SLR - December 2011 - Jamie L. Hall
Reference: Gourineni, P; Gupta, A. (2011). Medial Joint Space Widening of the Ankle in Displaced Tillaux and Triplane Fractures in Children. Journal of Orthopaedic Trauma, 25(10): 608-611.
Scientific Literature Review
Reviewed by: Jamie L. Hall, DPM
Residency Program: OCPM & University Hospital Richmond Heights Medical Center
Podiatric Relevance:
Articles featuring medial joint space widening in adults are not a highly researched topic, yet these same injuries in children are documented even less. Treatment in adults and children with the same type of injury varies widely due to the open physis in the immature skeleton. This article compares the reduction and fixation techniques required in children for optimal results. Due to the increased number of children participating in high-activity sports today, these eversion ankle fractures are becoming a more common occurrence.
Methods:
For this retrospective study, the authors gathered 22 consecutive cases of displaced triplane and Tillaux fractures over a 6 year period. The study group included 14 boys and 8 girls with an age range of 10-15 years. Plain film radiographs were obtained for each case at the time of injury. Any fracture with displacement measuring greater than 1mm of widening compared to the superior ankle space was treated with reduction. Medial joint space widening relative to the superior and lateral ankle spaces by greater than 1mm was noted on plain film radiographs of 17 subjects. Post-reduction measurements were taken from both the intraoperative and clinic radiographs. All 22 patients were followed in clinic for at least 1 year post reduction. Successful outcome was based upon pre- and post-operative reduction in the medial ankle joint space and closure of the physis.
Results:
On average, the medial joint space widening was 2.53mm. In 19 of the cases, the talus, lateral malleolus and the lateral tibial fragment moved together as one unit causing medal joint space widening. All Tillaux fractures that were evaluated consisted of two-part fractures with one fracture line. The triplane fractures were comprised of 11 two-part part fractures and 3 three-part fractures. Medial joint space widening was documented in 86% of the fractures evaluated. Five fractures were treated with closed reduction and screw fixation, while the remaining seventeen cases were treated with ORIF. Complete closure of the physis was seen in 3-9 months in 14 patients, six patients had an open physis at the end of the one year period. Two patients had hardware failure within several months of surgery, however, the authors were not aware of any complications from this failure.
Conclusions:
Unfortunately, this study only has 22 cases and they vary in treatment methods. The patients were also not examined beyond one year for a functional outcome of the reduction. The study suggests that medial joint space widening is a useful sign to evaluate displacement and is often an indication of fracture. The authors need to have a longer follow-up period with the patients. Functional outcome in children is of utmost importance as degenerative joint disease is a likely future diagnosis. This study should be limited to one fracture type, as well as one reduction technique to get a clear idea of the functional outcome. These separate studies could then be compared by functional outcomes to get a better understanding of which reduction and fixation technique could be the most beneficial.