- Email: [email protected]
The Foot and Ankle in Children and Adolescents
The Foot and Ankle in Children and Adolescents Henry G. Chambers, MD,*,† and Charles J. Haggerty, MD‡ As children participate in more cutting and collision sports, there are more foot and ankle injuries. Congenital problems can also lead to sports injuries by stiffening the foot or by causing chronic pain. This article reviews the common congenital (tarsal coalition, accessory navicular, and os subtibiale) and traumatic causes of foot and ankle pain in the child and adolescent athlete. The diagnosis and treatment of these relatively common disorders are provided. Oper Tech Sports Med 14:173-187 © 2006 Elsevier Inc. All rights reserved. KEYWORDS foot and ankle injuries, adolescent sports injuries, congenital problems of the foot and ankle
Y
oung children are participating in year-round sports, encountering injuries with greater energy and regularity, and are sustaining more of foot and ankle injuries.1,2 Foot and ankle musculoskeletal complaints are the second most-common reason for primary care visits by young athletes.3 A careful history, focused physical examination, comprehension of foot and ankle mechanics, understanding of the anatomy and anatomic variants of the growing child’s foot, appropriate imaging, and an awareness of the demands and injuries associated with each particular sport will help identify the pathology.4-6 A differential diagnosis of ankle problems includes tarsal coalitions, ossicles, osteochondroses, fractures, tendonitis, ankle impingement, osteochondral lesions of the talus, and sprains.7 Most of these conditions can be treated conservatively but many require surgical intervention.
Tarsal Coalition Although present at birth, tarsal coalitions do not often become symptomatic until increased sporting activity in older children and adolescents occurs. The history may reveal recurrent ankle sprains or distal fibular fractures. Patients describe vague activity-related ankle and foot pain that may be alleviated with rest.8,9 Coalitions are frequently bilateral; however, presentation is generally unilateral. Pain is the pre-
*Rady Children’s Hospital San Diego, San Diego, CA. †Department of Orthopedic Surgery, University of California at San Diego, San Diego, CA. ‡Wilford Hall Air Force Medical Center, San Antonio, TX. Address reprint requests to Henry G. Chambers, MD, Rady Children’s Hospital San Diego, 3030 Children’s Way, Suite 410, San Diego, CA 92123. E-mail: [email protected]
1060-1872/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.otsm.2006.08.002
senting complaint, usually localized over the sinus tarsi with calcaneonavicular coalitions and medially in the hindfoot with talocalcaneal coalitions. Tenderness may be focal, but it is often diffuse. The most important physical finding is diminished subtalar motion (inversion and eversion). There may be spasm of the peroneals tendons, but this finding is not a consistent one. External rotation or foot progression angle may be increased, inversion is limited on heel rise,10 and the patient may have difficulty walking on the lateral border of the foot.11 Initial plain radiographs may demonstrate a bony union or irregularity between the calcaneus and navicular on an oblique or the anterior projection of the calcaneus on the lateral (Fig. 1). The later has been described as the anteater’s nose.12-14 Harris views can aid in visualizing talocalcaneal coalitions with bony bridging across the medial subtalar joint. Radiographic narrowing suggests a fibrous or cartilaginous coalition. A computed tomography (CT) scan will definitively define the extent of a coalition as well as identify additional coalitions that may be missed on plain films (Figs. 2 and 3). Greater than 50% of posterior facet involvement with talocalcaneal coalitions has a poor prognosis for regaining motion after resection.15 Magnetic resonance imaging (MRI) can be used to identify fibrous coalitions.16 Initial conservative treatment includes activity modification, nonsteroidal anti-inflammatory drugs, stretching, orthotics, and immobilization in a short leg walking cast. However, in the senior author’s experience, these treatments may relieve the pain for a short period but does not permit the athlete to return to active cutting sports. Contraindications to surgical excision include massive calcaneal coalitions and degenerative arthritis. A relative contraindication may be an older teenager (⬎16 years of age). Anterior talar beaking seen on lateral plain films is not secondary to arthritis but caused by an abnormal subtalar 173
H.G. Chambers and C.J. Haggerty
174
Figure 2 CT of s calcaneonavicular coalition.
Technique The treatment of the calcaneonavicular coalition is to excise the bony or fibrous tissue through the sinus tarsi and the procedure is optimized with an interposition graft of fat or the extensor digitorum brevis muscle (EDB).21 The patient is placed supine, with a bump placed under the ipsilateral hemipelvis and prepped from the ipsilateral buttock to the foot. This allows excision of an interposition fat graft from the
Figure 1 Oblique radiograph of the foot demonstrating a calcaneonavicular coalition.
motion and is not a contraindication to surgical intervention.16-20 With anesthesia, the patient’s subtalar motion may increase with a fibrous coalition because of elimination of peroneal spasm.
Figure 3 CT of a talocalcaneal coalition.
The foot and ankle in children and adolescents
175
Accessory Navicular Os navicularis is the most common accessory bone in the foot25-28 and usually presents as a painful plantar medial enlargement near the navicular. It is most frequently seen in active adolescents with associated minor trauma. Mild erythema, swelling, and callus may be present. Plain films of the foot may require an oblique view to identify the ossicle (Fig. 5). Classification of os navicularis includes a type I, which is an isolated seasmoid, a type II has a syndesmostic attachment to the navicular, and a type III will have a bony attachment.29 Initial conservative management includes orthoses, footwear
Figure 4 Oblique radiograph demonstrating complete excision of the calcaneonavicular coalition.
gluteal fold.22,23 We have recently used an abdominal fat graft with good results and no complications. The amount to be harvested is a piece approximately 2 ⫻ 2 ⫻ 2 cm. A sterile tourniquet is then used. Calcaneonavicular coalitions are approached through a dorsolateral incision starting just anterior to the distal fibula, centered over the sinus tarsi, and directed toward the base of the fifth metatarsal (Fig. 3).24 The exact location of the incision can be determined by using fluoroscopy. Carefully dissect to the level of the EDB with medial retraction of the tendons and preservation of the dorsal cutaneous branches of the superficial peroneal nerve. The EDB is sharply detached from its origin, leaving a small cuff for reattachment. The calcaneonavicular coalition can then be identified and carefully removed with osteotomes, rongeurs, and curettes. The talonavicular and calcaneocuboid joints should be identified so that the normal joints are not damaged. Complete excision is verified by placing a Freer elevator at the site and visualizing its depth with fluoroscopic imaging (Fig. 4). One should note a marked increase in the range of motion of the subtalar joint. The fat graft is then interposed at the excision site. The EDB is reattached and both sites are closed. Cadaveric dissections done at our institution demonstrated that the EDB is not of sufficient length to completely obliterate the space from the excised calcaneonavicular coalition. A short leg walking cast is then worn for 3 to 4 weeks. The patient usually uses crutches for the first 7 to 10 days. The patient is then placed in a walking boot and instructed in range of motion exercises for an additional month before return to sport. Occasionally formal physical therapy is necessary. If the disorder is bilateral, the cases are done eight weeks apart to permit the child to adequately rehab each. Continued postoperative pain can be due to incomplete excision or a missed secondary coalition and requires repeated radiographic imaging.
Figure 5 Oblique radiograph of the foot demonstrating an accessory navicular.
176
H.G. Chambers and C.J. Haggerty the ossicle can be visualized and excised. The ossicle is often found within the tendon as it attaches to the navicular. An osteotome or small saw can be used to resect a navicular prominence making the medial border of the navicular flush with the medial cuneiform (Fig. 6). This resection should be done in varus to avoid any talar cartilaginous damage. Failure to remove the navicular prominence may result in continued postoperative pain. Any disruption of the posterior tibialis insertion is repaired. If the posterior tibialis tendon appears to be lax after excision of a large accessory navicular, it should be advanced to the superior surface of the excised navicular and can be sewn in place through drill holes or through suture anchors placed in the navicular. Postoperatively a short leg partial weight bearing cast is worn for 3 to 4 weeks. Percutaneous drilling of type II lesions in young athletes also has been described.33 This procedure attempts to stimulate bony union between the ossicle and navicular with fluoroscopic drilling of the os navicularis at multiple points with a 1 mm diameter k-wire. A similar postoperative protocol is followed and results showed that most patients have resolution of pain even in the absence of complete bony union. This procedure avoids any defect to the posterior tibialis and avoids muscle atrophy encountered with repeated casting.
Figure 6 Resection of accessory navicular and the medial aspect of the navicular bone.
and activity modification, stretching, NSAIDs, local injection, and cast immobilization.
Technique Surgical intervention entails removal of the ossicle with a partial ostectomy of the navicular. The operation can include advancement of the tibialis posterior tendon as in the Kidner procedure,30,31 percutaneous drilling, or percutaneous screw fixation.32 Excision is performed with the patient supine through a dorsomedial incision from the talus centered over the accessory navicular following the course of the posterior tibialis tendon and ending near the base of the first metatarsal. The posterior tibialis tendon is identified and preserved. The posterior tibialis tendon can be reflected superiorly with minimal insertional disruption. With the tendon retracted,
Figure 7 Talar fracture with complete lateral ligament complex tear.
