respecting strategies. State 'I NEVER place screws perpendicular to open physis' - shows understanding of growth arrest risk.

Indications for ORIF

Absolute Indications

Intra-articular displacement greater than 2mm on any view (SH III, SH IV, Tillaux, triplane)
Physeal displacement greater than 3mm that is irreducible or unstable after closed reduction
Open physeal fractures requiring irrigation and debridement
Compartment syndrome requiring fasciotomy with associated unstable fracture
Polytrauma requiring stabilization for mobilization

Relative Indications

SH II fractures with 2-3mm physeal displacement that are reducible but unstable
Associated syndesmotic injury preventing mortise reduction
Distal fibula fracture preventing ankle mortise reduction (fibula too long)
Delayed presentation (greater than 7-10 days) with early healing in malposition
Patient/family unable to comply with non-operative management requiring immobilization

Contraindications

Undisplaced or minimally displaced fractures (less than 2mm articular, less than 3mm physeal)
Fractures that achieve and maintain anatomic reduction with closed manipulation
SH V crush injuries (no surgical role - already maximally injured)
Severe soft tissue compromise precluding safe surgery (defer until soft tissues recovered)
Active infection at surgical site

Pre-operative Planning

Imaging Requirements

Plain radiographs: AP, lateral, and MORTISE views (mortise most critical for assessing reduction)
Contralateral ankle: helpful for comparing physeal width and identifying normal anatomic variants
CT scan: MANDATORY for triplane fractures to understand three-dimensional fracture pattern and plan approach(es)
Stress views: if stability uncertain after closed reduction, can perform gentle valgus/varus stress under fluoroscopy

Fracture Classification

Salter-Harris type (I-V) - determines prognosis and urgency
Location (medial malleolus, lateral malleolus, distal tibia, combination)
Special patterns: Tillaux (SH III anterolateral), triplane (complex three-part)
Associated injuries: fibula fracture, syndesmotic injury, soft tissue compromise

Age-Based Considerations

Age less than 10 years: maximal growth remaining, most conservative with implants crossing physis, prefer smooth K-wires
Age 10-14 years: transitional age, Tillaux fractures begin appearing, individualize based on bone age and physeal status
Age greater than 14 years: minimal growth remaining, can use screws more liberally but still respect physis if open
Check bone age radiograph if skeletal maturity uncertain

Positioning and Preparation

Patient Position: Supine with bump under ipsilateral hip for medial malleolar fractures (rotates ankle medially for improved access). No bump for lateral/Tillaux approaches. Affected leg prepped circumferentially from mid-thigh to toes (allows full ankle manipulation and contralateral comparison). Tourniquet on thigh (not calf - interferes with ankle access). Radiolucent table and leg support essential for fluoroscopy.

Image Intensifier Setup: C-arm positioned for perfect AP, lateral, and MORTISE views before draping. Mortise view is most critical (20 degrees internal rotation of entire leg from true AP) - shows symmetric ankle joint and detects talar shift. Test all views before prepping to avoid delays.

Surgical Approach: Direct approach based on fracture pattern determined from pre-operative imaging. Anterolateral for Tillaux/triplane lateral component (between tibialis anterior and EHL). Anteromedial for medial malleolus (anterior to malleolus tip). Posteromedial for triplane posterior fragment (between Achilles and FDL). May require combination of approaches for complex triplane fractures.

Tourniquet Use: Inflate to 200-250mmHg (50-75mmHg above systolic BP). Use judiciously as paediatric skin is sensitive to pressure - minimize tourniquet time to less than 60 minutes if possible. Consider performing case without tourniquet if good hemostasis achievable and fracture not complex.

Incision Planning: Mark incision with surgical marker before prepping. Palpate fracture fragment if displaced (guides incision placement). Skin incisions should be slightly longer than anticipated bone exposure (paediatric skin is mobile and stretches easily).

Operative Technique

Step 1: Fracture Classification & Surgical Planning

Fracture Classification & Surgical Planning: CLASSIFY using Salter-Harris: Type I (through physis only - rare in ankle), Type II (metaphyseal fragment - most common, 60-70% of paediatric ankle fractures), Type III (epiphyseal fragment - intra-articular, example: Tillaux), Type IV (metaphysis + physis + epiphysis - example: medial malleolus), Type V (crush - no surgical role, physeal arrest inevitable). SPECIAL PATTERNS: (1) TILLAUX equals SH III of anterolateral distal tibia (AITFL avulsion), occurs when medial physis closed but lateral open (age 12-14 years). (2) TRIPLANE equals complex combination of SH II plus III plus IV, has 3 fracture planes (sagittal through metaphysis, coronal through physis, axial through epiphysis), requires CT for surgical planning. Assess: displacement (greater than 2mm articular needs ORIF), stability after closed reduction attempt, age and growth remaining (bone age if uncertain), soft tissue envelope (delay if significant swelling or blisters), associated injuries (fibula fracture, syndesmotic injury).

Exam Pearl

Classification and Planning: In viva, state 'I classify ALL paediatric ankle fractures by Salter-Harris as it determines prognosis and guides treatment. Type I/II: mostly extra-articular, 3-5% arrest risk, can accept some displacement. Type III/IV: INTRA-ARTICULAR, 15-20% arrest risk, demand anatomic reduction less than 2mm. TILLAUX is SH III, occurs age 12-14 when medial physis closed but lateral still open - AITFL avulses anterolateral fragment. TRIPLANE is complex 3-part fracture with three fracture planes, I ALWAYS get CT for surgical planning to understand the three-dimensional anatomy.'

