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Back to Journal »Orthopedic Research and Review» Volume 10

Author Gill LE, Klingele KE 

Published on April 4, 2018, Volume 2018: 10 pages, 19-30

DOI https://doi.org/10.2147/ORR.S129990

Single anonymous peer review

Editor who approved for publication: Professor Clark Hung

Laura E Gill,1,2 Kevin E Klingele,1,2 1 Department of Orthopaedics, National Children's Hospital, Columbus, Ohio, USA; 2 Department of Orthopedics, Ohio State University Wexner Medical Center, Columbus, Ohio, USA Abstract: In this review In, we focus on the treatment of foot and ankle injuries of young athletes. Although many injuries of adolescents’ ankles are similar or overlapping with those of adults, the anatomy of adolescents’ ankles, especially the presence of growth plates, in many cases will lead to different injury patterns, so specific management methods are required. We discussed the unique anatomy of pediatric patients and the diagnostic evaluation and treatment of common injuries in young athletes. Keywords: foot, ankle, lower limbs, pediatric athletes, growth plate, Lisfranc injury

The feet and ankles are the most commonly injured parts of the lower limbs of young athletes. Due to the existence of growth plates, the injury pattern of young athletes is different from that of adults, and these injuries require special non-surgical and surgical treatment. In some injury patterns, there is overlap with adult counterparts; however, treatment sometimes varies with age and bone maturity. In these cases, for example, open reduction and internal fixation with epiphysis-sparing or joint-sparing techniques can be used instead of fusion. We will review the anatomy of the ankle joint in adolescents, focusing on the treatment of specific injuries, including triangular bone syndrome, talar osteochondral injury, tarsal syndesmosis, Lisfranc injury, fifth metatarsal (MT) base fracture, combined injury, ankle joint Sprains and broken bones, and broken big toe.

The ankle joint is a true articulated joint, consisting of the talus, medial malleolus, distal tibia and distal fibula/lateral malleolus joints and supporting ligament structures. On the medial side, the ankle joint is stabilized by the deltoid ligament, which is composed of the surface attachments of the proximal medial malleolus and distal talus, calcaneus and scaphoid, and deep fibers inserted into the talus at the distal end. Laterally, there are three ankle stabilizing ligaments: the anterior and posterior talofibular ligaments (ATFL and PTFL) and the calcaneofibular ligament (CFL). Interosseous ligament injuries, injuries to the anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament that stabilize the ankle joint, as well as the closure mode of the distal tibia epiphysis, are very important and form the basis of the unique tibial syndesmosis injuries and fractures in adolescents (Tillaux and triplane ankle joint) fracture).1

The tarsometatarsal (TMT) joint, also known as the Lisfranc joint, is prone to injury. It consists of the three medial MTs and their respective cuneiform joints, and the fourth and fifth MT joints with the cuboid. The joint is stabilized by the unique bone structure of the MT trapezoid shape, forming a "Roman arch". The base of the second MT is the cornerstone recessed between the inner and outer wedge-shaped bones. The joint is stabilized by the lateral ligaments from the second to fifth MT. The oblique ligament between the medial cuneiform and the base of the second MT is composed of dorsal, interosseous and plantar ligaments (Lisfranc ligaments), of which the interosseous ligaments and plantar ligaments are the strongest.

Foot accessory ossicles are common in mature skeletal individuals, and may be present in 20% of children around the foot and ankle, including the triangle and the accessory navicular bone, which may cause symptoms.

The ossicles (appearing between 7 and 10 years old) can be seen below the ankle. These are usually bilateral and usually fuse with secondary ossification centers when the bones mature, but may persist. "Os subtibiale" is more common and is present in about 20% of individuals, while "os fibulare" is only present in about 1% of individuals. 3

The boy was 12 years old and the girl was 10 years old. The fifth MT basal process appeared on the plain radiograph. The fusion of the bony process with the base of the MT usually occurs within the next 2-4 years. 4

The developmental changes of the calcaneal process include ossification beginning at an average age of 8 years in boys and 6 years in girls.

