Authors of section


Daniel Green, Philip Henman, Mamoun Kremli

Executive Editor

James Hunter

General Editor

Fergal Monsell

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Clinical evaluation

1. General considerations

After the wrist, the ankle is the second most common site of physeal injury.

Most ankle injuries in children are the result of sport and leisure activities.

The pattern of injury depends on the age of the child as well as the mechanism and direction of force.

Proximal swelling may indicate an isolated or associated syndesmotic injury.

Skeletal maturity

The age at which the distal tibial physis closes is variable and should be assessed individually. In skeletally mature patients, distal tibial fractures commonly have adult patterns.

Isolated ligament injuries are more common after skeletal maturity.

2. History

A careful history should exclude additional and nonaccidental injuries. It should also include the mechanism of injury and reports of any witnesses to the incident.

3. Patient assessment

Symptoms and signs

The main symptom is pain in the lower leg or ankle.

In most cases, the patient is not able to walk.

The signs include:

  • Swelling
  • Bruising
  • Tenderness
  • Deformity

Physical examination

Injuries at other sites should be considered, especially in high-energy trauma.

The patient should be assessed using standard algorithms (ATLS).

The soft-tissue envelope, and vascular and neurological status of the limb must be accurately assessed and recorded. This should occur after any injury but is particularly important after a high-energy mechanism and significant fracture displacement. Examination should be repeated after temporary or definitive reduction.

Medial and lateral malleolar tenderness should be identified. The ankle is likely to be stable if there is no medial tenderness.

Assessment of passive range of motion should be performed cautiously to avoid unnecessary pain.

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