Dangers at this step

Misclassification leading to inappropriate treatment plan (example: treating SH III like SH II, accepting articular displacement)
Underestimating displacement on plain films alone - CT helpful for triplane and complex fractures
Missing associated syndesmotic injury or distal fibula fracture requiring treatment
Operating without understanding growth remaining and physeal status (check bone age if uncertain)
Inadequate soft tissue assessment - delay surgery if blisters or severe swelling present

Step 2: Closed Reduction Attempt - May Avoid Surgery

Closed Reduction Attempt - May Avoid Surgery: ALL displaced fractures deserve closed reduction attempt in Emergency Department or Operating Room under adequate sedation/anesthesia - never attempt in awake distressed child. Technique: reverse mechanism (most are supination-external rotation injuries). MEDIAL MALLEOLUS SH: direct pressure laterally on medial malleolus, pronate foot to close medial gap, slight eversion if needed. LATERAL/TILLAUX: direct pressure medially on lateral fragment, internal rotation of foot, slight plantarflexion to relax AITFL. TRIPLANE: longitudinal traction first, correct rotation (lateral fragment usually externally rotated), then direct pressure on displaced fragments. ASSESS STABILITY: if anatomic reduction achieved and STABLE on fluoroscopy with gentle ankle motion, ORIF may be avoided - proceed with long leg casting. X-ray AP, lateral, mortise after reduction. If reduction: (1) anatomic (intra-articular less than 2mm, physeal less than 3mm), (2) stable with casting, proceed with non-operative management. If non-anatomic or unstable, proceed to ORIF.

Exam Pearl

Closed Reduction First: State 'I ALWAYS attempt closed reduction first under adequate sedation or anesthesia, even if planning surgery. Many paediatric ankle fractures reduce anatomically and remain stable in cast - avoiding surgery entirely. I use gentle longitudinal traction, reverse the injury mechanism (usually supination-external rotation), apply direct pressure on displaced fragment, and assess reduction on fluoroscopy. If anatomic and stable: long leg cast in slight equinus for 4-6 weeks, non-weight-bearing. If displaced greater than 2mm articular or unstable: proceed to ORIF. Closed reduction also decreases soft tissue trauma even if ORIF ultimately needed.'

Dangers at this step

Excessive force during reduction equals physeal crush creating iatrogenic SH V injury (growth arrest)
Accepting non-anatomic reduction in intra-articular fracture (SH III/IV) - leads to post-traumatic arthritis
Multiple aggressive reduction attempts equals increased swelling, physeal damage, and soft tissue injury
Inadequate sedation/anesthesia leading to muscle spasm preventing reduction
Assuming instability without proper assessment - may subject patient to unnecessary surgery

Step 3: Positioning & Tourniquet Application

Positioning & Tourniquet Application: Supine, bump under ipsilateral hip for medial malleolar fractures (rotates entire leg medially improving medial access and bringing medial malleolus to apex). No bump for lateral/Tillaux fractures (want neutral or slight external rotation for anterolateral access). Affected leg on radiolucent triangle or leg holder allowing full ankle manipulation. Prep entire lower leg circumferentially from mid-thigh to toes (allows assessment of rotation, comparison to contralateral). Tourniquet on THIGH not calf (calf tourniquet interferes with surgical access to ankle). Inflate to 200-250mmHg (50-75mmHg above systolic BP). USE JUDICIOUSLY - paediatric skin more sensitive to pressure than adults, minimize tourniquet time less than 60 minutes if possible, consider no tourniquet for straightforward cases. C-arm for AP, lateral, and MORTISE views - test ALL views before draping (mortise requires 20 degrees internal rotation of entire leg). Position C-arm from contralateral side usually easiest.

Exam Pearl

Positioning Strategy: State 'Patient supine with thigh tourniquet inflated to 200-250mmHg - I use it judiciously as paediatric skin is sensitive to pressure. Bump under ipsilateral hip for medial malleolus fractures (rotates ankle medially bringing malleolus to apex for easier access and screw placement). No bump for lateral/Tillaux approaches (neutral rotation best). I ensure C-arm can get perfect AP, lateral, and MORTISE views before starting - mortise is most critical for assessing ankle joint symmetry and talar shift. I test mortise view by internally rotating entire leg 20 degrees from true AP.'

Dangers at this step

Tourniquet on calf equals limited access to ankle and early tourniquet interference
Excessive tourniquet pressure or prolonged time equals skin injury, potential compartment syndrome after deflation
Inadequate C-arm positioning causes delays during procedure and poor quality fluoroscopy
Wrong limb positioned or prepped (always verify site marking and consent)
Bump under hip for lateral approach rotates ankle away from surgeon (makes access difficult)

Step 4: Tillaux Fracture - Anterolateral Approach

Tillaux Fracture - Anterolateral Approach: TILLAUX equals SH III fracture, anterolateral distal tibial epiphysis avulsed by AITFL (anterior inferior tibiofibular ligament) during supination-external rotation. Transitional fracture occurring when medial and central physis closed but anterolateral still open (age 12-14 years typically). APPROACH: 5-7cm longitudinal incision over anterolateral ankle, centered over fracture (palpable if displaced). Incise skin, identify and PROTECT superficial peroneal nerve in subcutaneous tissue (crosses at this level, 8-10cm proximal to ankle joint line, branches into medial and intermediate dorsal cutaneous nerves). Use vessel loop for gentle retraction. Incise deep fascia longitudinally. Develop interval between: tibialis anterior (medial) and EHL (lateral). Retract EHL laterally with deep peroneal nerve and anterior tibial artery running on its medial side. Incise periosteum longitudinally, expose fracture with minimal soft tissue stripping. Use small Hohmann retractors placed directly on bone (not soft tissue) for visualization.