The normal talus has medial and lateral posterior nodules, and its secondary ossification centers appear in girls 8-10 years old and boys 11-13 years old, and they fuse in the same year. 5 Between these nodules is the flexor pollicis longus tendon (FHL). Due to the impact of the talus and the back of the calcaneus, acute fractures or chronic repetitive microtrauma6, extension of the lateral tubercle (Steida process), or failure of lateral process fusion may cause this pain syndrome. 7 Usually accompanied by FHL pathology and tenosynovitis/tendon hypertrophy. Stenotic FHL tendinitis may cause mechanical triggering or locking of the interphalangeal joint of the big toe. 8 Athletes, such as dancers, football players, divers, and cricket players, require repeated plantar flexion of the ankle and may experience movement limitations, activity-related chronic pain, and swelling of the back of the ankle. 6,9 Diagnosis is usually made by plain radiographs and computed tomography (CT) (Figure 1). The largest plantar flexion film may show impingement. Magnetic resonance imaging (MRI) will show inflammation and tenosynovitis and accompanying pathology.

Figure 1 Side view of the ankle, the arrow indicates the triangle bone.

Treatment is initially conservative and includes activity adjustments or rest, ice packs, non-steroidal anti-inflammatory drugs (NSAIDs), or, in more severe cases, fixation in walking boots or casts. Physical therapy focusing on stretching, strengthening, and proprioception is also performed. 6,10 Ultrasound-guided steroid injections can be beneficial, both diagnosing and treating. 11

Surgical treatment is only suitable for patients who have failed conservative measures, including open or endoscopic debridement for FHL synovitis and triangular bone resection. In the event of mechanical symptoms or triggers, the FHL sheath may be released. 8

The osteochondral injury of the talar dome is defined as the separation of cartilage and subchondral bone secondary to trauma or vascular injury. 12 They can be caused by acute trauma or chronic repetitive microtrauma. Ischemia of the subchondral bone causes the fragments to separate from the underlying bed. Osteochondral lesions of the talus occur on the anterolateral side, but posteromedial changes are common, accounting for 74% of these lesions. 13 Central lesions are rare. In 10-25% of cases, they may be bilateral. Anterolateral lesions are usually caused by acute trauma (98%); these tend to be shallower in depth and larger in size, while posteromedial (PM) lesions are usually caused by chronic/remote injuries, which may be accidentally found on X-rays of the ankle . In as many as 70% of cases, they are related to trauma. PM lesions are smaller in size and deeper in nature.

The patient usually presents with pain and swelling in the ankle, but may experience instability or mechanical symptoms, such as a click or lock-up from a detached or loose body in the joint. The injury mechanism of anterolateral lesions is varus/dorsiflexion force, while PM injury occurs in plantar flexion and varus.

Diagnosis can usually be performed on plain radiographs, including anteroposterior (​​AP), lateral, and mortise views of the ankle joint (Figure 2A, B). CT scans can be performed to locate and characterize lesions, look for loose bodies in joints, and make preoperative planning. MRI helps to assess stability and classify lesions, as well as assess the integrity of the overlying cartilage (Figure 2C, D). This is also important for diagnosing concomitant injuries of peripheral ligaments and tendons that may require simultaneous treatment.

Figure 2 (A) Anterior and posterior view of the ankle joint and (B) mortise view, showing the posterior medial osteochondral lesion of the talus (arrow); (C, D) Magnetic resonance imaging of the lesion showing edema of the lower talus and fluid underneath the debris; (E) Intraoperative pictures of unstable osteochondral lesions; (F) After curettage and microfracture.

Treatment is based on the stage of the disease. Berndt and Harty14 divided these lesions into four stages: stage 1, a small area of ​​subchondral compression; stage 2, some fragments detached but not displaced; stage 3, fragments completely detached without displacement; and stage 4 , Displacement debris. For stage 1 and stage 2 and small stage 3 lesions, NSAID, activity adjustment, or non-weight bearing splints or casts can be used for successful non-surgical treatment for 4-6 weeks. 15 After this, there is usually weight gain wearing walking boots and physical therapy. Tol et al., 16 Verhagen et al., 17 and Letts et al., 18 reviewed the literature and showed that the success rate of conservative treatment was 45-54%.

The indication for surgical treatment is the failure of long-term non-surgical treatment in symptomatic stage 1-3 lesions and all stage 4 lesions. 15 Surgery can be performed by arthroscopy or open surgery. Anterolateral lesions can be accessed through the anterolateral approach of the ankle joint, while posteromedial lesions can be accessed through a posteromedial arthrotomy between the posterior part of the tibia and the tibia. Osteochondral drilling works best in patients with immature bones19 who have complete cartilage coverage, minimal changes in sclerosis, and fragmentation stability (stage 1-2). 15,20 Anterograde drilling can be done through arthroscopic portal or arthrotomy. Transankle drilling can be used for difficult-to-access lesions, but this is not ideal for patients with open epiphyseal plates. Alternatively, retrograde drilling with a sight can be used; this has the advantage of not destroying intact cartilage. 15,21,22 For the third and fourth stages of cartilage destruction, the microfracture or drilling of the necrotic bone and subchondral bone under curettage has shown good results, and the formation of fibrocartilage in defects 15, 21, 22 ( Figure 2E, F).