The foot and ankle in children and adolescents
177
Figure 8 Berndt and Harty Classification of osteochondral lesions of the talus. (Reprinted with permission from Chambers.34)
Os Subtibiale An os subtibiale is an accessory ossification center on the medial side of the ankle adjacent to the articular side of the medial malleolus (Fig. 7). Patients will complain of medialsided ankle pain that is worse with activity. Stress views can be obtained to determine the extent of ossicle motion. If conservative measures fail a standard anteromedial approach can be taken to the ankle and the ossicle can be excised. Cast immobilization for 3 weeks after surgery is also preferred.34,35
Osteochondral Lesion of the Talus Although relatively uncommon, osteochondral lesions of the talus (OLTs) should be considered when addressing children or young athletes that present with ankle pain.36 Initial imaging work up should include appropriate plain radiographs. The use of MRI is indicated if a talar lesion is viewed on plain films; if the history elicits catching, popping, locking, or a twisting injury; or if an effusion is found on physical examination. A CT scan is helpful to look for loose bodies but not as useful in identifying potential mechanical wear of adjacent cartilage and associated soft tissues. Surgical intervention is indicated if a loose body is identified on magnetic resonance or computed tomography. An identified lesion with an intact articular surface can initially be treated with a 6-week period of nonweight-bearing activity and immobilization in a short leg cast. After failure of nonoperative treatment, the surgical treatment options vary. Arthroscopic surgery using transtalar (retrograde) drilling of the lesion offers the benefit of penetrating the sclerotic rim of the lesion, theoretically promoting revascularization while minimizing potential damage to the articular surface. Antegrade drilling of the talar lesion necessitates drilling through intact cartilage and risks further articular damage.36 These lesions of the talar dome usually are secondary to ankle inversion; however, the etiology is controversial. Osteochondritis dissecans is a diagnostic term suggesting avascular necrosis whereas the term osteochondral lesion is purely descriptive and does not pinpoint an etiology. An
early report by Roden and coworkers in 1953 associated 55 lesions of the talus with a traumatic cause.37 Then, in 1959, Berndt and Harty found that these talar lesions were transchondral and attributable to trauma.36 At that time, they presented their classification system that is still widely reference today. Their staging system for OLTs: Stage I: small area of subchondral compression; Stage II: partially detached fragment; Stage III: completely detached fragment in the crater; and Stage IV: free fragment within the joint (Fig. 8). Multiple studies have reinforced the thought that lateral lesions of that talar dome are caused by trauma. Most recently, the metaanalysis by Tol and coworkers38 of 32 article with 52 patients showed that 44% of lesions were lateral and 56% were medial. Of these lesions, ankle trauma was reported in 94% of lateral lesions and in 62% of medial lesions. Lateral lesions usually are located more anteriorly in the talar dome whereas medial lesions more often are positioned more posterior. Avascular necrosis plays a role in the pathway of these lesions but is thought to be a secondary event, rather than the principle inciting factor. In practice, an unstable lesion with a loose body in the joint mandates operative treatment to reduce any additional mechanical wear or damage to the articular surface. Initial treatment in the pediatric population is conservative for stage I through III lesions. Good or excellent results can be expected in 45%, with a better prognosis the younger the patient and the longer the duration of nonoperative therapy.39-41 Surgical treatment options include open or arthroscopic debridement, bone grafting, autologous chondrocyte implantation, open drilling, microfracture, osteoarticular transfer, open or arthroscopic reduction and internal fixation, intra-articular drilling, and transtalar drilling.34,39-42 Open treatment is effective but is associated with ankle stiffness, and osteotomies performed for improved visualization may lead to nonunion or malunion.43,44 Arthroscopic treatment is less invasive in nature, leads to a more rapid recovery, and provides good results.38-43 However, arthroscopy can be limited by poor visualization of posterior and larger lesions, necessitating alternative open procedures.34 Standard radiographs consisting of anteroposterior, lat-
178
H.G. Chambers and C.J. Haggerty
Figure 9 Coban wrapping to provide traction for ankle arthroscopy. (Reprinted with permission from Tis et al.44)
eral, and mortise ankle views (Fig. 7). Ankle dorsiflexion and plantarflexion improve visualization of anterolateral and posteromedial lesions, respectively, and are used if there is any suspicion of a talar lesion. With identified talar dome radiolucencies or patients with convincing histories and physicals, an MRI is acquired. Identification of other soft-tissue pathology in the absence of talar osteochondral lesions makes MRI a better screening tool than a CT scan. MRI or CT scan of the ankle, in conjunction with plain films and diagnostic arthroscopy, aid in lesion classification and dictate treatment options. Imaging studies also pinpoint location, determine size, and the extent of the lesion which guides surgical planning. One also can use MRI to evaluate the articular cartilage integrity and associated soft-tissue pathology.
Technique for Transtalar Drilling of Osteochondral Lesions The hallmark of treatment of osteochondral lesions is drilling of the lesion to stimulate a healing response. There are no specific contraindications to transtalar drilling; however, the
Figure 10 Ankle arthroscopy set up. (Reprinted with permission from Tis et al.44)
Figure 11 Model demonstrating pin placement in the talus. (A) Anteroposterior (AP) view; (B) lateral view. (Reprinted with permission from Tis et al.44)
size of lesions should be taken into account. Lesions with cartilage loss less than 1 to 2 cm are more amenable to this treatment modality. Larger lesions have poorer outcomes because of the growth of fibrocartilaginous tissue that is biomechanically weaker to native hyaline cartilage. In addition, mechanical forces are not well tolerated by larger lesions. Fortunately, larger lesions are infrequent in the pediatric population. Surgical treatment begins with standard portals for diagnostic ankle arthroscopy; subsequent findings dictate any potential surgical intervention. Synovitis and unstable flaps are débrided, and loose bodies are removed. An effort is made to protect partially or fully intact articular surfaces with the transtalar (retrograde) drilling technique. Any lesions with a disrupted articular surface can be drilled retrograde or antegrade depending on technical feasibility and the surgeon’s experience. Complete lesions that are reducible and of adequate size may be fixed with buried bioabsorbable pins; however, this finding is exceedingly rare. In addition, these reducible lesions may be augmented with sclerotic rim drilling to enhance healing potential. The patient is positioned supine on a radiolucent operative table with a proximal thigh tourniquet. Distraction through a
The foot and ankle in children and adolescents
Figure 12 AP image of pin in the OLT. (Reprinted with permission from Tis et al.44)
standard sterile ankle strap or fashioned coban loop may be used per surgeon preference, but is not as helpful in younger patients as with adults (Fig. 9). The standard anatomic ankle landmarks are used for anterolateral portal placement. The peroneus tertius tendon is identified and an 18-gauge needle is placed just lateral to the tendon at the level of the joint line. As with all arthroscopic portals, incisions and instrument introduction should be accomplished with extreme care to avoid articular cartilage damage. Slightly tangential needle and cannula placement can help preserve the articular surface and facilitate introduction. Joint distention with 10 to 15 mL of sterile saline is performed through the needle, which is left in place to serve as an outflow cannula. The standard anteromedial portal is made medial to the tibialis anterior tendon. A longitudinal incision is made at the joint
Figure 13 Placement of pin. (Reprinted with permission from Tis et al.44)
179
Figure 14 Lateral image of pin in the OLT. (Reprinted with permission from Tis et al.44)
line and the portal tract dilated down to the capsule with an hemostat. A blunt trocar is used to create a capsular opening followed by the 2.7-mm short 30° arthroscope insertion. Routine diagnostic ankle arthroscopy is performed and the lesion is identified (Fig. 10). Any loose, unstable cartilage flaps are cautiously debrided with an arthroscopic shaver with care taken not to proprogate any existing flaps. Any lesions with a disrupted articular surface can be drilled in a retrograde or antegrade manner depending on technical feasibility and surgeon experience. Anterolateral lesions are more amenable to drilling through the articular cartilage. Complete lesions that are reducible and of adequate size may be fixed with buried bioabsorbable pins, however this finding is exceedingly rare. Additionally, these reducible lesions may be augmented with sclerotic rim drilling to enhance healing potential. A draped fluoroscopic image intensifier is positioned in an anteroposterior orientation over the center of the ankle. A wire driver with a 0.062 Kirschner wire (K-wire) is inserted through the talus on the opposite side of the lesion and then placed in the talus toward the lesion (Figs. 11 and 12). Imaging is then positioned laterally and the K-wire position is verified (Fig. 13). Once the trajectory is verified on anteroposterior and lateral imaging, the wire is advanced into the center of the lesion under the cartilage cap without penetrating the articular cartilage. Wire position is again confirmed under the anteroposterior view. This central K-wire is cut leaving 3 cm of the wire protruding from the skin, a second K-wire of the same diameter is used to circumferentially drill around the cut central wire (2-5 times; Fig. 14). Circumferential drilling around the central wire is also verified with biplanar fluoroscopy to ensure adequate depth placement due to the convexity of the talar dome. During retrograde
H.G. Chambers and C.J. Haggerty
180
Figure 15 (A) Preoperative lesion of the talus; (B) postoperative lesion of the talus. (Reprinted with permission from Tis et al.44)
drilling, arthroscopic visualization of the ankle can be used in conjunction with fluoroscopy to ensure continued preservation of articular integrity. Once drilling is complete, the central guide wire is removed from the talus followed by removal of the arthroscopic instruments. Portal sites are closed with single buried 4-0 Monocryl sutures. The patient is then placed in a nonweight-bearing cast for 4 weeks and a removeable boot with partial weight bearing for an additional 4 weeks. At 6 and 12 weeks, postoperatively plain radiographs are taken to evaluate the progress of the healing of the osteochondral lesion. Complications for transtalar drilling are similar to those associated with any arthroscopic ankle techniques. With moer than 600 ankle arthroscopies, Stetson and Ferkel reported a 9% overall complication rate.43 Infection, neurologic injury, ligamentous compromise, instrument failure, incisional pain, injury exacerbation, and articular surface
Figure 16 Hypertrophic synovium and scar tissue in the anterolateral ankle.