Exam Pearl

Tillaux Approach: State 'Tillaux is the classic transitional fracture - occurs at age 12-14 when medial physis has closed but lateral remains open. AITFL avulses the anterolateral epiphyseal fragment during supination-external rotation injury. My approach is anterolateral, longitudinal incision between tibialis anterior and EHL. The superficial peroneal nerve crosses here in the subcutaneous tissue - I MUST identify and protect it with vessel loop before deeper dissection. I develop the interval, retract EHL laterally with its neurovascular bundle (deep peroneal nerve and anterior tibial artery on medial side of EHL), expose fracture with minimal periosteal stripping.'

Dangers at this step

Superficial peroneal nerve injury - most common complication of anterolateral approach (1-2% incidence)
Deep peroneal nerve and anterior tibial artery if retraction of EHL too aggressive medially
Damage to AITFL insertion if dissection too proximal (ligament inserts on anterolateral fragment)
Inadequate exposure from incision too small - extend rather than retract forcefully
Electrocautery near superficial peroneal nerve causing thermal injury

Step 5: Tillaux Fracture - Reduction & Fixation

Tillaux Fracture - Reduction & Fixation: REDUCTION: Remove hematoma with irrigation and suction. Identify and remove interposed periosteum blocking reduction (common). Use small periosteal elevator or dental pick to gently manipulate fragment. Reduce with direct medial-to-lateral pressure and foot pronation/internal rotation. Fragment often locks into place when anatomically reduced. Provisionally hold with 1.6mm or 2.0mm smooth K-wire placed parallel to physis from anterolateral direction. ASSESS reduction: direct visualization of articular surface (should be anatomic, zero step), fluoroscopy AP/lateral/mortise (articular step less than 2mm, mortise symmetric). DEFINITIVE FIXATION: Single 3.5mm or 4.0mm cannulated screw PARALLEL TO PHYSIS (critical to prevent growth arrest). Screw trajectory: anterolateral to posteromedial, stays entirely in epiphysis or crosses physis OBLIQUELY (greater than 45 degrees angle) not perpendicular. Use partially threaded screw for compression across fracture. Guidewire first, confirm position on fluoroscopy all views, measure length (subtract 5mm from measurement to avoid medial cortex prominence), insert cannulated screw over wire. Final fluoroscopy AP, lateral, mortise to confirm reduction maintained and screw position appropriate.

Exam Pearl

Tillaux Fixation: State 'Reduction sequence: first remove hematoma and interposed periosteum, then reduce fragment with direct pressure and foot pronation/internal rotation, provisionally hold with K-wire parallel to physis. Once I confirm anatomic reduction on direct visualization and fluoroscopy, I place definitive fixation - single 3.5mm or 4.0mm cannulated screw PARALLEL TO PHYSIS or within epiphysis entirely. Screw direction anterolateral to posteromedial, partially threaded for compression. I NEVER place screw perpendicular to physis as this would cause physeal bar and growth arrest. Final check: mortise view must show anatomic articular reduction less than 2mm step and symmetric joint spaces.'

Dangers at this step

Screw perpendicular to physis equals high risk physeal bar causing growth arrest and angular deformity
Screw too long penetrating medial cortex causes prominence and potential neurovascular injury (saphenous nerve/vein)
Accepting articular incongruity greater than 2mm equals post-traumatic arthritis risk
Over-compression with screw causing fragment comminution (paediatric bone softer than adult)
Guidewire or screw penetrating ankle joint (too distal placement) causing articular damage

Step 6: Medial Malleolus SH Fracture - Anteromedial Approach

Medial Malleolus SH Fracture - Anteromedial Approach: Medial malleolus fractures are SH II (most common, 70% - metaphyseal Thurston-Holland fragment) or SH IV (30% - intra-articular epiphyseal fracture). APPROACH: 5-7cm curvilinear incision starting anterior and superior to medial malleolus, curving posteriorly and distally along malleolus if needed for displaced posterior metaphyseal spike. Make incision anterior to malleolus tip (protects saphenous vein and nerve which run anteriorly/superiorly). Incise skin and subcutaneous tissue, identify and PROTECT saphenous vein and nerve (anterior). Retract neurovascular structures anteriorly with vessel loop or gentle retractor. Incise periosteum directly over fracture site. Expose fracture with minimal soft tissue stripping. For SH II with posterior spike, may need to extend dissection posteriorly but stay anterior to posterior tibial neurovascular bundle. Use small Hohmann retractors on bone for visualization.

Exam Pearl

Medial Malleolus Approach: State 'Medial malleolus is commonly SH II (metaphyseal Thurston-Holland spike) or SH IV (intra-articular epiphyseal fragment). I use anteromedial approach with curvilinear incision anterior to medial malleolus tip. Critical to identify and protect saphenous vein and nerve anteriorly - I retract them gently with vessel loop. For SH II with large posterior spike, I extend dissection posteriorly but remain anterior to posterior tibial neurovascular bundle. SH II is extra-articular and less critical - some displacement acceptable. SH IV is INTRA-ARTICULAR and demands anatomic reduction less than 2mm step to prevent arthritis.'