For large fractures (>1.5 cm), fractures that are acutely injured and have no obvious potential for hardening, and when bony components need to be fixed to the affected cartilage to achieve bone fixation, fixation of the fracture should be considered. This can be achieved by absorbable nails or darts or headless compression screws. These operations are usually performed using open arthrotomy. Kumai et al.20 reported an 89% success rate of elevation and subchondral drilling in 24 patients with stage 2-4 lesions.

Lisfranc injuries are rare in children and adolescents and are often misdiagnosed or ignored. 23,24 In mild cases or spontaneous reduction, a high degree of suspicion is required. 25 Lisfranc joint enlargement can only be seen on stress X-rays, so symptomatic patients with injury or clinical examination suggesting mechanisms should be investigated. Simultaneous fracture of the cuboid and the second MT base is highly suspected of TMT joint injury. 25 The injury mechanism may be direct (such as crush injury), or more commonly, indirect, fixed forced plantar flexion and abduction injury. Feet (for example, in sports such as football or football, another player falls on the heel of the plantar bent foot, or falls from a height). Patients usually present with pain, swelling, and inability to bear weight, and may have plantar ecchymosis at the medial longitudinal arch. When the swelling is severe, they are at risk of developing compartment syndrome. 25,26

Quenu and Kuss27 proposed a classification based on the displacement direction in 1909, and divided these damages into three categories: ipsilateral, isolated and divergent. Myerson et al. 28 further classified these into AC types and sub-categorized them according to the degree of displacement. Hill et al.23 found in their study that 52% of skeletal immature patients had Myerson B1, the first MT was partially uncoordinated with medial displacement, and 56% of closed epiphysis patients had partial uncoordinated and Myerson B2 with lateral displacement.

The diagnosis is usually based on plain AP, lateral and oblique radiographs (Figure 3A). For minor injuries, bilateral AP and lateral X-rays can be compared. MRI can be used for pure ligament injuries to assess the integrity of Lisfranc ligaments. CT scans can be important for preoperative planning, especially in cases of intra-articular injury and comminution.

Figure 3 (A) The anterior and posterior X-rays of the feet show that the gap between the first and second metatarsals is widened, and the positive "spot sign" represents the medial cuneiform ligament avulsion fragments. (B) Anterior and posterior position, (C) Oblique position, and (D) postoperative side view of the foot, showing the use of partially threaded hollow screws for reduction and fixation. The patient also had slightly displaced fractures of the second and third metatarsals, which received non-surgical treatment.

Non-surgical treatment can be used for minor displacement injuries (<2 mm displacement), including 6 weeks of non-weight-bearing casts, followed by protective weight-bearing. Perform follow-up X-ray examinations within 1-2 weeks to ensure that there is no more displacement. 25,26

Surgical treatment is suitable for more displaced fractures. In the case of severe displacement of the skin damage, a finger clamp can be used for closed reduction, and then according to the degree of swelling, immediate or delayed treatment. Staged treatment after reducing skin and soft tissue swelling will reduce the risk of skin damage and concerns about wound healing. Closure therapy with percutaneous Kirschner wire or screw fixation may be an option,29 if anatomical or acceptable reduction can be achieved, especially in children and adolescents. In older adolescents, open treatment with direct anatomical reduction and screw fixation may produce better results30,31 (Figure 3B-D). If the base of the MT is significantly shattered, it may be necessary to bridge the wedge-shaped bone. Incisions centered on the first and second MT allow visualization of the corresponding TMT joints. As shown in the figure, the central incision and lateral incision between the third and fourth MT are used to account for any residual displacement of the fifth TMT joint. Need to rigidly fix the stiffer medial and middle columns of the foot, but due to the mobility of the lateral column, it is recommended to use Kirschner wires to fix the fourth and fifth TMT joints, and remove these metals at 4-6 weeks Silk. After surgery, the patient remains non-weight-bearing in casts or boots for 6-8 weeks, and resumes all activities at 3-4 months. It is recommended to remove the hardware of the inner column at 3-4 months to allow movement and prevent the screw from breaking.