The foot and ankle in children and adolescents
181
Figure 17 Abduction Salter Harris II fracture of the distal tibia. (A) AP view; (B) lateral view.
damage are all potential complications. Meticulous surgical technique, use of small joint instruments, and the appropriate confirmation of wire position with fluoroscopic imaging can minimize most complications. The majority of complications reported in Stetson and Ferkel’s series were secondary to invasive distraction. The pediatric population has more compliant soft tissues which minimizes the need for distraction. The arthroscopic treatment results of OLTs in 12 ankles in 11 children during a 5 year period from 1997 to 2002 were documented by Chambers and coworkers.44 Six of 12 ankles were treated with transtalar drilling, with a mean age of 10.3 years and follow-up of 2.8 years. Using staging based on the Berndt and Harty system, Chambers and colleagues classified 4 patients with stage II lesion, 1 with a stage III lesion, and the last patient with a stage IV lesion. A 10-point scale was used to measure patient outcome in both pain and function. Severe pain and full, unrestricted activity were both rated as 10. Before surgery, pain, and function were respectively mea-
Figure 18 Supination external rotation Salter Harris II fracture of the distal tibia.
H.G. Chambers and C.J. Haggerty
182
corner of the ankle. Often referred to as a “meniscoid” lesion, this can cause chronic pain whenever the patient dorsiflexes his foot. An MRI with arthrography can be obtained that may demonstrate a soft-tissue lesion in the majority of cases. Occasionally, a hypertrophic distal anterior tibial-fibular ligament may be encountered. Most of the time, injecting steroids in the joint will not improve the symptoms. Arthroscopic debridement is effective in the majority of cases (Fig. 16).
Foot and Ankle Fractures in Children and Adolescents Physeal Fractures of the Ankle and Foot The most common fractures in children and adolescents are fractures through the physes of the distal tibia and distal fibula. The physis is the biomechanically weak link when a twisting injury is applied to the foot and ankle, and most of the injuries to the foot and ankle have some component of physeal injury associated with them. Although most of these injuries readily heal, there must be close follow-up as complete or partial physeal arrests can lead to limb length discrepancy as well as angular deformity.
Salter Harris I Fractures of the Fibula Perhaps the most common injury in the young child, most Salter Harris I fractures are nondisplaced and are diagnosed by tenderness and swelling over the distal fibula. The radiograph is often normal with the exception of soft tissue swelling. The fracture can be displaced. It should be reduced and rarely requires open reduction. A small percentage of patients will have a physeal arrest and in those patients with severe
Figure 19 Tillaux fracture.
sured at 8.5 and 1.3. Postoperatively pain improved to 2.3 and function to 9. Radiographic assessment showed lesion consolidation by 5 months in 5 of 6 lesions, with the remaining patient having marked clinical improvement despite absence of radiographic healing (Fig. 15).
Anterolateral Impingement of the Ankle Some children and adolescents will have continued pain in the anterior aspect of their ankles after either a bony injury or a sprain of the lateral ankle. After bleeding in the ankle and perhaps injury to the ligamentous structures and synovium there may be a coalition of scar tissue in the anterolateral
Figure 20 Fixation of the Tillaux fracture.
The foot and ankle in children and adolescents
183
Figure 21 (A) AP radiograph oft fracture (Salter Harris III); (B) lateral radiograph of triplane fracture (Salter Harris II).
swelling and a more violent mechanism of injury, long term follow-up is necessary.
Salter Harris II Fractures of the Distal Tibia Many textbooks state that there is a low incidence of problems with distal tibial Salter Harris I and Salter Harris II fractures of the distal tibia. In a recent study performed at San Diego Children’s Hospital, 140 ankle fractures were studied and it was found that 38% of the patients with this injury had physeal arrests associated with displaced frac-
ture of the distal tibia. The authors found that the abduction type injury (Fig. 17) was worse than the supinationexternal rotation injury (Fig. 18) and felt that anatomic reduction with removal of the interposed periosteum improved the outcome versus incomplete closed reduction.
Triplane and Tillaux Fractures Triplane and Tillaux fracture patterns in adolescents occur as a result of the ossification pattern of the distal tibia.
184 Ossification starts centrally and then progresses anteromedial, then posteromedial, and ends laterally. This circular pattern of ossification is responsible for these fractures with external rotation injuries in adolescents. They are generally considered part of a spectrum with initial injury causing Tillaux fractures and further external rotation leading to triplane fractures. These fractures present with minimal deformity, swelling, and focal tenderness to palpation after trauma. The fibular protects against fragment displacement and prevents gross deformity. Ankle sprains and associated tenderness are typically below the joint line. Tenderness at the joint line allows differentiation of these fractures with sprains.45 Appropriate treatment of these injuries is mandated to prevent complications as leg length discrepancy, post-traumatic arthritis, angular and rotational deformities.45 Tillaux fractures are Salter Harris III avulsion fractures of the anterolateral tibia epiphysis with an external rotation force leading to anterior tibiofibular ligament avulsion (Fig. 19). This tends to occur in adolescents during a window while the lateral physis is the last remaining part of the distal tibia that remains open. Appropriate plain films and a CT scan for displaced fractures can be used to help differentiate the two types of fractures and be used for preoperative planning. Nondisplaced and reducible fractures with less than 1 to 2 mm of displacement can be place in a nonweight-bearing long leg cast with slight knee flexion and tibial internal rotation for three weeks followed by a weight-bearing short leg cast. Closed reduction can be performed with internal rotation of the foot with direct pressure on the anterolateral tibial fragment. The reduction can be supplemented with a k-wire to help joystick the fragment. The fragment can be fixed with a percutaneously placed 4.0 mm cannulated cancellous screw. Open reduction uses a 2- to 3-cm incision directly over the fracture line. Care is taken to protect the superficial peroneal nerve while dissecting down to the fracture site. Interposed soft tissues are removed, fracture edges debrided, and the exposed articular surfaces are inspected for damage. Once reduced the screw is passed past the fracture site with care taken to ensure that the screw threads do not violate the distal tibial articular surface. The screw can be placed across the physis if necessary (Fig. 20). A nonweight-bearing short leg cast for 3 weeks followed by a weight bearing short leg cast is the standard postoperative course.45 Triplane fractures are managed in a similar manner but appear as a Salter Harris II on a lateral and a Salter Harris III on anteroposterior images (Fig. 21). Preoperative CT scans are essential to determine the course of fracture lines to determine appropriate screw placement orientation (Fig. 22). Nondisplaced and reducible fractures with less than 2 mm of displacement can be treated nonoperatively. The reduction is similar to Tillaux fractures, but multiple screw placement is required to hold the reduction with the anteroposterior plane in the metaphysis and in the epiphysis (Fig. 23). Triplane fractures also carry the risk of physeal bar formation, leading to growth irregularity.
H.G. Chambers and C.J. Haggerty
Figure 22 CT scan of a triplane fracture. (Color version of figure is available online.)
Postoperatively, the course is the same with a weightbearing short leg cast. Rehabilitation after cast removal requires full range of motion and strengthening before any return to activity. Initially the patient is allowed to jog and then may run if ankle is pain free. The patient will need to demonstrate unrestricted activity before participation in sporting activities.
Fifth Metatarsal Fractures Fifth metatarsal fracture fixation may be needed in young athletes for true Jones fractures as the fracture line occurs at the watershed area in the proximal aspect of the bone, which is susceptible to nonunions. An os vesalianum can
The foot and ankle in children and adolescents
185 ity. A bone scan or MRI can help differentiate a calcaneal stress fracture if uncertainty persists after the examination and plain films. The condition is self limited and not seen in adolescents after the closure of the apophysis. Treatment consists of conservative management with activity modification, NSAIDs, heel lifts, Achilles stretching, anterior leg compartment strengthening, or trial of short leg weight-bearing casts.
Kohler’s Disease
Figure 23 Fixation of the fracture carefully avoiding the physis.