Dangers at this step

Saphenous vein and nerve injury from incision directly over structures or aggressive retraction
Deltoid ligament damage if dissection too extensive posteriorly (preserve ankle stability)
Posterior tibial neurovascular bundle if incision extended too far posterior without identifying anatomy
Inadequate exposure of posterior metaphyseal spike if incision too anterior (extend posteriorly if needed)
Excessive periosteal stripping compromising fracture healing blood supply

Step 7: Medial Malleolus - Reduction & Fixation

Medial Malleolus - Reduction & Fixation: REDUCTION: Remove hematoma and identify fracture surfaces. For SH II, reduce metaphyseal spike back to metaphysis with direct lateral pressure and foot pronation/eversion. For SH IV, reduce epiphyseal fragment anatomically (intra-articular). Check for interposed periosteum or deltoid ligament fibers blocking reduction (can divide partially if necessary). Provisionally hold with K-wire. Assess reduction on fluoroscopy and direct visualization (SH IV must be anatomic). FIXATION OPTIONS depend on age and fracture pattern: (1) Young children less than 10 years: TWO parallel 1.6-2.0mm smooth K-wires parallel to physis, removed at 4-6 weeks (safest for growth plate). (2) Older children greater than 12 years: single or two 3.5-4.0mm cannulated screws, placed parallel to physis or crossing obliquely (not perpendicular if growth remaining). (3) SH IV intra-articular: preferred fixation is epiphyseal screw from medial malleolus epiphysis into talar body (does not cross physis, zero arrest risk, provides excellent stability for articular fracture). Alternative for SH IV: screw parallel to physis in metaphysis. Avoid crossing physis perpendicularly if any growth remaining. Check AP, lateral, and mortise views for reduction and hardware position. Ensure screw heads countersunk or flush (avoid prominence causing skin irritation).

Exam Pearl

Medial Malleolus Fixation Strategy: State 'Fixation depends on patient age, fracture type, and growth remaining. Young children less than 10 years: I use two smooth K-wires parallel to physis, removed at 4-6 weeks - safest option for growth plate. Older children greater than 12 years with minimal growth: cannulated screws acceptable but still avoid perpendicular to physis. For SH IV intra-articular fracture: my preferred technique is EPIPHYSEAL screw from medial malleolus into talar body - screw stays entirely in epiphysis, does not cross physis, provides excellent stability for articular reduction. Critical principle: NEVER perpendicular to physis if growth remaining - causes physeal bar and arrest.'

Dangers at this step

Screw perpendicular to open physis equals physeal arrest (angular deformity as sequela)
Hardware prominence medially causing skin irritation and need for early removal (countersink screw heads)
Inadequate fixation (single K-wire in unstable fracture) equals loss of reduction
K-wire migration if not bent adequately or buried beneath skin (can migrate into joint)
Screw too long penetrating lateral cortex into fibula or peroneal tendons

Step 8: Triplane Fracture - Assessment & Planning

Triplane Fracture - Assessment & Planning: TRIPLANE equals complex transitional fracture with THREE fracture components in three orthogonal planes: (1) SAGITTAL fracture through lateral metaphysis, (2) CORONAL fracture through physis (central to lateral), (3) AXIAL fracture through epiphysis (anterolateral articular fragment). Occurs age 12-15 years when medial and central physis closed but anterolateral open. PRE-OPERATIVE CT MANDATORY for surgical planning - plain films significantly underestimate fracture complexity and cannot show three-dimensional anatomy. TWO-PART vs THREE-PART fracture: Two-part (more common, 70%) has single medial fragment (epiphysis plus medial metaphysis fused) and lateral fragment (anterolateral epiphysis plus lateral metaphysis). Three-part (less common, 30%) has separate medial epiphysis, lateral epiphysis, and posterior metaphysis. Review CT carefully identifying all fragments and displacement. Plan approach based on main displacement: usually need anterolateral approach for lateral component which has most displacement. May need additional medial or posteromedial approach for separate medial or posterior fragments. Surgical goal: anatomic reduction of articular surface (intra-articular fracture) and stable fixation respecting physis.

Exam Pearl

Triplane Planning: State 'Triplane is the most complex paediatric ankle fracture - has THREE fracture planes hence the name. Sagittal through metaphysis, coronal through physis, axial through epiphysis. Occurs at age 12-15 during transitional physeal closure. I ALWAYS get CT for surgical planning - plain x-rays do not show the true three-dimensional fracture pattern. Most are two-part fractures (medial fragment and lateral fragment), but some are three-part requiring careful identification of all components. I plan my approach based on CT: usually anterolateral first for lateral fragment which has most displacement, then assess intra-operatively if need additional medial or posterior approach for other fragments.'

Dangers at this step

Operating without CT equals inadequate understanding of fracture complexity and high risk malreduction
Missing separate medial or posterior fragment requiring additional approach and fixation
Underestimating articular displacement on plain films alone (CT shows true step)
Inadequate surgical planning leading to wrong approach or inadequate exposure
Not reviewing three-dimensional CT reconstructions before surgery (sagittal, coronal, axial, and 3D views all essential)

Step 9: Triplane Fracture - Anterolateral Approach & Reduction

Triplane Fracture - Anterolateral Approach & Reduction: APPROACH: Anterolateral incision similar to Tillaux approach (between tibialis anterior and EHL) but may need to extend more proximally for metaphyseal component and posteriorly for posterior fragment. Typically 6-8cm incision. Protect superficial peroneal nerve in subcutaneous tissue. Develop interval between tibialis anterior and EHL. Expose lateral fragment (combined metaphyseal-epiphyseal component for two-part, or separate lateral epiphyseal fragment for three-part). REDUCTION SEQUENCE critical: (1) Address ROTATION first - lateral fragment often externally rotated, must de-rotate to align articular surface. (2) Then address translation and displacement - reduce articular surface under direct visualization. (3) Goal is anatomic articular reduction less than 2mm step (this is intra-articular fracture demanding perfection). Use K-wires for provisional fixation once reduced. Fluoroscopy AP, lateral, mortise to confirm articular reduction. May need separate posteromedial approach for large posterior metaphyseal component or medial approach if separate medial epiphyseal fragment in three-part pattern - assess after reducing lateral component.

