Adult & Pediatric Fracture Care


 

Adult & Pediatric Fracture Care

Fractures or broken bones are very common injuries in the lower extremity.  At Florida Orthopedic Foot & Ankle Center we are well trained and have treated hundreds of traumatic conditions of the lower extremity.  In all cases a detailed exam is performed and all treatment options are explained and offered to patients.  There are many fractures that can be treated

In some situations, a fracture may need to be stabilized temporarily with an external fixator in order to let the swelling reduce.  If one of these are used, they are usually in place for a week or two and then definitive surgery can be performed and the bones put back into proper alignment.  However, most of the time fractures can be fixed in one trip to the operating room once the swelling is reduced enough to safely perform the surgery. 

Ankle Fractures

What Is an Ankle Fracture?   

A fracture is a partial or complete break in a bone. Fractures in the ankle can range from the less serious avulsion injuries (small pieces of bone that have been pulled off) to severe shattering-type breaks of the tibia, fibula or both.

Ankle fractures are common injuries most often caused by the ankle rolling inward or outward. Many people mistake an ankle fracture for an ankle sprain, but they are quite different and therefore require an accurate and early diagnosis. They sometimes occur simultaneously.

Symptoms

An ankle fracture is accompanied by one or all of these symptoms:

  • Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
  • Significant swelling, which may occur along the length of the leg or may be more localized.
  • Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
  • Bruising that develops soon after the injury.
  • Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
  • Change in the appearance of the ankle—it will look different from the other ankle.
  • Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.

 

 


Diagnosis

Following an ankle injury, it is important to have the ankle evaluated by a foot and ankle surgeon for proper diagnosis and treatment. If you are unable to do so right away, go to the emergency room and then follow up with a foot and ankle surgeon as soon as possible for a more thorough assessment.

The affected limb will be examined by the foot and ankle surgeon who will touch specific areas to evaluate the injury. In addition, the surgeon may order x-rays and other imaging studies, as necessary.

Nonsurgical Treatment

Treatment of ankle fractures depends on the type and severity of the injury. At first, the foot and ankle surgeon will want you to follow the RICE protocol:

  • Rest: Stay off the injured ankle. Walking may cause further injury.
  • Ice: Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
  • Compression: An elastic wrap should be used to control swelling.
  • Elevation: The ankle should be raised slightly above the level of your heart to reduce swelling.

Additional treatment options include:

  • Immobilization. Certain fractures are treated by protecting and restricting the ankle and foot in a cast or splint. This allows the bone to heal.
  • Prescription medications. To help relieve the pain, the surgeon may prescribe pain medications or anti-inflammatory drugs.
  • When Is Surgery Needed?

For some ankle fractures especially displaced fractures, surgery is needed to repair the fracture and other soft tissue-related injuries. The foot and ankle surgeon will select the procedure that is appropriate for your injury.

Follow-Up Care

It is important to follow your surgeon’s instructions after treatment. Failure to do so can lead to infection, deformity, arthritis and chronic pain.


  

This is a 40-year-old female who presented to the ER after a water slide accident.  She sustained a severe tibia and ankle fracture which was displaced.

 


She was immediately taken to the operating room and the fibula was fixed and a temporary external fixator was applied to let the soft tissue swelling to resolve.


 

X-ray of the reduced tibia fracture and the fibula which has been plated and brought out to anatomical position

  


Definitive fixation of the fractures. The ankle joint has been restored anatomically.

 

  

This is a 78 year-old patient who fell at home.  The ankle is broken in multiple areas and is dislocated.


 

Internal fixation was applied and the ankle joint is now in anatomic position.


 

Lateral view of an ankle fracture

 

AP view of a displaced ankle fracture

 

Lateral view after a temporary external fixator has been placed

 

  

Anterior view of the same ankle with external fixator in place.  Note the excellent alignment.  The external fixator allowed the soft tissue swelling to go down and held the bones in proper position.

 

 

AP view after final ORIF.

 


Lateral view after final ORIF

 

 

Lateral view of a displaced ankle fracture

 

AP view of the same displaced ankle fracture

 

External fixator has been placed to allow the soft tissue swelling to reduce before final ORIF of the ankle


 

 

   

Interoperative confirmation that the joint is reduced with an external fixator


Pediatric Fractures

Growth plates are areas at the end of bones that allow bones to grow in height and width.  When injured, mild to severe consequences can develop because growth plates are generally weaker than bones and ligaments around them.  Injuries occur more frequently to this area.  The younger the age of the child or teenager when they develop the fracture, the more critical it is to be seen because of the devastating problems that can develop.  These include premature growth plate closure, angular problems in the extremity, limb length discrepancy in which one leg is longer than the other and fractures in the joint that could cause arthritis at a later time.

Fractures in children can be caused by twisting of the ankle and/or foot which can cause the growth plate to fracture or even move out of position.  These types of injuries are common in sports especially football, soccer and basketball.  In addition, direct trauma or an injury to a growth plate, falling from a height and even an axial load are other common causes of these injuries. 

Mild injuries that are low energy can cause a small degree of pain and swelling directly on the growth plate or the joint.  Weightbearing may be uncomfortable but tolerable.  Children may limp.  Moderate injuries can cause more pain, swelling and cause more difficulty weightbearing.  There would be a general avoidance of trying to put weight on the foot or ankle.  Severe injuries can cause pain, swelling, difficulty weightbearing, and the bone and joint may even appear out of place. 

A thorough history and physical examination of the injured body part and surrounding joints, muscles, ligaments and bones is necessary.  X-rays may show the fracture in many cases.  However, in more simple injuries an x-ray may appear to be normal. When x-rays show no abnormality but pain is significant, an MRI may be ordered to better evaluate the bone, marrow and growth plate.  Salter I and Salter V fractures are often better visualized on MRIs.  When x-rays show a bone abnormality and there is displacement of the bone fragments and growth plates, a CT scan is a better imaging modality.  It helps to better guide treatment for the child or teenager.  CT scans are necessary to assess the position of the bone and growth plates and are used for pre-operative planning in those cases that need surgery.  In those cases that do require surgery, Dr. Cottom will often utilize an arthroscope to visualize the ankle joint and make sure the fracture is reduced perfectly. 



This is a 14 year-old who sustained a growth plate fracture which involved the ankle joint.



  

Dr. Cottom performed an arthroscopic assisted repair of the fracture and growth plate.  The scope allows direct visualization of the fracture which enters the joint.  The advantage of this is that confirmation that the fracture is perfectly reduced can be confirmed with the scope.


 

This is a 16 year-old who fell while playing soccer and sustained a right ankle fracture with growth plate separation.


 

 

The CT scan better demonstrates the fracture in the tibia, involvement of the growth plate and ankle joint.

 

 

After open reduction and internal fixation of the fibula and tibia.  The joint surface is reduced into anatomic positon.  Note, the plate on the fibula is just above the growth plate and the comminuted, displaced fibular fracture has been realigned.

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