Kohler’s disease presents in young children with complaints of pain and medial tenderness along the extent of the navicular. History will reveal gradual onset pain without antecedent trauma. The child may have antalgic gait with supination of the foot to shift weight to the lateral
occasionally be mistaken for a fracture when tenderness is present at the proximal metatarsal. Fractures at the base of the metatarsal are transverse and can be differentiated by the sagittal orientation of the os vesalianum. In addition Iselin’s disease or traction apophysitis at the proximal metatarsal must also be distinguished from a fracture with appropriate plain films. Isslen’s is due to tension from the insertion of the abductor digiti minimi and not from the peroneal brevis. True Jones metatarsal fractures require operative fixation due to their high nonunion rate and extended periods of immobilization required for conservative treatment. Fractures more distal to a Jones fracture with greater than 3 mm of displacement also require fixation. Operative intervention entails k-wire placement under fluoroscopic imaging through a small skin opening just proximal to the metatarsal base. Once verification on fluoroscopic imaging has been obtained showing appropriate k-wire placement within the intramedullary canal, a 4-mm partially threaded cannulated cancellous screw is placed. If necessary, bone graft from the distal tibia or iliac crest can be used to supplement the fixation.45
Overuse Injuries and Osteochondroses of the Foot and Ankle Calcaneal Apophysitis Sever’s apophysitis of the calcaneus is a frequent cause of heel pain in the immature athlete. It occurs more often in boys and is bilateral 60% of the time.46 On clinical examination no erythema, swelling, or warmth is found, and night pain is absent. Pain is worse with compression and with increased activity. A mild Achilles tendon contracture may be observed. Radiographic images can show sclerosis and irregularity, which may be normal and should be compared with the contralateral side. However, most radiographs, even in children who are asymptomatic will demonstrate irregular-
Figure 24 (A) Kohler’s disease (AP); (B) Kohler’s disease (lateral).
H.G. Chambers and C.J. Haggerty
186 border of the foot. On examination, the patient will have some dorsomedial tenderness and may have some mild swelling, no deformity will be present. Radiographic workup will show changes similar to Perthes disease with flattening, sclerosis, and irregular rarefaction (Fig. 24). Disruption of the blood supply secondary to compression with weight bearing has been thought to lead to Kohler’s disease. The course is self limited and recovery may be accelerated with immobilization in a short leg walking cast and other conservative measures. As with Sever’s disease there is no role for surgery in this self limiting condition. In the workup of both osteochondroses other conditions as stress fractures and coalitions must be ruled out.
17. 18. 19.
20. 21.
22. 23.
Conclusion Treatment of pediatric ankle injuries requires an understanding the developing immature ankle, mechanisms of injury, appropriate radiographic imaging, clinical examination, and correlation with patient history. Once the problem has been identified and other conditions have been excluded, appropriate treatment measures are easily implemented. Most pediatric ankle problems can be treated conservatively, but surgical measures are often successful in treating the injuries refractory to nonoperative management.
24.
25. 26.
27.
28. 29.
References 1. Stanitski C: Management of sports injuries in children and adolescents. Orthop Clin N Am 19:689-698, 1988 2. Wojtys EM: Sports injuries in the immature athlete. Orthop Clin N Am 18:689-708, 1987 3. Stanish WD: Lower leg, foot, and ankle injuries in young athletes. Clin Sports Med 14:651-668, 1995 4. Gregg J, Das M: Foot and ankle problems in preadolescent and adolescent athletes. Clin Sports Med 1:131-147, 1982 5. Griffin LY: Common sports injuries of the foot and ankle seen in children and adolescents. Orthop Clin N Am 25:83-93, 1994 6. McManama GB Jr: Ankle injuries in the young athlete. Clin Sports Med 7:547-562, 1988 7. Mafulli N: Intensive training in young athletes. Sports Med 9:229-243, 1990 8. Elkus RA: Tarsal coalition in the young athlete. Am J Sports Med 14: 477-480, 1986 9. O’Neill DB, Micheli LJ: Tarsal coalition: a follow-up of adolescent athletes. Am J Sports Med 17:544-549, 1989 10. Mosca VS: Flexible flatfoot and tarsal coalition, in Richards B, (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 211 11. Tachdjian MO: Tarsal Coalition, in, Herring HA (ed): Tachdjian’s Pediatric Orthopaedics (ed 3). Philadelphia, PA, Saunders, 2002, p 974 12. Drennan J: Tarsal coalitions. Instr Course Lect 45:323, 1996 13. Conway J, Cowell H: Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology 92:799, 1969 14. Oestreich AE, Mize WA, Crawford, et al: The “anteater nose”: a direct sign of calcaneonavicular coalition on the lateral radiograph. J Bone Joint Surg 7:709-711, 1987 15. Wilde P, Torode I, Dickens D, et al: Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg 76:797, 1994 16. Wechsler R, Schweitzer M, Deely D, et al: Tarsal coalition: depiction
30. 31. 32.
33.
34. 35. 36. 37.
38.
39.
40.
41. 42.
and characterization with CT and MR imaging. Radiology 193:447, 1994 Scranton PJ: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 69:533, 1987 Swiontkowski M, Scranton P, Hansen S: Tarsal coalitions: long-term results of surgical treatment. J Pediatr Orthop 3:287, 1983 Takakura Y, Sugimoto K, Tanaka Y, et al: Symptomatic talocalcaneal coalition: its clinical significance and treatment. Clin Orthop 269:249, 1991 Wilde P, Torode I, Dickens D, et al: Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg Br 76:797, 1994 Swiontkowski MF, Scranton PE, Hansen S: Tarsal coalitions: long term results of surgical treatment. J Pediatr Orthop 3:287-292, 1983 Scranton PJ: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 69:533, 1987 Olney B, Asher M: Excision of symptomatic coalition of the middle facet of the talocalcaneal joint. J Bone Joint Surg Am 69:539, 1992 Hoppenfeld S: The foot and ankle, in Hoppenfeld S, deBoer P (eds): Surgical Exposures in Orthopaedics: the anatomic approach, (ed 3). Philadelphia, PA, Lippincott Williams and Wilkins, 2003, pp 607675 Zadek I, Gold AM: The accessory tarsal scaphoid. J Bone Joint Surg 30-A:1948, 1948 Harris RI, Beath T: Army Foot Survey: an Investigation of Foot Ailments in Canadian soldiers. Ottawa, Ontario, Canada: National Research Council of Canada, 1947 Shands AR Jr., Wentz IJ: Congenital anomalies, accessory bones and osteochondritis in the feet of 850 children. Surg Clin North Am 33: 1643, 1953 Geist ES: The accessory scaphoid bone. J Bone Joint Surg 7:570, 1925 Grogan DP, Gasser SI, Ogden JA: The painful accessory navicular: a clinical and histopathological study. Foot Ankle 10:164, 1989 Kidner FC: The pre-hallux in relation to flatfoot. JAMA 101:1539, 1933 Kidner FC: The pre-hallux (accessory scaphoid) in its relation to flatfoot. J Bone Joint Surg 11:831, 1929 Otsuka K, Takagishi K, Tomizawa S, et al: Operative treatment of the accessory navicular in children. J Jpn Pediatr Orthop Assoc 10:117120, 2001 Shoichiro N, Kazuya S, Yoshinori T, et al: Percutaneous drilling of symptomatic accessory navicular in young athletes. Am Journal of Sports Med 33:531-535, 2005 Chambers HG: Ankle and foot disorders in skeletally immature athletes. Orthop Clin N Am 34:445-459, 2003 Stanitski CL, Micheli LJ: Observations on symptomatic medial malleolar ossification centers. J Pediatr Orthop 13:164-8, 1993 Berndt AL, Harty M: Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg 41A:988, 1959 Roden S, Tillegaard P, Unander-Scharin L: Osteochondritis dessecans and similar lesions of the talus: report of 55 cases with special reference to etiology and treatment. Acta Orthop Scand 23:51-66, 1953 Tol JL, Struijs PA, Bossuyt PM, et al: Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int 21:119-126, 2000 Lahm A, Erggelet C, Steinwachs M, et al: Arthroscopic management of osteochondral lesions of the talus: results of drilling and usefulness of magnetic resonance imaging before and after treatment. Arthroscopy 16:299-304, 2000 Schuman L, Struijs PA, van Dijk CN: Arthroscopic treatment for osteochondral defects of the talus. Results at follow-up at 2 to 11 years. J Bone Joint Surg Br 84:364-368, 2002 Ogilvie-Harris DJ, Sarrosa EA: Arthroscopic treatment of osteochondritis dissecans of the talus. Arthroscopy 15:805-808, 1999 Kumai T, Takakura Y, Higashiyama I, et al: Arthroscopic drilling for the
The foot and ankle in children and adolescents treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 81:1229-1235, 1999 43. Stetson WB, Ferkel RD: Ankle arthroscopy: I. Techniques and complications. J Am Acad Orthop Surg 4:17-23, 1996 44. Tis J, Ball S, Chambers HG: Extraarticular drilling of osteochondral lesions of the talus. Tech Foot Ankle Surg 3:62-67, 2004
187 45. Cummings RJ: Distal Tibial and Fibular Fractures, in Beaty JH, Kasser JR (eds): Rockwood and Wilkins’ Fractures in Children (ed 6). Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 1077-1128 46. Micheli L, Ireland M: Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop 7:34, 1987
Y
oung children are participating in year-round sports, encountering injuries with greater energy and regularity, and are sustaining more of foot and ankle injuries.1,2 Foot and ankle musculoskeletal complaints are the second most-common reason for primary care visits by young athletes.3 A careful history, focused physical examination, comprehension of foot and ankle mechanics, understanding of the anatomy and anatomic variants of the growing child’s foot, appropriate imaging, and an awareness of the demands and injuries associated with each particular sport will help identify the pathology.4-6 A differential diagnosis of ankle problems includes tarsal coalitions, ossicles, osteochondroses, fractures, tendonitis, ankle impingement, osteochondral lesions of the talus, and sprains.7 Most of these conditions can be treated conservatively but many require surgical intervention.