Exam Pearl

Triplane Reduction: State 'Anterolateral approach for lateral component - same interval as Tillaux between tibialis anterior and EHL, protecting superficial peroneal nerve. Reduction sequence is critical: ROTATION first - lateral fragment is usually externally rotated and must be de-rotated to align articular surface. Then translation and displacement. I achieve anatomic articular reduction under direct vision - this is intra-articular fracture demanding less than 2mm step to prevent arthritis. Hold with K-wires provisionally. Then assess on fluoroscopy whether I need additional approaches for other fragments - sometimes lateral approach alone sufficient if other fragments minimally displaced.'

Dangers at this step

Superficial peroneal nerve injury (same risk as Tillaux approach)
Inadequate exposure of all fracture components (extend incision if needed)
Malrotation of lateral fragment equals residual articular incongruity even if translation corrected
Accepting non-anatomic articular reduction in complex fracture (leads to arthritis)
Failure to assess whether additional approaches needed for complete reduction

Step 10: Triplane Fracture - Fixation Strategy

Triplane Fracture - Fixation Strategy: GOAL: Anatomic articular reduction with stable fixation while respecting residual open physis segments. FIXATION OPTIONS: (1) EPIPHYSEAL SCREWS from lateral malleolus across lateral epiphyseal fragment toward medial epiphysis (stays entirely in epiphysis, safest option, my preference). (2) Screws PARALLEL TO PHYSIS or crossing OBLIQUELY greater than 45 degrees (acceptable if growth remaining). (3) Metaphyseal screw from lateral tibial metaphysis to medial metaphysis crossing above physis (for metaphyseal component in two-part fracture). Typically need 1-2 screws for adequate stability. Common configuration for two-part: one lateral epiphyseal screw from lateral malleolus to medial epiphysis, plus one anterior-to-posterior screw parallel to physis for metaphyseal component. Use 3.5-4.0mm partially threaded cannulated screws for compression. Fluoroscopy AP, lateral, MORTISE critical to confirm articular reduction and hardware position. May need additional screw for separate medial fragment in three-part pattern. AVOID screws perpendicular to physis even though most triplane patients approaching skeletal maturity - growth arrest still possible if physis segments remain open.

Exam Pearl

Triplane Fixation: State 'Fixation strategy for triplane prioritizes anatomic articular reduction and physeal protection. My preferred technique: (1) Epiphyseal screw from lateral malleolus across lateral fragment to medial epiphysis - stays entirely in epiphysis, zero physeal arrest risk. (2) Second screw parallel to physis or crossing metaphysis above physis for stability. Usually 1-2 screws provide adequate fixation. Although triplane occurs near skeletal maturity with physis nearly closed, I still respect remaining open physis segments - avoid perpendicular screws. Final check on mortise view - articular surface must be anatomic, joint spaces symmetric, no talar shift.'

Dangers at this step

Screw perpendicular to residual open physis segments causing late arrest
Under-fixation with single screw in complex unstable fracture (risk loss of reduction)
Over-compression causing comminution of fragments in paediatric bone
Missing separate fragment requiring additional fixation (check all views)
Screw penetrating ankle joint if too distal or wrong trajectory

Step 11: Distal Fibula Fracture - Assessment & Management

Distal Fibula Fracture - Assessment & Management: Distal fibula physeal fractures commonly ASSOCIATED with distal tibia fractures (30-40% of paediatric ankle fractures). Most are SH I or SH II at fibular physis (located 1cm proximal to tibial physis). DECISION ALGORITHM: (1) If fibula fracture UNDISPLACED and ankle mortise anatomically reduced after tibial fixation: observe fibula, no fixation needed - heals reliably without surgery. (2) If fibula fracture PREVENTS ankle mortise reduction because fibula too long: MUST reduce fibula to restore mortise anatomy. (3) Older adolescent greater than 14 years with minimal growth remaining: can fix fibula like adult with plate or intramedullary screw. (4) YOUNG CHILDREN less than 12 years with significant growth: avoid crossing fibular physis if possible - use smooth K-wires parallel to physis or accept some fibular displacement if ankle mortise anatomic. KEY CONCEPT: ankle mortise reduction is PRIMARY GOAL - symmetric medial, superior, and lateral clear spaces on mortise view. Fibula fixation is secondary and only needed if fibula prevents mortise reduction or is grossly unstable. Always assess mortise symmetry after tibial fixation before deciding on fibular treatment.

Exam Pearl

Fibula Management: State 'Distal fibula fracture commonly accompanies distal tibia fracture. My key question: is the ankle mortise reduced anatomically after tibial fixation? I assess this on mortise view - medial clear space should equal superior clear space, both 2-4mm. If mortise is anatomic and symmetric, and fibula undisplaced, I leave fibula alone - it heals reliably without fixation. If fibula prevents mortise reduction because it is too long, I must reduce and potentially fix fibula to restore mortise anatomy. In young children less than 12 years, I avoid crossing fibular physis - use smooth K-wires parallel to physis. In older adolescents greater than 14 years, I can fix like adults.'