There are few studies on Lisfranc injury management in children, and most of the information comes from adult literature. In the study by Hill et al.23, 56 patients with bone/ligament Lisfranc injuries were reviewed. They found that patients with mature bones were more likely to need surgery. Open reduction screw fixation was used in 89% of patients. A large proportion of these patients, including 33% of patients with open pelvis, require surgery. This study cannot clarify the long-term results, such as the incidence of post-traumatic arthritis; however, due to the age and bone maturity of these patients, the author prefers to preserve the joints rather than fusion, which is consistent with adults who can choose the first fusion Compared. 32,33

Fracture of the fifth metatarsal base

Approximately 40% of MT fractures occur in the fifth MT, 34 up to 22% involve the base of MT, and 90% of them occur in children over 10 years of age. 35 Injury mechanisms include sports, of which football is the most common; falling from a height; or ankle sprain with fixed forefoot. 36 Patients usually have a history of sprain/varus ankle injury, and the pain and swelling are confined to the base of the fifth MT.

Standard AP, lateral and oblique positions of the foot can be used for diagnosis; however, additional lateral ankle views can be considered, including the fifth MT, as up to 23% of tears may be missed in traditional X-ray images Prolapse fracture. 37 Lawrence and Botte 38 divided proximal fractures into three anatomical subgroups: regional nodular avulsion fractures Figure 1 (Figure 4A), fractures at the metaphyseal/diaphyseal junction, but did not extend to region 2 (Figure 4B) The fourth or fifth metatarsal joint (Jones fracture) in the middle, and the stress fracture of the proximal diaphysis in zone 3. Torg et al. 39 further classified Jones fractures according to the presence and degree of sclerosis of the fracture site, and according to its healing potential, type 1 is an acute fracture, type 2 is a delayed union, and type 3 is a nonunion. These classification systems have an impact on treatment based on their healing potential.

Figure 4 (A) Nodular avulsion fracture in zone 1; (B) Jones fracture in zone 2; (C) fifth metatarsal bony process, often confused with fracture; (D) clockwise from the upper left corner: place one Root guide wire, and then place a hollow part threaded screw to fix Jones fracture.

Avulsion fractures of the fifth MT base are the most common isolated injuries caused by varus or adduction,25 and are often confused with os peroneum and osversalinum or bony processes at the base of MT (Figure 4C). The injury is caused by the traction of the peroneus brevis or the origin of the little finger abductor. 34 X-rays showed that the fracture was perpendicular to the MT plane, possibly intra-articular. They are rarely displaced. Treatment is non-surgical, wearing hard-soled shoes, short-leg walking casts or boots for 6 weeks. When patients have no pain and their strength and range of motion are normal, they can resume activities.

For zone 2 and zone 3 fractures of the 5th MT, the displacement greater than 3-4 mm and the angulation greater than 10 degrees should be reduced. 40 Non-displacement fractures can be treated non-surgically and fixed in a short period of time. The leg is fixed in a non-weight-bearing plaster for 6-8 weeks until radiological healing is achieved. 40,41 Athletes should consider acute immobilization, as this leads to more predictable healing and earlier resumption of exercise. 42,43 Intramedullary screw fixation is the preferred method of fixing these fractures. In the case of delayed or nonunion (Torg 2-3 type), fixation with or without autologous bone grafting can be used. A guide wire passes through the fracture site through a lateral approach at the bottom of the MT. Once this line is properly positioned, a hollow drill bit can be used to drill the distal end of the fracture site and then replaced with a solid screw. Use the largest screw that fits the medullary canal; in general, screws of 4.5 mm or larger are associated with the least risk of re-fracture or nonunion (Figure 4D).

Syndrome tarsus is defined as an abnormal connection between two or more bones in the foot. They may be bony (arthropathy), fibrous (arthropathy) or cartilage (arthropathy). 44 The association is rare, accounting for 1% of the population, and the incidence is estimated to be between 2% and 13%. 45 Up to 50-60% are bilateral. 10,44 The heel bone and the calcaneal joint account for 90% of the foot joint. 46 The middle articular surface of the calcaneus is most commonly affected.

The restricted movement of the subtalar joint in conjunction with the tarsal bone causes a flatfoot deformity. The abnormal load and stress of the ankle and subtalar joints can cause pain caused by sinus tarsal impingement, fibula spasm, inflammation, and degenerative joint changes.