Tarsal Coalition Although present at birth, tarsal coalitions do not often become symptomatic until increased sporting activity in older children and adolescents occurs. The history may reveal recurrent ankle sprains or distal fibular fractures. Patients describe vague activity-related ankle and foot pain that may be alleviated with rest.8,9 Coalitions are frequently bilateral; however, presentation is generally unilateral. Pain is the pre-
*Rady Children’s Hospital San Diego, San Diego, CA. †Department of Orthopedic Surgery, University of California at San Diego, San Diego, CA. ‡Wilford Hall Air Force Medical Center, San Antonio, TX. Address reprint requests to Henry G. Chambers, MD, Rady Children’s Hospital San Diego, 3030 Children’s Way, Suite 410, San Diego, CA 92123. E-mail: [email protected]
1060-1872/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.otsm.2006.08.002
senting complaint, usually localized over the sinus tarsi with calcaneonavicular coalitions and medially in the hindfoot with talocalcaneal coalitions. Tenderness may be focal, but it is often diffuse. The most important physical finding is diminished subtalar motion (inversion and eversion). There may be spasm of the peroneals tendons, but this finding is not a consistent one. External rotation or foot progression angle may be increased, inversion is limited on heel rise,10 and the patient may have difficulty walking on the lateral border of the foot.11 Initial plain radiographs may demonstrate a bony union or irregularity between the calcaneus and navicular on an oblique or the anterior projection of the calcaneus on the lateral (Fig. 1). The later has been described as the anteater’s nose.12-14 Harris views can aid in visualizing talocalcaneal coalitions with bony bridging across the medial subtalar joint. Radiographic narrowing suggests a fibrous or cartilaginous coalition. A computed tomography (CT) scan will definitively define the extent of a coalition as well as identify additional coalitions that may be missed on plain films (Figs. 2 and 3). Greater than 50% of posterior facet involvement with talocalcaneal coalitions has a poor prognosis for regaining motion after resection.15 Magnetic resonance imaging (MRI) can be used to identify fibrous coalitions.16 Initial conservative treatment includes activity modification, nonsteroidal anti-inflammatory drugs, stretching, orthotics, and immobilization in a short leg walking cast. However, in the senior author’s experience, these treatments may relieve the pain for a short period but does not permit the athlete to return to active cutting sports. Contraindications to surgical excision include massive calcaneal coalitions and degenerative arthritis. A relative contraindication may be an older teenager (⬎16 years of age). Anterior talar beaking seen on lateral plain films is not secondary to arthritis but caused by an abnormal subtalar 173
H.G. Chambers and C.J. Haggerty
174
Figure 2 CT of s calcaneonavicular coalition.
Technique The treatment of the calcaneonavicular coalition is to excise the bony or fibrous tissue through the sinus tarsi and the procedure is optimized with an interposition graft of fat or the extensor digitorum brevis muscle (EDB).21 The patient is placed supine, with a bump placed under the ipsilateral hemipelvis and prepped from the ipsilateral buttock to the foot. This allows excision of an interposition fat graft from the
Figure 1 Oblique radiograph of the foot demonstrating a calcaneonavicular coalition.
motion and is not a contraindication to surgical intervention.16-20 With anesthesia, the patient’s subtalar motion may increase with a fibrous coalition because of elimination of peroneal spasm.
Figure 3 CT of a talocalcaneal coalition.
The foot and ankle in children and adolescents
175
Accessory Navicular Os navicularis is the most common accessory bone in the foot25-28 and usually presents as a painful plantar medial enlargement near the navicular. It is most frequently seen in active adolescents with associated minor trauma. Mild erythema, swelling, and callus may be present. Plain films of the foot may require an oblique view to identify the ossicle (Fig. 5). Classification of os navicularis includes a type I, which is an isolated seasmoid, a type II has a syndesmostic attachment to the navicular, and a type III will have a bony attachment.29 Initial conservative management includes orthoses, footwear
Figure 4 Oblique radiograph demonstrating complete excision of the calcaneonavicular coalition.
gluteal fold.22,23 We have recently used an abdominal fat graft with good results and no complications. The amount to be harvested is a piece approximately 2 ⫻ 2 ⫻ 2 cm. A sterile tourniquet is then used. Calcaneonavicular coalitions are approached through a dorsolateral incision starting just anterior to the distal fibula, centered over the sinus tarsi, and directed toward the base of the fifth metatarsal (Fig. 3).24 The exact location of the incision can be determined by using fluoroscopy. Carefully dissect to the level of the EDB with medial retraction of the tendons and preservation of the dorsal cutaneous branches of the superficial peroneal nerve. The EDB is sharply detached from its origin, leaving a small cuff for reattachment. The calcaneonavicular coalition can then be identified and carefully removed with osteotomes, rongeurs, and curettes. The talonavicular and calcaneocuboid joints should be identified so that the normal joints are not damaged. Complete excision is verified by placing a Freer elevator at the site and visualizing its depth with fluoroscopic imaging (Fig. 4). One should note a marked increase in the range of motion of the subtalar joint. The fat graft is then interposed at the excision site. The EDB is reattached and both sites are closed. Cadaveric dissections done at our institution demonstrated that the EDB is not of sufficient length to completely obliterate the space from the excised calcaneonavicular coalition. A short leg walking cast is then worn for 3 to 4 weeks. The patient usually uses crutches for the first 7 to 10 days. The patient is then placed in a walking boot and instructed in range of motion exercises for an additional month before return to sport. Occasionally formal physical therapy is necessary. If the disorder is bilateral, the cases are done eight weeks apart to permit the child to adequately rehab each. Continued postoperative pain can be due to incomplete excision or a missed secondary coalition and requires repeated radiographic imaging.
Figure 5 Oblique radiograph of the foot demonstrating an accessory navicular.
176
H.G. Chambers and C.J. Haggerty the ossicle can be visualized and excised. The ossicle is often found within the tendon as it attaches to the navicular. An osteotome or small saw can be used to resect a navicular prominence making the medial border of the navicular flush with the medial cuneiform (Fig. 6). This resection should be done in varus to avoid any talar cartilaginous damage. Failure to remove the navicular prominence may result in continued postoperative pain. Any disruption of the posterior tibialis insertion is repaired. If the posterior tibialis tendon appears to be lax after excision of a large accessory navicular, it should be advanced to the superior surface of the excised navicular and can be sewn in place through drill holes or through suture anchors placed in the navicular. Postoperatively a short leg partial weight bearing cast is worn for 3 to 4 weeks. Percutaneous drilling of type II lesions in young athletes also has been described.33 This procedure attempts to stimulate bony union between the ossicle and navicular with fluoroscopic drilling of the os navicularis at multiple points with a 1 mm diameter k-wire. A similar postoperative protocol is followed and results showed that most patients have resolution of pain even in the absence of complete bony union. This procedure avoids any defect to the posterior tibialis and avoids muscle atrophy encountered with repeated casting.
Figure 6 Resection of accessory navicular and the medial aspect of the navicular bone.
and activity modification, stretching, NSAIDs, local injection, and cast immobilization.
Technique Surgical intervention entails removal of the ossicle with a partial ostectomy of the navicular. The operation can include advancement of the tibialis posterior tendon as in the Kidner procedure,30,31 percutaneous drilling, or percutaneous screw fixation.32 Excision is performed with the patient supine through a dorsomedial incision from the talus centered over the accessory navicular following the course of the posterior tibialis tendon and ending near the base of the first metatarsal. The posterior tibialis tendon is identified and preserved. The posterior tibialis tendon can be reflected superiorly with minimal insertional disruption. With the tendon retracted,
Figure 7 Talar fracture with complete lateral ligament complex tear.