Dangers at this step

Over-fixation of fibula in young children crossing physis perpendicularly equals physeal arrest
Under-treatment of fibula preventing mortise reduction equals persistent talar shift and instability
Damage to peroneal tendons with posterolateral fibula approach (stay directly lateral on fibula)
Sural nerve injury with lateral fibula approach (runs posterior to lateral malleolus)
Accepting asymmetric mortise (medial space wider than superior) equals residual talar shift

Step 12: Final Reduction Assessment - Mortise View Critical

Final Reduction Assessment - Mortise View Critical: FINAL FLUOROSCOPY in three standard views is mandatory before accepting reduction: (1) AP VIEW: medial clear space less than 4mm and should equal superior clear space (both 2-4mm normal). Assess physeal reduction and hardware position. (2) MORTISE VIEW (most critical): obtained by internally rotating entire leg 20 degrees from true AP. Shows medial clear space, superior clear space, and lateral (tibiofibular) clear space - all three should be EQUAL (1-4mm, symmetric joint). Any asymmetry indicates talar shift from malreduction, syndesmotic injury, or fibular length problem. (3) LATERAL VIEW: no anterior or posterior talar subluxation, assess posterior malleolus if involved, check hardware position. ACCEPTABLE REDUCTION CRITERIA: Articular congruity less than 2mm step on any view (zero tolerance for SH III/IV intra-articular fractures), physeal reduction less than 3mm gap (some displacement acceptable as physes remodel), symmetric mortise with equal joint spaces (non-negotiable - asymmetry indicates instability). UNACCEPTABLE FINDINGS requiring revision: Articular step greater than 2mm, asymmetric mortise with medial space greater than superior space (talar shift), talar subluxation on lateral view, malpositioned hardware crossing physis perpendicularly. If any unacceptable finding: revise reduction and fixation before closing.

Exam Pearl

Final Assessment: State 'Final assessment before closing is critical - I check AP, lateral, and MORTISE views on fluoroscopy. Mortise view is most important - shows ankle joint symmetry. I look for three equal clear spaces: medial, superior, and lateral tibiofibular - all should be 2-4mm and symmetric. If medial space wider than superior space, this indicates talar shift from residual displacement, syndesmotic injury, or fibular malreduction - I must revise. I accept less than 2mm articular step (preferably anatomic for intra-articular fractures), less than 3mm physeal gap, but I do NOT accept asymmetric mortise or talar shift - these cause instability and arthritis.'

Dangers at this step

Accepting talar shift with asymmetric mortise equals ankle instability and early post-traumatic arthritis
Missing syndesmotic injury masked by fracture and swelling (widened tibiofibular clear space on mortise)
Malreduced fibula causing lateral clear space widening and mortise asymmetry
Inadequate fluoroscopy images leading to acceptance of malreduction (ensure perfect views)
Failing to obtain true mortise view (must internally rotate entire leg 20 degrees, not just foot)

Step 13: Wound Closure & Immobilization

Wound Closure & Immobilization: IRRIGATE wound thoroughly with normal saline (3 liters minimum, pulsatile lavage for higher energy fractures). Remove any debris or devitalized tissue. Close in layers with absorbable sutures: periosteum if opened with 3-0 Vicryl (interrupted), subcutaneous tissue with 3-0 or 4-0 Vicryl (interrupted), skin with 4-0 or 5-0 Monocryl subcuticular (absorbable subcuticular preferred in children - avoids traumatic suture removal) or 4-0 nylon (if concern for wound healing). Apply sterile dressing. IMMOBILIZATION: Long leg posterior splint or bivalved long leg cast for first 2 weeks (allows swelling), then convert to circumferential long leg cast for 4-6 weeks total. Position: SLIGHT equinus 10-15 degrees (relaxes Achilles tendon minimizing physeal distraction forces, protects reduction). Avoid excessive equinus greater than 20 degrees (causes ankle stiffness requiring prolonged physical therapy). Knee flexed 20-30 degrees to prevent hyperextension and promote comfort. Well-padded cast with extra padding over bony prominences. NON-WEIGHT-BEARING for 4-6 weeks minimum (until radiographic healing). Post-operative radiographs AP, lateral, mortise in splint immediately to document maintained reduction (rarely loses reduction but must document). Mark affected leg with surgery date and non-weight-bearing instructions.

Exam Pearl

Closure and Immobilization: State 'I close in layers with absorbable sutures where possible - periosteum, subcutaneous, and subcuticular skin - children tolerate suture removal poorly so I use absorbable Monocryl for skin. Apply well-padded long leg posterior splint initially allowing for swelling. Position ankle in SLIGHT equinus 10-15 degrees to relax Achilles and protect physis and reduction - avoid excessive equinus which causes stiffness. Knee flexed 20-30 degrees. NON-weight-bearing strict for 4-6 weeks minimum. I see patient at 2 weeks for wound check and x-ray confirming maintained reduction, then 6 weeks for cast removal and ROM initiation.'