Patients usually develop calcaneal and talar-heel joints at 8-12 years old and 12-16 years old, 47 with joint ossification and foot stiffness. Patients with a history of repeated ankle sprains, especially those with rigid flatfoot deformity, should be suspected of tarsal bones. The patient may have valgus hindfoot and increase the tibial heel angle, but the varus cannot be corrected by heel elevation, which indicates that the subtalar joint is stiff. They usually have forefoot abduction and may have peroneal tendon spasms. Patients may complain of pain in the lateral ankle joint of the sinus tarsal, which is caused by impact, or directly above the joint, as in the case of the navicular joint. Patients with the talus-calcaneal syndrome may have medial pain at the distal end of the medial malleolus. There may be a contracture of the fundus muscle complex, and the Silfverskiold test should be performed.

Weight-bearing AP, lateral, and 45-degree non-weight-bearing oblique views of both feet should be obtained. In the AP view, the head of the talus and the abduction of the forefoot will be exposed. On the side view, in the talar-calcaneal symphysis, there may be a positive C mark (Figure 5A), which represents a line formed by the medial contour of the talar dome and the posterior lower contour of the talus. 48 In addition, you can see the characteristic beak of the head of the talus, as well as the "anteater nose sign", which represents the elongation of the calcaneus protuberance to the navicular bone in the calcaneal symphysis (Figure 6A). The calcaneal symphysis is best visualized in an oblique view (Figure 6B). A CT scan can be performed because it shows the bone structure and can be used to evaluate the accompanying joint. It can also be used for surgical planning of the Talar Syndrome (Figure 5B). MRI scans can also be used to determine whether there are any other lesions in soft tissues, tendons, etc.

Figure 5 (A) C sign (arrow) of the talar-heel joint; (B) Coronal computed tomography shows the osseous symphysis.

Figure 6 (A) The elongation of the calcaneus protrusion (anteater sign, arrow); (B) Oblique plantar film showing the calcaneal vessel union (arrow); (C) Union after excision.

The first-line treatment is non-surgical treatment for all coalition and asymptomatic patients. It includes activity adjustments, analgesics (NSAID), or for more severe cases, fixation in walking boots or casts for 4-6 weeks and then treatment. Surgical treatment is reserved for patients who have failed non-surgical treatment. For the calcaneal symphysis, the Ollier method excises the trapezoidal wedge-shaped bone directly above the joint (Figure 6C) and inserts the extensor digitorum brevis, fat, or bone wax. 49 Achieve 80-90% acceptable results. The choice of interventional materials is controversial, but it is believed that the combination of adequate hemostasis and adequate resection is related to reducing the risk of recurrence and improving the outcome. 50

Talar-calcaneal syndesses without obvious flatfoot deformities can be treated separately if they involve less than 50% of the middle facet joints and no significant posterior facet joint degenerative changes. 51, 52 This is done through a lateral incision located at the distal end of the flat foot. The medial malleolus and directly above the league. A combination of osteotome and drill is used to remove a rectangular bone, forming a clear space from the back to the front facet joint, and visualizing the cartilage of the subtalar joint on the medial side. It may be difficult to assess the anatomy during surgery. Aibinder et al.53 recommended the use of intraoperative three-dimensional CT-assisted resection to reduce morbidity, reduce bone removal and preserve the intact subtalar joint, and allow effective, thorough, and controlled resection joints. Insert materials include autologous fat, bone wax, or flexor pollicis longus tendon. In the case of flat foot deformity with severe hindfoot valgus (>16 degrees), several authors have suggested that inward displacement of the calcaneus/calcaneal lengthening can improve the results. 54,55

Postoperative treatment includes 3 weeks of immobilization with splints or casts, and then transition to walking boots and physical therapy. In the long run, over-the-counter orthotics can be used. Patients can usually resume exercise within 3-4 months after surgery.

In the United States, the incidence of ankle sprains is estimated to be 2.15 per 1,000 person-years. The peak incidence of ankle sprains occurs between 15 and 19 years of age. Half of ankle sprains occur during sports activities. 56 Lateral ankle sprains and combined sprains are the most common foot and ankle injuries in college football players, occurring in 31% and 15% of players, respectively. 57 Repeated ankle sprains may cause chronic instability and pain of the ankle joint, loss of normal ankle kinematics and proprioception, and put patients at risk of degenerative changes in the ankle joint. 58,59

These sprains are usually caused by varus and external rotation of the ankle. 58 The lateral ankle ligament is most commonly injured. They are composed of ATFL, PTFL and CFL. Among them, ATFL is the most frequently injured, followed by CFL. 57,58 In addition, the musculature of the ankle joint, especially the peroneus longus and brevis, actively stabilize the ankle joint. Weakness or injury such as tendon tears or subluxation (broken support band on the fibula) may play a role in ankle instability. 57

Ankle sprains are divided into three grades according to the degree of ligament injury and the degree of looseness of the ankle joint. 60 Grade I is related to ligament stretching without obvious tearing and unstable. In grade II injuries, the ATFL is completely torn, with or without a partial tear, and the joint may be mildly unstable. Grade III tears are serious and are related to complete tears of ATFL and CFL, and may be accompanied by PTFL and joint capsule injuries and ankle instability.