The foot and ankle in children and adolescents
177
Figure 8 Berndt and Harty Classification of osteochondral lesions of the talus. (Reprinted with permission from Chambers.34)
Os Subtibiale An os subtibiale is an accessory ossification center on the medial side of the ankle adjacent to the articular side of the medial malleolus (Fig. 7). Patients will complain of medialsided ankle pain that is worse with activity. Stress views can be obtained to determine the extent of ossicle motion. If conservative measures fail a standard anteromedial approach can be taken to the ankle and the ossicle can be excised. Cast immobilization for 3 weeks after surgery is also preferred.34,35
Osteochondral Lesion of the Talus Although relatively uncommon, osteochondral lesions of the talus (OLTs) should be considered when addressing children or young athletes that present with ankle pain.36 Initial imaging work up should include appropriate plain radiographs. The use of MRI is indicated if a talar lesion is viewed on plain films; if the history elicits catching, popping, locking, or a twisting injury; or if an effusion is found on physical examination. A CT scan is helpful to look for loose bodies but not as useful in identifying potential mechanical wear of adjacent cartilage and associated soft tissues. Surgical intervention is indicated if a loose body is identified on magnetic resonance or computed tomography. An identified lesion with an intact articular surface can initially be treated with a 6-week period of nonweight-bearing activity and immobilization in a short leg cast. After failure of nonoperative treatment, the surgical treatment options vary. Arthroscopic surgery using transtalar (retrograde) drilling of the lesion offers the benefit of penetrating the sclerotic rim of the lesion, theoretically promoting revascularization while minimizing potential damage to the articular surface. Antegrade drilling of the talar lesion necessitates drilling through intact cartilage and risks further articular damage.36 These lesions of the talar dome usually are secondary to ankle inversion; however, the etiology is controversial. Osteochondritis dissecans is a diagnostic term suggesting avascular necrosis whereas the term osteochondral lesion is purely descriptive and does not pinpoint an etiology. An
early report by Roden and coworkers in 1953 associated 55 lesions of the talus with a traumatic cause.37 Then, in 1959, Berndt and Harty found that these talar lesions were transchondral and attributable to trauma.36 At that time, they presented their classification system that is still widely reference today. Their staging system for OLTs: Stage I: small area of subchondral compression; Stage II: partially detached fragment; Stage III: completely detached fragment in the crater; and Stage IV: free fragment within the joint (Fig. 8). Multiple studies have reinforced the thought that lateral lesions of that talar dome are caused by trauma. Most recently, the metaanalysis by Tol and coworkers38 of 32 article with 52 patients showed that 44% of lesions were lateral and 56% were medial. Of these lesions, ankle trauma was reported in 94% of lateral lesions and in 62% of medial lesions. Lateral lesions usually are located more anteriorly in the talar dome whereas medial lesions more often are positioned more posterior. Avascular necrosis plays a role in the pathway of these lesions but is thought to be a secondary event, rather than the principle inciting factor. In practice, an unstable lesion with a loose body in the joint mandates operative treatment to reduce any additional mechanical wear or damage to the articular surface. Initial treatment in the pediatric population is conservative for stage I through III lesions. Good or excellent results can be expected in 45%, with a better prognosis the younger the patient and the longer the duration of nonoperative therapy.39-41 Surgical treatment options include open or arthroscopic debridement, bone grafting, autologous chondrocyte implantation, open drilling, microfracture, osteoarticular transfer, open or arthroscopic reduction and internal fixation, intra-articular drilling, and transtalar drilling.34,39-42 Open treatment is effective but is associated with ankle stiffness, and osteotomies performed for improved visualization may lead to nonunion or malunion.43,44 Arthroscopic treatment is less invasive in nature, leads to a more rapid recovery, and provides good results.38-43 However, arthroscopy can be limited by poor visualization of posterior and larger lesions, necessitating alternative open procedures.34 Standard radiographs consisting of anteroposterior, lat-
178
H.G. Chambers and C.J. Haggerty
Figure 9 Coban wrapping to provide traction for ankle arthroscopy. (Reprinted with permission from Tis et al.44)
eral, and mortise ankle views (Fig. 7). Ankle dorsiflexion and plantarflexion improve visualization of anterolateral and posteromedial lesions, respectively, and are used if there is any suspicion of a talar lesion. With identified talar dome radiolucencies or patients with convincing histories and physicals, an MRI is acquired. Identification of other soft-tissue pathology in the absence of talar osteochondral lesions makes MRI a better screening tool than a CT scan. MRI or CT scan of the ankle, in conjunction with plain films and diagnostic arthroscopy, aid in lesion classification and dictate treatment options. Imaging studies also pinpoint location, determine size, and the extent of the lesion which guides surgical planning. One also can use MRI to evaluate the articular cartilage integrity and associated soft-tissue pathology.
Technique for Transtalar Drilling of Osteochondral Lesions The hallmark of treatment of osteochondral lesions is drilling of the lesion to stimulate a healing response. There are no specific contraindications to transtalar drilling; however, the
Figure 10 Ankle arthroscopy set up. (Reprinted with permission from Tis et al.44)
Figure 11 Model demonstrating pin placement in the talus. (A) Anteroposterior (AP) view; (B) lateral view. (Reprinted with permission from Tis et al.44)
size of lesions should be taken into account. Lesions with cartilage loss less than 1 to 2 cm are more amenable to this treatment modality. Larger lesions have poorer outcomes because of the growth of fibrocartilaginous tissue that is biomechanically weaker to native hyaline cartilage. In addition, mechanical forces are not well tolerated by larger lesions. Fortunately, larger lesions are infrequent in the pediatric population. Surgical treatment begins with standard portals for diagnostic ankle arthroscopy; subsequent findings dictate any potential surgical intervention. Synovitis and unstable flaps are débrided, and loose bodies are removed. An effort is made to protect partially or fully intact articular surfaces with the transtalar (retrograde) drilling technique. Any lesions with a disrupted articular surface can be drilled retrograde or antegrade depending on technical feasibility and the surgeon’s experience. Complete lesions that are reducible and of adequate size may be fixed with buried bioabsorbable pins; however, this finding is exceedingly rare. In addition, these reducible lesions may be augmented with sclerotic rim drilling to enhance healing potential. The patient is positioned supine on a radiolucent operative table with a proximal thigh tourniquet. Distraction through a
The foot and ankle in children and adolescents
Figure 12 AP image of pin in the OLT. (Reprinted with permission from Tis et al.44)
standard sterile ankle strap or fashioned coban loop may be used per surgeon preference, but is not as helpful in younger patients as with adults (Fig. 9). The standard anatomic ankle landmarks are used for anterolateral portal placement. The peroneus tertius tendon is identified and an 18-gauge needle is placed just lateral to the tendon at the level of the joint line. As with all arthroscopic portals, incisions and instrument introduction should be accomplished with extreme care to avoid articular cartilage damage. Slightly tangential needle and cannula placement can help preserve the articular surface and facilitate introduction. Joint distention with 10 to 15 mL of sterile saline is performed through the needle, which is left in place to serve as an outflow cannula. The standard anteromedial portal is made medial to the tibialis anterior tendon. A longitudinal incision is made at the joint
Figure 13 Placement of pin. (Reprinted with permission from Tis et al.44)
179
Figure 14 Lateral image of pin in the OLT. (Reprinted with permission from Tis et al.44)
line and the portal tract dilated down to the capsule with an hemostat. A blunt trocar is used to create a capsular opening followed by the 2.7-mm short 30° arthroscope insertion. Routine diagnostic ankle arthroscopy is performed and the lesion is identified (Fig. 10). Any loose, unstable cartilage flaps are cautiously debrided with an arthroscopic shaver with care taken not to proprogate any existing flaps. Any lesions with a disrupted articular surface can be drilled in a retrograde or antegrade manner depending on technical feasibility and surgeon experience. Anterolateral lesions are more amenable to drilling through the articular cartilage. Complete lesions that are reducible and of adequate size may be fixed with buried bioabsorbable pins, however this finding is exceedingly rare. Additionally, these reducible lesions may be augmented with sclerotic rim drilling to enhance healing potential. A draped fluoroscopic image intensifier is positioned in an anteroposterior orientation over the center of the ankle. A wire driver with a 0.062 Kirschner wire (K-wire) is inserted through the talus on the opposite side of the lesion and then placed in the talus toward the lesion (Figs. 11 and 12). Imaging is then positioned laterally and the K-wire position is verified (Fig. 13). Once the trajectory is verified on anteroposterior and lateral imaging, the wire is advanced into the center of the lesion under the cartilage cap without penetrating the articular cartilage. Wire position is again confirmed under the anteroposterior view. This central K-wire is cut leaving 3 cm of the wire protruding from the skin, a second K-wire of the same diameter is used to circumferentially drill around the cut central wire (2-5 times; Fig. 14). Circumferential drilling around the central wire is also verified with biplanar fluoroscopy to ensure adequate depth placement due to the convexity of the talar dome. During retrograde
H.G. Chambers and C.J. Haggerty
180
Figure 15 (A) Preoperative lesion of the talus; (B) postoperative lesion of the talus. (Reprinted with permission from Tis et al.44)
drilling, arthroscopic visualization of the ankle can be used in conjunction with fluoroscopy to ensure continued preservation of articular integrity. Once drilling is complete, the central guide wire is removed from the talus followed by removal of the arthroscopic instruments. Portal sites are closed with single buried 4-0 Monocryl sutures. The patient is then placed in a nonweight-bearing cast for 4 weeks and a removeable boot with partial weight bearing for an additional 4 weeks. At 6 and 12 weeks, postoperatively plain radiographs are taken to evaluate the progress of the healing of the osteochondral lesion. Complications for transtalar drilling are similar to those associated with any arthroscopic ankle techniques. With moer than 600 ankle arthroscopies, Stetson and Ferkel reported a 9% overall complication rate.43 Infection, neurologic injury, ligamentous compromise, instrument failure, incisional pain, injury exacerbation, and articular surface
Figure 16 Hypertrophic synovium and scar tissue in the anterolateral ankle.