Dangers at this step

Tight circumferential cast immediately post-op equals compartment syndrome risk (use splint first 2 weeks)
Excessive equinus greater than 20 degrees equals ankle stiffness requiring prolonged physical therapy
Loss of reduction during splint/cast application (check x-rays in splint immediately)
Inadequate padding causing cast sores over malleoli or pressure areas
Premature weight-bearing causing loss of reduction or hardware failure

Step 14: Post-Operative Monitoring for Growth Arrest

Post-Operative Monitoring for Growth Arrest: ALL paediatric physeal ankle fractures require LONG-TERM FOLLOW-UP for potential physeal arrest - this is non-negotiable and must be explained to family. SURVEILLANCE SCHEDULE: (1) 2 weeks: wound check and x-ray in splint confirming maintained reduction. (2) 6 weeks: cast removal, x-ray, initiate ROM exercises and progressive weight-bearing. (3) 3 months: clinical examination and x-ray, assess early signs of arrest (angular deformity, asymmetric growth line). (4) 6 months: x-ray to assess physeal growth, compare to contralateral. (5) 12 months: x-ray checking for physeal bar (sclerotic bridge across physis), angular deformity progression. (6) 18-24 months: final x-ray if significant growth remaining and high-risk fracture. ASSESS FOR: (1) Angular deformity - varus more common than valgus from medial physeal arrest. (2) Leg length discrepancy - measure clinically and radiographically (usually less than 1cm from ankle, well-tolerated). (3) Physeal bar on radiographs - sclerosis, asymmetric growth, bridging bone across physis. RISK FACTORS for arrest: SH III/IV intra-articular fractures (15-20% risk), initial displacement greater than 3mm, crush component suggesting SH V, screws crossing physis perpendicularly, high-energy mechanisms. Counsel family that growth arrest is possible even with perfect surgery - related to initial injury energy. If arrest develops, treatment options depend on percentage of physis involved and growth remaining.

Exam Pearl

Growth Arrest Surveillance: State 'ALL paediatric physeal ankle fractures need long-term follow-up for growth arrest - I explain this to family pre-operatively. My surveillance schedule: 2 weeks wound check, 6 weeks cast removal, then 3, 6, 12 months minimum with x-rays. SH III/IV and triplane fractures have highest arrest risk 15-20% so I follow these even longer. Signs I monitor: progressive angular deformity (varus most common), leg length discrepancy, physeal bar visible as sclerotic bridge on x-rays. If bar develops: options include physeal bar resection with fat interposition if less than 50% physis involved and significant growth remaining, completion epiphysiodesis if greater than 50% bar or minimal growth left, or corrective osteotomy if deformity established after growth complete.'

Dangers at this step

Inadequate follow-up equals missed physeal arrest with progressive deformity becoming uncorrectable
Delaying intervention for physeal bar until deformity severe (early bar resection has better outcomes)
Failure to counsel family pre-operatively about arrest risk (medicolegal and expectation management)
Assuming fracture healed at 6 weeks means no further follow-up needed (growth arrest develops months later)
Not obtaining comparison views of contralateral ankle to assess asymmetric growth

Step 15: Hardware Removal Considerations

Hardware Removal Considerations: HARDWARE REMOVAL decisions depend on implant type, location, and patient factors: (1) K-WIRES: MUST remove at 4-6 weeks (risk of migration, pin tract infection, breakage if left long-term). Removal usually in clinic with local anesthesia in cooperative children, or brief sedation/anesthesia if needed. (2) SCREWS CROSSING PHYSIS: controversial - some surgeons routinely remove once fracture healed (3-6 months) to minimize physeal tether risk, others leave unless symptomatic. I preferentially REMOVE screws crossing physis at 3-6 months if significant growth remaining (greater than 2 years to maturity) - erring on side of caution despite uncertain benefit. (3) EPIPHYSEAL SCREWS not crossing physis: can leave permanently unless symptomatic (prominence, pain). (4) Screws in older adolescents near skeletal maturity: can leave unless symptomatic as minimal growth remains. POST-REMOVAL PROTOCOL: protect in CAM boot or short leg cast for 2-3 weeks to allow screw tract to fill in with bone, avoid impact sports for 4-6 weeks (refracture risk through screw holes which weaken bone temporarily). Counsel patient on activity restrictions - premature return to sports risks refracture. Hardware removal is outpatient procedure, typically quicker and easier than initial surgery. Document in chart and discuss with family before initial surgery so expectations clear.

Exam Pearl

Hardware Removal: State 'K-wires MUST come out at 4-6 weeks without exception - risk of migration, infection, breakage if left. Usually remove in clinic with local anesthesia. Screws crossing physis are controversial - some leave them, but I preferentially remove at 3-6 months if significant growth remaining (greater than 2 years to maturity) to minimize any potential physeal tether effect, though evidence for this is limited. Epiphyseal screws not crossing physis can stay permanently unless causing symptoms. Post-removal: protect in boot for 2-3 weeks, avoid impact sports 4-6 weeks due to refracture risk through screw holes which temporarily weaken bone.'

Dangers at this step

Leaving K-wires long-term equals migration risk (into joint, neurovascular structures), infection, breakage
Leaving screws crossing physis in young children equals theoretical physeal tether causing arrest (controversial)
Premature return to activity after hardware removal equals refracture through screw tracts
Inadequate anesthesia/sedation for hardware removal in uncooperative child (traumatic experience)
Not protecting in boot after removal allowing early refracture before bone fills screw holes

Post-operative Management Protocol by Time Period

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 13-year-old presents with an ankle injury after a football tackle. X-rays show a displaced fracture of the anterolateral distal tibia. How would you classify this injury and what is your management approach?"

