Do These Ankle Films Show More Than One Fracture?

Children’s Hospital of Michigan

Dr Fichadia is a fellow in pediatric emergency medicine and Dr Stankovic is fellowship director, pediatric emergency medicine at Children’s Hospital of Michigan in Detroit.

WILLIAM YAAKOB, MD—Series Editor: Dr Yaakob is a radiologist in Tallahassee, Fla.

salter-harris fracture

An 11-year-old girl presented to the emergency department with a limp after she had slipped and fallen on her left foot. As she fell, the foot became caught underneath her, twisting in a plantar inverted direction.

Examination revealed localized tenderness and swelling over the left lateral malleolus. The child had limited dorsiflexion and plantar flexion of the ankle secondary to pain.

Lateral and anteroposterior plain radiographs of the left ankle are shown.

What do the findings suggest?

A. Salter-Harris II fracture.

B. Salter-Harris III fracture.

C. Salter-Harris IV fracture.

D. Triplane fracture.

E. All of the above.

(Answer and discussion on next page.)

Answer: E, all of the above

The radiographs showed a Salter-Harris IV fracture. CT scans confirmed the presence of a triplane fracture of the distal tibial epiphysis (Figure).

Distal tibial epiphyseal fractures are one of the most common types of epiphyseal fractures.1,2 As the name suggests, Triplane fractures involve coronal, sagittal, and axial planes. They are also known as transitional fractures because patients with these fractures are often transitioning into skeletal maturity.3

As in this case, a plain radiograph will show a Salter-Harris II fracture on the lateral view and a Salter-Harris III fracture on the anteroposterior view. CT is needed to clearly delineate the fracture planes and segments.4,5

Treatment of triplane fractures depends on whether the fracture is displaced or nondisplaced as well as on the degree of displacement and intra-articular involvement. Fractures with less than 2-mm displacement are managed with a long-leg cast, whereas those with greater than 2-mm displacement usually require some form of reduction.3 The fracture in this patient had minimal displacement and was managed with a fiberglass cast for 3 weeks. At follow-up in 3 weeks, radiographs of the ankle showed a healing triplane fracture. She was transitioned to a CAM walker boot for the next 4 weeks.