The foot and ankle in children and adolescents
181
Figure 17 Abduction Salter Harris II fracture of the distal tibia. (A) AP view; (B) lateral view.
damage are all potential complications. Meticulous surgical technique, use of small joint instruments, and the appropriate confirmation of wire position with fluoroscopic imaging can minimize most complications. The majority of complications reported in Stetson and Ferkel’s series were secondary to invasive distraction. The pediatric population has more compliant soft tissues which minimizes the need for distraction. The arthroscopic treatment results of OLTs in 12 ankles in 11 children during a 5 year period from 1997 to 2002 were documented by Chambers and coworkers.44 Six of 12 ankles were treated with transtalar drilling, with a mean age of 10.3 years and follow-up of 2.8 years. Using staging based on the Berndt and Harty system, Chambers and colleagues classified 4 patients with stage II lesion, 1 with a stage III lesion, and the last patient with a stage IV lesion. A 10-point scale was used to measure patient outcome in both pain and function. Severe pain and full, unrestricted activity were both rated as 10. Before surgery, pain, and function were respectively mea-
Figure 18 Supination external rotation Salter Harris II fracture of the distal tibia.
H.G. Chambers and C.J. Haggerty
182
corner of the ankle. Often referred to as a “meniscoid” lesion, this can cause chronic pain whenever the patient dorsiflexes his foot. An MRI with arthrography can be obtained that may demonstrate a soft-tissue lesion in the majority of cases. Occasionally, a hypertrophic distal anterior tibial-fibular ligament may be encountered. Most of the time, injecting steroids in the joint will not improve the symptoms. Arthroscopic debridement is effective in the majority of cases (Fig. 16).
Foot and Ankle Fractures in Children and Adolescents Physeal Fractures of the Ankle and Foot The most common fractures in children and adolescents are fractures through the physes of the distal tibia and distal fibula. The physis is the biomechanically weak link when a twisting injury is applied to the foot and ankle, and most of the injuries to the foot and ankle have some component of physeal injury associated with them. Although most of these injuries readily heal, there must be close follow-up as complete or partial physeal arrests can lead to limb length discrepancy as well as angular deformity.
Salter Harris I Fractures of the Fibula Perhaps the most common injury in the young child, most Salter Harris I fractures are nondisplaced and are diagnosed by tenderness and swelling over the distal fibula. The radiograph is often normal with the exception of soft tissue swelling. The fracture can be displaced. It should be reduced and rarely requires open reduction. A small percentage of patients will have a physeal arrest and in those patients with severe
Figure 19 Tillaux fracture.
sured at 8.5 and 1.3. Postoperatively pain improved to 2.3 and function to 9. Radiographic assessment showed lesion consolidation by 5 months in 5 of 6 lesions, with the remaining patient having marked clinical improvement despite absence of radiographic healing (Fig. 15).
Anterolateral Impingement of the Ankle Some children and adolescents will have continued pain in the anterior aspect of their ankles after either a bony injury or a sprain of the lateral ankle. After bleeding in the ankle and perhaps injury to the ligamentous structures and synovium there may be a coalition of scar tissue in the anterolateral
Figure 20 Fixation of the Tillaux fracture.
The foot and ankle in children and adolescents
183
Figure 21 (A) AP radiograph oft fracture (Salter Harris III); (B) lateral radiograph of triplane fracture (Salter Harris II).
swelling and a more violent mechanism of injury, long term follow-up is necessary.
Salter Harris II Fractures of the Distal Tibia Many textbooks state that there is a low incidence of problems with distal tibial Salter Harris I and Salter Harris II fractures of the distal tibia. In a recent study performed at San Diego Children’s Hospital, 140 ankle fractures were studied and it was found that 38% of the patients with this injury had physeal arrests associated with displaced frac-
ture of the distal tibia. The authors found that the abduction type injury (Fig. 17) was worse than the supinationexternal rotation injury (Fig. 18) and felt that anatomic reduction with removal of the interposed periosteum improved the outcome versus incomplete closed reduction.
Triplane and Tillaux Fractures Triplane and Tillaux fracture patterns in adolescents occur as a result of the ossification pattern of the distal tibia.
184 Ossification starts centrally and then progresses anteromedial, then posteromedial, and ends laterally. This circular pattern of ossification is responsible for these fractures with external rotation injuries in adolescents. They are generally considered part of a spectrum with initial injury causing Tillaux fractures and further external rotation leading to triplane fractures. These fractures present with minimal deformity, swelling, and focal tenderness to palpation after trauma. The fibular protects against fragment displacement and prevents gross deformity. Ankle sprains and associated tenderness are typically below the joint line. Tenderness at the joint line allows differentiation of these fractures with sprains.45 Appropriate treatment of these injuries is mandated to prevent complications as leg length discrepancy, post-traumatic arthritis, angular and rotational deformities.45 Tillaux fractures are Salter Harris III avulsion fractures of the anterolateral tibia epiphysis with an external rotation force leading to anterior tibiofibular ligament avulsion (Fig. 19). This tends to occur in adolescents during a window while the lateral physis is the last remaining part of the distal tibia that remains open. Appropriate plain films and a CT scan for displaced fractures can be used to help differentiate the two types of fractures and be used for preoperative planning. Nondisplaced and reducible fractures with less than 1 to 2 mm of displacement can be place in a nonweight-bearing long leg cast with slight knee flexion and tibial internal rotation for three weeks followed by a weight-bearing short leg cast. Closed reduction can be performed with internal rotation of the foot with direct pressure on the anterolateral tibial fragment. The reduction can be supplemented with a k-wire to help joystick the fragment. The fragment can be fixed with a percutaneously placed 4.0 mm cannulated cancellous screw. Open reduction uses a 2- to 3-cm incision directly over the fracture line. Care is taken to protect the superficial peroneal nerve while dissecting down to the fracture site. Interposed soft tissues are removed, fracture edges debrided, and the exposed articular surfaces are inspected for damage. Once reduced the screw is passed past the fracture site with care taken to ensure that the screw threads do not violate the distal tibial articular surface. The screw can be placed across the physis if necessary (Fig. 20). A nonweight-bearing short leg cast for 3 weeks followed by a weight bearing short leg cast is the standard postoperative course.45 Triplane fractures are managed in a similar manner but appear as a Salter Harris II on a lateral and a Salter Harris III on anteroposterior images (Fig. 21). Preoperative CT scans are essential to determine the course of fracture lines to determine appropriate screw placement orientation (Fig. 22). Nondisplaced and reducible fractures with less than 2 mm of displacement can be treated nonoperatively. The reduction is similar to Tillaux fractures, but multiple screw placement is required to hold the reduction with the anteroposterior plane in the metaphysis and in the epiphysis (Fig. 23). Triplane fractures also carry the risk of physeal bar formation, leading to growth irregularity.
H.G. Chambers and C.J. Haggerty
Figure 22 CT scan of a triplane fracture. (Color version of figure is available online.)
Postoperatively, the course is the same with a weightbearing short leg cast. Rehabilitation after cast removal requires full range of motion and strengthening before any return to activity. Initially the patient is allowed to jog and then may run if ankle is pain free. The patient will need to demonstrate unrestricted activity before participation in sporting activities.
Fifth Metatarsal Fractures Fifth metatarsal fracture fixation may be needed in young athletes for true Jones fractures as the fracture line occurs at the watershed area in the proximal aspect of the bone, which is susceptible to nonunions. An os vesalianum can
The foot and ankle in children and adolescents
185 ity. A bone scan or MRI can help differentiate a calcaneal stress fracture if uncertainty persists after the examination and plain films. The condition is self limited and not seen in adolescents after the closure of the apophysis. Treatment consists of conservative management with activity modification, NSAIDs, heel lifts, Achilles stretching, anterior leg compartment strengthening, or trial of short leg weight-bearing casts.
Kohler’s Disease
Figure 23 Fixation of the fracture carefully avoiding the physis.