EXCEPTIONAL ANSWER

This is a Tillaux fracture - a Salter-Harris Type III fracture of the anterolateral distal tibial epiphysis. It is a transitional fracture that occurs during predictable physeal closure. The physis closes in a specific pattern: central first at age 12-14, then medial at 14-15, finally anterolateral at 15-16 years. A Tillaux occurs when the medial and central physis have closed but the anterolateral segment remains open. During a supination-external rotation injury, the AITFL (anterior inferior tibiofibular ligament) avulses the open anterolateral epiphyseal fragment. This is an intra-articular fracture demanding anatomic reduction. Management: First, I would classify using Salter-Harris and assess displacement on AP, lateral, and mortise x-rays. I would attempt closed reduction under sedation or anesthesia - direct medial-to-lateral pressure, internal rotation, slight plantarflexion. If I achieve anatomic reduction (less than 2mm step) and it is stable, I would proceed with long leg cast immobilization. If displacement persists greater than 2mm or reduction is unstable, I would proceed with ORIF. Surgical approach is anterolateral between tibialis anterior and EHL, protecting the superficial peroneal nerve. Fixation is typically a single 3.5 or 4.0mm cannulated screw placed parallel to the physis or entirely within the epiphysis - critically, never perpendicular to the physis to avoid growth arrest. Post-operatively: long leg cast for 4-6 weeks non-weight-bearing, then progressive weight-bearing and ROM. Long-term follow-up is essential to monitor for physeal arrest, though the risk is moderate (15-20%) as the patient is approaching skeletal maturity.

VIVA SCENARIOStandard

EXAMINER

"Describe the Salter-Harris classification and explain why it is important when treating paediatric ankle fractures. Which types require operative fixation and why?"

EXCEPTIONAL ANSWER

The Salter-Harris classification describes physeal (growth plate) injuries in five types, each with different prognosis and treatment implications. Type I: fracture through physis only, rare in ankle, carries lowest arrest risk (3%). Type II: fracture through physis with metaphyseal fragment (Thurston-Holland sign), most common paediatric ankle fracture (60-70%), extra-articular, arrest risk 5%. Type III: fracture through physis with epiphyseal fragment extending into joint (example: Tillaux), intra-articular, arrest risk 15%. Type IV: fracture line crosses metaphysis-physis-epiphysis (example: medial malleolus with articular involvement), intra-articular, arrest risk 20-25%. Type V: crush injury to physis, worst prognosis with near 100% arrest risk, no surgical role. Importance: The classification predicts prognosis (arrest risk increases I to V), determines treatment urgency (intra-articular demand anatomic reduction), and guides surgical approach. Types I and II are predominantly extra-articular and can tolerate some displacement (up to 3mm physeal gap acceptable) as they remodel well - many managed non-operatively. Types III and IV are intra-articular and demand anatomic reduction to less than 2mm to prevent post-traumatic arthritis - these typically require ORIF if displaced. The classification also helps with counseling families about arrest risk and need for long-term follow-up. ORIF indications: articular displacement greater than 2mm (SH III/IV), physeal displacement greater than 3mm that is unstable after closed reduction (SH II), open fractures, polytrauma requiring stabilization. The key is attempting closed reduction first for all displaced fractures - many reduce anatomically and remain stable, avoiding surgery.

VIVA SCENARIOStandard

EXAMINER

"You are fixing a Salter-Harris Type IV medial malleolar fracture in a 12-year-old. What fixation options do you have, and how do you decide? Explain your technique for protecting the physis."

EXCEPTIONAL ANSWER

For a SH IV medial malleolus fracture in a 12-year-old, I have several physeal-respecting fixation options and my choice depends on fracture stability requirements and growth remaining. This is an intra-articular fracture demanding anatomic reduction less than 2mm, so stable fixation is essential, but I must balance this with physeal protection as the patient has 3-4 years of growth remaining. My options ranked from safest to least safe for the physis: First choice - EPIPHYSEAL SCREW: This is my preferred technique for SH IV medial malleolus. I place a 3.5 or 4.0mm cannulated screw from the medial malleolar epiphysis into the talar body. This screw remains entirely within the epiphysis, does not cross the physis at all, providing excellent stability for the articular fracture with zero risk of physeal arrest. This works because the medial malleolus epiphysis and talus articulate, allowing secure fixation. Second choice - SMOOTH K-WIRES parallel to physis: Two 1.6 or 2.0mm smooth K-wires placed parallel to the physis crossing the fracture obliquely. Safe for physis but less rigid than screws, may need longer immobilization. Must be removed at 4-6 weeks. Better for younger children (less than 10 years). Third choice - SCREW parallel to or crossing physis OBLIQUELY: 3.5mm screw placed parallel to physis in metaphysis, or crossing physis at greater than 45 degrees oblique angle (not perpendicular). Acceptable in 12-year-old approaching maturity but I would plan removal at 3-6 months if crossing physis. What I would NEVER do - perpendicular screw across physis: This creates physeal bar and growth arrest. Only acceptable if skeletal maturity imminent (bone age greater than 14 in girls, greater than 16 in boys). My technique: After achieving anatomic reduction of the articular surface under direct visualization, I provisionally hold with K-wire. I then place guidewire for epiphyseal screw from medial malleolus aimed at talar body, confirm on AP and mortise fluoroscopy that it remains in epiphysis, measure, and insert partially threaded 3.5mm cannulated screw achieving compression. Final fluoroscopy confirms articular reduction less than 2mm and screw position entirely epiphyseal.