Patients usually present with pain, swelling and bruising in the ankle, as well as unbearable or unable to bear weight. They may have a history of repeated ankle sprains or chronic instability. The anterior drawer test is used to assess the stability of the ankle joint; this applies a forward-oriented force to the hind foot while stabilizing the tibia and tests the integrity of ATFL, which is the main resistance to anterior subluxation of the talus. CFL tests include tilted talus and varus stress tests and ankle neutral dorsiflexion.

The need for X-rays is determined according to the Ottawa rules. 61 Ankle views include standard AP, lateral and mortise to exclude related fractures. The value of stress radiographs is controversial. 57 MRI may be valuable for determining the nature and extent of the injury, but it should be reserved for chronic injuries that do not respond to conservative measures and for preoperative planning or excluding concomitant injuries.

Treatment of acute ankle sprain

The first line of treatment for acute ankle sprains is non-surgical treatment. 60 The National Sports Coaches Association position statement 59 recommends cryotherapy, non-steroidal anti-inflammatory drugs, compression, and elevation. For grade I and II sprains, functional rehabilitation is more effective than immobilization. For grade III sprains, it is recommended to use a rigid brace or cast for short-term fixation, followed by controlled rehabilitation. Electrical stimulation can be used to reduce swelling in the acute phase.

Preventive treatment of ankle sprains is important to avoid primary and recurrent injuries, and should aim to reduce modifiable risk factors, such as body mass index. It includes injury prevention plans, braces or straps, strengthening, reducing sports participation or changing athlete positions, and changing the playing field and equipment. 57 Proprioceptive physical therapy, single-leg balance training and neuromuscular control have proven to be the most effective methods. Most effectively prevent ankle sprains. 57 Strength and range of motion should also start at the same time. Braces or tapes can also be used for stabilization and have been shown to reduce the incidence of recurrent sprains in high-risk groups by 70%. 62

Treatment of unstable chronic ankle sprains

Surgical treatment is reserved for chronically unstable patients who fail conservative measures. The method can be divided into two categories: anatomical fixation and tendon fixation techniques. 57,60 In addition, any osseous correction of hindfoot misalignment, such as varus deformity, should be addressed to prevent failure.

The anatomical fixation of the direct repair of ATFL and CFL was first described by Brostrom and later modified by Gould. 63 The broken or thinned ligament is shortened and repaired to the anatomical position on the fibula with sutures, suture anchors or drill holes, and the outer part of the inferior extensor retinaculum is brought to the proximal end and sutured to the fibular periosteum to add extra Stability and enhanced repair. This repair depends on the integrity of the remaining ligaments, and in these cases the suture fixation (InternalBrace™; Arthrex, Naples, Florida, USA) has recently been successfully used to strengthen the repair. 64,65 In patients with thinning of the ligament and for patients who cannot be repaired, other tissues can be used for anatomical repair, such as periosteal flaps, autologous gracilis tendon grafts, or allogeneic grafts.

Tendon fixation techniques involve the use of whole or split peroneal brevis tendons braided and placed through drill holes in the distal fibula, calcaneus, and/or talus in an attempt to rebuild and restore the stability of the ankle joint. The most common techniques described are Watson-Jones, Chrisman-Snook, and Evans procedures.

It is said that the advantage of anatomical fixation is to preserve more normal ankle mechanics. Overall, studies have shown that anatomical repair has better results and fewer complications than tendon fixation techniques, and is usually the first choice. 60,66 The anatomical technique avoids the peroneal tendon, which is important for maintaining normal ankle mechanics and muscle balance.