Kohler’s disease presents in young children with complaints of pain and medial tenderness along the extent of the navicular. History will reveal gradual onset pain without antecedent trauma. The child may have antalgic gait with supination of the foot to shift weight to the lateral
occasionally be mistaken for a fracture when tenderness is present at the proximal metatarsal. Fractures at the base of the metatarsal are transverse and can be differentiated by the sagittal orientation of the os vesalianum. In addition Iselin’s disease or traction apophysitis at the proximal metatarsal must also be distinguished from a fracture with appropriate plain films. Isslen’s is due to tension from the insertion of the abductor digiti minimi and not from the peroneal brevis. True Jones metatarsal fractures require operative fixation due to their high nonunion rate and extended periods of immobilization required for conservative treatment. Fractures more distal to a Jones fracture with greater than 3 mm of displacement also require fixation. Operative intervention entails k-wire placement under fluoroscopic imaging through a small skin opening just proximal to the metatarsal base. Once verification on fluoroscopic imaging has been obtained showing appropriate k-wire placement within the intramedullary canal, a 4-mm partially threaded cannulated cancellous screw is placed. If necessary, bone graft from the distal tibia or iliac crest can be used to supplement the fixation.45
Overuse Injuries and Osteochondroses of the Foot and Ankle Calcaneal Apophysitis Sever’s apophysitis of the calcaneus is a frequent cause of heel pain in the immature athlete. It occurs more often in boys and is bilateral 60% of the time.46 On clinical examination no erythema, swelling, or warmth is found, and night pain is absent. Pain is worse with compression and with increased activity. A mild Achilles tendon contracture may be observed. Radiographic images can show sclerosis and irregularity, which may be normal and should be compared with the contralateral side. However, most radiographs, even in children who are asymptomatic will demonstrate irregular-
Figure 24 (A) Kohler’s disease (AP); (B) Kohler’s disease (lateral).
H.G. Chambers and C.J. Haggerty
186 border of the foot. On examination, the patient will have some dorsomedial tenderness and may have some mild swelling, no deformity will be present. Radiographic workup will show changes similar to Perthes disease with flattening, sclerosis, and irregular rarefaction (Fig. 24). Disruption of the blood supply secondary to compression with weight bearing has been thought to lead to Kohler’s disease. The course is self limited and recovery may be accelerated with immobilization in a short leg walking cast and other conservative measures. As with Sever’s disease there is no role for surgery in this self limiting condition. In the workup of both osteochondroses other conditions as stress fractures and coalitions must be ruled out.
17. 18. 19.
20. 21.
22. 23.
Conclusion Treatment of pediatric ankle injuries requires an understanding the developing immature ankle, mechanisms of injury, appropriate radiographic imaging, clinical examination, and correlation with patient history. Once the problem has been identified and other conditions have been excluded, appropriate treatment measures are easily implemented. Most pediatric ankle problems can be treated conservatively, but surgical measures are often successful in treating the injuries refractory to nonoperative management.
24.
25. 26.
27.
28. 29.
References 1. Stanitski C: Management of sports injuries in children and adolescents. Orthop Clin N Am 19:689-698, 1988 2. Wojtys EM: Sports injuries in the immature athlete. Orthop Clin N Am 18:689-708, 1987 3. Stanish WD: Lower leg, foot, and ankle injuries in young athletes. Clin Sports Med 14:651-668, 1995 4. Gregg J, Das M: Foot and ankle problems in preadolescent and adolescent athletes. Clin Sports Med 1:131-147, 1982 5. Griffin LY: Common sports injuries of the foot and ankle seen in children and adolescents. Orthop Clin N Am 25:83-93, 1994 6. McManama GB Jr: Ankle injuries in the young athlete. Clin Sports Med 7:547-562, 1988 7. Mafulli N: Intensive training in young athletes. Sports Med 9:229-243, 1990 8. Elkus RA: Tarsal coalition in the young athlete. Am J Sports Med 14: 477-480, 1986 9. O’Neill DB, Micheli LJ: Tarsal coalition: a follow-up of adolescent athletes. Am J Sports Med 17:544-549, 1989 10. Mosca VS: Flexible flatfoot and tarsal coalition, in Richards B, (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 211 11. Tachdjian MO: Tarsal Coalition, in, Herring HA (ed): Tachdjian’s Pediatric Orthopaedics (ed 3). Philadelphia, PA, Saunders, 2002, p 974 12. Drennan J: Tarsal coalitions. Instr Course Lect 45:323, 1996 13. Conway J, Cowell H: Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology 92:799, 1969 14. Oestreich AE, Mize WA, Crawford, et al: The “anteater nose”: a direct sign of calcaneonavicular coalition on the lateral radiograph. J Bone Joint Surg 7:709-711, 1987 15. Wilde P, Torode I, Dickens D, et al: Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg 76:797, 1994 16. Wechsler R, Schweitzer M, Deely D, et al: Tarsal coalition: depiction
30. 31. 32.
33.
34. 35. 36. 37.
38.
39.
40.
41. 42.
and characterization with CT and MR imaging. Radiology 193:447, 1994 Scranton PJ: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 69:533, 1987 Swiontkowski M, Scranton P, Hansen S: Tarsal coalitions: long-term results of surgical treatment. J Pediatr Orthop 3:287, 1983 Takakura Y, Sugimoto K, Tanaka Y, et al: Symptomatic talocalcaneal coalition: its clinical significance and treatment. Clin Orthop 269:249, 1991 Wilde P, Torode I, Dickens D, et al: Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg Br 76:797, 1994 Swiontkowski MF, Scranton PE, Hansen S: Tarsal coalitions: long term results of surgical treatment. J Pediatr Orthop 3:287-292, 1983 Scranton PJ: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 69:533, 1987 Olney B, Asher M: Excision of symptomatic coalition of the middle facet of the talocalcaneal joint. J Bone Joint Surg Am 69:539, 1992 Hoppenfeld S: The foot and ankle, in Hoppenfeld S, deBoer P (eds): Surgical Exposures in Orthopaedics: the anatomic approach, (ed 3). Philadelphia, PA, Lippincott Williams and Wilkins, 2003, pp 607675 Zadek I, Gold AM: The accessory tarsal scaphoid. J Bone Joint Surg 30-A:1948, 1948 Harris RI, Beath T: Army Foot Survey: an Investigation of Foot Ailments in Canadian soldiers. Ottawa, Ontario, Canada: National Research Council of Canada, 1947 Shands AR Jr., Wentz IJ: Congenital anomalies, accessory bones and osteochondritis in the feet of 850 children. Surg Clin North Am 33: 1643, 1953 Geist ES: The accessory scaphoid bone. J Bone Joint Surg 7:570, 1925 Grogan DP, Gasser SI, Ogden JA: The painful accessory navicular: a clinical and histopathological study. Foot Ankle 10:164, 1989 Kidner FC: The pre-hallux in relation to flatfoot. JAMA 101:1539, 1933 Kidner FC: The pre-hallux (accessory scaphoid) in its relation to flatfoot. J Bone Joint Surg 11:831, 1929 Otsuka K, Takagishi K, Tomizawa S, et al: Operative treatment of the accessory navicular in children. J Jpn Pediatr Orthop Assoc 10:117120, 2001 Shoichiro N, Kazuya S, Yoshinori T, et al: Percutaneous drilling of symptomatic accessory navicular in young athletes. Am Journal of Sports Med 33:531-535, 2005 Chambers HG: Ankle and foot disorders in skeletally immature athletes. Orthop Clin N Am 34:445-459, 2003 Stanitski CL, Micheli LJ: Observations on symptomatic medial malleolar ossification centers. J Pediatr Orthop 13:164-8, 1993 Berndt AL, Harty M: Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg 41A:988, 1959 Roden S, Tillegaard P, Unander-Scharin L: Osteochondritis dessecans and similar lesions of the talus: report of 55 cases with special reference to etiology and treatment. Acta Orthop Scand 23:51-66, 1953 Tol JL, Struijs PA, Bossuyt PM, et al: Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int 21:119-126, 2000 Lahm A, Erggelet C, Steinwachs M, et al: Arthroscopic management of osteochondral lesions of the talus: results of drilling and usefulness of magnetic resonance imaging before and after treatment. Arthroscopy 16:299-304, 2000 Schuman L, Struijs PA, van Dijk CN: Arthroscopic treatment for osteochondral defects of the talus. Results at follow-up at 2 to 11 years. J Bone Joint Surg Br 84:364-368, 2002 Ogilvie-Harris DJ, Sarrosa EA: Arthroscopic treatment of osteochondritis dissecans of the talus. Arthroscopy 15:805-808, 1999 Kumai T, Takakura Y, Higashiyama I, et al: Arthroscopic drilling for the
The foot and ankle in children and adolescents treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 81:1229-1235, 1999 43. Stetson WB, Ferkel RD: Ankle arthroscopy: I. Techniques and complications. J Am Acad Orthop Surg 4:17-23, 1996 44. Tis J, Ball S, Chambers HG: Extraarticular drilling of osteochondral lesions of the talus. Tech Foot Ankle Surg 3:62-67, 2004
187 45. Cummings RJ: Distal Tibial and Fibular Fractures, in Beaty JH, Kasser JR (eds): Rockwood and Wilkins’ Fractures in Children (ed 6). Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 1077-1128 46. Micheli L, Ireland M: Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop 7:34, 1987