Daniel Green, Philip Henman, Mamoun Kremli
The physeal fragment is fixed with a retrograde intramedullary screw. This risks growth arrest and is only recommended in adolescents.
Open reduction is necessary if it is not possible to obtain or maintain adequate reduction by closed manipulation.
The main treatment goals are:
Appropriately sized cannulated or noncannulated screws can be used.
The following equipment is used:
Place the patient in a supine position on a radiolucent table with a block under the lower leg proximal to the heel.
Perform a lateral incision from just distal to the tip of the fibula to the level of the fracture.
It may be necessary to remove interposed soft tissue and periosteum before reducing the fracture under direct vision, without devitalizing the fracture fragments.
Insert a screw in a standard manner.
Confirm reduction, fracture stability, and screw placement with an image intensifier.
Recheck the fracture alignment and implant position clinically and with an image intensifier before anesthesia is reversed.
Confirm stability of the fixation by moving the ankle through a range of dorsi/plantar flexion.
A molded below-knee cast or fixed ankle boot is recommended for a period of 2–6 weeks as the strength of fixation may not provide sufficient stability for unrestricted weight bearing.
Weight-bearing is encouraged.
Older children may be able to use crutches or a walker.
Younger children may require a period of bed rest followed by mobilization in a wheelchair.
Patients tend to be more comfortable if the limb is splinted.
Routine pain medication is prescribed for 3–5 days after surgery.
The patient should be examined frequently to exclude neurovascular compromise or evolving compartment syndrome.
Discharge follows local practice and is usually possible within 48 hours.
The first clinical and radiological follow-up is usually undertaken 5–7 days after surgery to check the wound and confirm that reduction has been maintained.
A cast or boot can be removed 2–6 weeks after injury.
After cast removal, graduated weight-bearing is usually possible.
Patients are encouraged to start range-of-motion exercises. Physiotherapy supervision may be required in some cases but is not mandatory.
Sports and activities that involve running and jumping are not recommended until full recovery of local symptoms.
Implant removal is not mandatory and requires a risk-benefit discussion with patient and carers.