A high ankle sprain is a ligament injury that occurs on the ankle syndesmosis ligament, which is higher than the more distal ankle ligament. The ligaments involved are the anterior tibiofibular ligament, the posterior tibiofibular ligament and the interosseous ligament. The deltoid ligament also provides stability because it can resist lateral displacement of the talus. These injuries may occur with or without fibula fractures. The mechanism of injury involves external rotation of the foot and dorsiflexion of the ankle. The talus forces the joint separation. This is more common in high-speed sports that involve jumping, cutting, and changing direction, such as football, basketball, and hockey. 1,57

Patients usually present with pain and swelling around the ankle joint. Clinical examination may reveal swelling. There are several specific tests that can be used to evaluate patients with suspected joint damage. The squeeze test involves squeezing the tibia and fibula at the level of the middle leg. The patient is sitting with the knee bent 90 degrees away from the table. If it causes pain, the test result is positive. The external rotation test is performed by externally rotating the foot and stabilizing the tibia. The squeeze test is more sensitive and specific than the external rotation test. 67

The standard AP, lateral, and mortise views of the ankle joint may be normal, or show a widening of the medial clear space of the ankle joint mortise, accompanied by displacement of the lateral talus (Figure 7A). The imaging should also include the full-length tibia and fibula membranes to evaluate the concomitant high fibula fractures (Maisonneuve fractures). Pressure X-rays may be required to demonstrate the instability of the joint, and should be performed under high suspicion. These include a bilateral weight-bearing standing AP view of the ankle or a bilateral external rotation stress radiograph (Figure 7B). Reduced tibiofibular overlap (normal in AP view> 6 mm, mortice view> 1 mm), increased medial clear space (normal ≤ 4 mm), or increased tibiofibular space (normal in AP and mortise view <6 mm) Joint injury. Ankle MRI is both sensitive and specific in detecting the syndesmosis and any related injuries. 68 Joint injuries are classified into grade I-III, with partial rupture of grade I and II ligaments, and complete tearing of grade III ligaments with mortice instability. However, the classification system does not specify treatment or prognostic information. 69

Figure 7 A 16-year-old male was injured while playing football. (A) The initial ankle mortise looks normal; (B) However, the external rotation stress plate shows that as the talus shifts, the mortise and medial clear space widens; (C) After joint fixation with a steel wire structure.

The treatment of high ankle sprains is based on the stability of the ankle mortise. For injuries without ankle instability, treatment is non-surgical treatment, including rest, ice, anti-inflammatory drugs, and fixation in walking boots or casts for 3-4 weeks or until the patient is pain-free. The patient is then allowed to undergo progressive protective weight-bearing and rehabilitation, as well as physical therapy under supervision, proprioceptive training, neuromuscular training, strengthening, and range of motion. The criteria for returning to the sports field are similar to those for an ankle sprain, but patients should be informed that this usually takes longer than a lateral ankle sprain. 57,69

For patients with unstable imaging, surgical treatment and combined or combined fixation without fracture fixation is recommended. Perform a lateral approach to the distal fibula; place a clip on the tibia and fibula to maximize dorsiflexion of the ankle to reduce the mortise. Then two parallel 3.5 or 4.5 mm solid screws can be placed 2-5 cm above the ankle joint for joint fixation. In a randomized controlled trial of 120 patients with joint fractures, Moore et al. found that there was no difference between tri-cortical and quad-cortical fixation in terms of loss of reduction, broken screws, or the need to remove implants. 70 Alternative fixation suture buttons are made up of a strong suture ring, which is tensioned and fixed between two metal buttons, which are close to the outer cortex of the tibia and fibula, with or without the fibula plate 69 (Figure 7C). The flexibility of the suturing button structure is believed to lead to anatomical fixation of the joint joint, because micro-motion allows the fibula to "settle" back to the tibial incision and reduces the incidence of poor reduction; an additional advantage is that the device usually does not need to be disassembled.

Inge et al. 71 conducted a systematic review of static and dynamic combined fixation and found that dynamic fixation is a viable alternative to static fixation devices, with a lower reoperation rate and fewer complications. This method can accurately stabilize the ruptured joint without causing device rupture or loss of reset.

For athletes with lateral and high ankle sprains, only when the range of motion and strength of the injured limb returns to the baseline or at least 90% of the normal side, will they be allowed to resume competition. Athletes with a history of ankle sprains should use tape or braces for preventive treatment during sports to prevent re-injury. 55

Ankle fractures account for 12% of all pediatric fractures. 72 Acute fractures in the pediatric population are unique because the epiphysis is a weakness, and injuries usually occur in this area. 10 The most common and commonly used classification system is the Salter-Harris (SH) classification. 73 Type I injury involves the growth plate, but does not damage adjacent bones. Type II injuries involve epiphyseal and metaphyseal fragments. Type III injury occurs when the fracture line extends from the epiphysis to the epiphysis. Type IV injury extends from the metaphysis, passes through the metaphysis, and enters the epiphysis in a vertical manner. V-shaped injuries involve compression or crush injuries to the epiphysis. Types I and V are usually not obvious on a plain film because only the epiphysis is involved. Type III and IV fractures are intra-articular fractures, the risk of epiphyseal arrest is the highest, and there is a risk of angular deformity. This risk is as high as 38%, especially the medial malleolus type. 74 Among them, type IV fractures have the highest risk because they involve all layers of the epiphysis. Therefore, these fractures should be reduced and fixed anatomically.

The SH I fracture of the distal fibula is the most common fracture mode in the ankle area. This fracture is equivalent to a sprained ankle in children. Due to the lack of initial radiological findings, a definitive diagnosis may be difficult. Sankar et al. 75 found that 18% of patients with pain and swelling around the lateral ankle joint observed occult fractures through the periosteal reaction on the later film. Usually, patients may have non-displaced SH Type I or Type II distal fibula fractures or ankle tip avulsion fractures. Immobilization in walking boots or short-leg weight-bearing casts for 3-4 weeks is appropriate.

Two unique fracture patterns (adolescent Tillaux fracture and triplanar ankle fracture) occur around the distal tibia close to skeletal maturity, and are related to the pattern that the distal tibia closes from the center to the medial, posterior medial, and lateral sides. Over the course of 18 months. 76

Tillaux ankle fractures are equivalent to SH III fractures, involving the anterolateral part of the ankle joint. The mechanism of the injury is a dorsiflexion and external rotation force, which avulsed the fracture from the anterior inferior talofibular ligament.

Triplanar ankle fractures are three-dimensional, involving coronal, axial and sagittal planes. On the AP radiograph of the ankle joint, the tri-plane fracture showed an SH III fracture, while in the side view it showed an SH type II fracture with a posterior medial fracture (Figure 8). The injury mechanism is similar to Tilaux's ankle fracture.

Figure 8 (AC) Triplane ankle fracture variant with Salter-Harris type IV components (magnetic resonance imaging); (D, E) Postoperative fixation with hollow screws parallel to the epiphysis (D, anterior and posterior; E, lateral) .

The patient presented with ankle pain, swelling and deformity. Non-displaced fractures and fractures with articular surface displacement less than 2 mm after reduction can be treated non-surgically in a long-leg cast for 4 weeks, and then converted to non-weight-bearing, short-leg cast, or a walker for 2 weeks. Closed reduction was performed under sedation in the emergency room. For Tillaux fractures, the reduction method is plantar flexion and internal rotation to reduce the fragment. A similar internal rotation is used for triplane ankle fractures, but in addition, ankle dorsiflexion is usually required to reduce the SH II component. CT scans should be performed for all intra-articular fractures after reduction, because the intra-articular displacement of more than 2 mm is an indication for surgery (Figure 9).

Figure 9 (A) posterior and (B) lateral Tillaux ankle fracture (arrow); (C) posterior fixation and (D) transepiphyseal fixation, in almost skeletal mature women.

For individuals with immature bones, it is recommended to use epiphyseal protection technology for fixation. Usually, 3.5-4.0 mm hollow screws are placed perpendicular to the fracture site. For SH type IV and triplanar fractures, screws may be used in the metaphysis and epiphyseal fragments to maintain fracture stability. The approach depends on the location of the epiphyseal fragments: the lateral approach is used for Tillaux fractures, and the medial approach is used for medial malleolus or triplanar fractures. It is recommended to perform arthrotomy and directly observe the fragments to ensure anatomical reduction. The postoperative fixation was fixed with a short-leg non-weight-bearing plaster for 4-6 weeks.

Phalanx fractures may account for 18% of foot fractures. 34 The most common are SH type I and II fractures. When this kind of fracture involves the distal phalanx, the nail bed must be carefully checked for damage, because this is an open fracture, and if not treated properly, there is a high risk of advanced osteomyelitis. 77,78 Close reduction of displaced fractures to stabilize Kirschner wires if necessary. Any bleeding around the nail indicates damage to the germinal matrix, which requires nail removal, irrigation, debridement, and repair. Patients should be treated with short-term antibiotics, usually first-generation cephalosporins or clindamycin. It is recommended to fix it in postoperative/hard-soled shoes for 4 weeks.

Due to basic anatomical differences, the treatment of ankle injuries in adolescent athletes is different from that of adults. In most cases, non-surgical treatment is first-line treatment. Obtaining appropriate radiography for a suspected injury is the key to determining the correct diagnosis and treatment process. A step-by-step approach and proper management are needed for adolescent patients so that they can resume exercise with completely painless functions. It is important to avoid epiphyseal injury through fixation, and to consider the use of joint protection techniques in this population as much as possible.

The authors did not receive funding for this study and report no conflicts of interest.

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