All-epiphyseal versus trans-epiphyseal screw fixation for tillaux fractures:Does it matter?

BACKGROUND Tillaux fractures occur primarily in adolescents due to the pattern of physeal closure and are classified as Salter-Harris type III physeal fractures.Operative management with screw fixation is recommended for more than 2 mm of displacement or more than 1 mm of translation.However,the efficacy and complications of trans-physeal vs all-physeal screw fixation have not been investigated extensively.AIM To compare the clinical and functional outcomes of trans-physeal(oblique)and all-epiphyseal(parallel)screw fixation in management of Tillaux fractures among pediatric patients.METHODS This was an ethics board approved retrospective review of pediatric patients who presented to our tertiary children’s care facility with Tillaux fractures.We included patients who had surgical fixation of a Tillaux fracture over a 10 year period.Data analysis included demographics,mode of injury,management protocols,and functional outcomes.The patients were divided into group 1(oblique fixation)and group 2(parallel fixation).Baseline patient characteristics and functional outcomes were compared between groups.Statistical tests to evaluate differences included Fisher’s Exact or Chi-squared and independent samples t or Mann Whitney tests for categorical and continuous variables,respectively.RESULTS A total of 42 patients(28 females and 14 males)were included.There were no significant differences in body mass index,sex,age,or time to surgery between the groups[IK2].Sports injuries accounted for 61.9%of the cases,particularly non-contact(57.1%)and skating(28.6%)injuries.Computed Tomography(CT)scan was ordered for 28 patients(66.7%),leading to diagnosis confirmation in 17 patients and change in management plan in 11 patients.[GRC3]Groups 1 and 2 consisted of 17 and 25 patients,respectively.For mid to long-term functional outcomes,there were 14 and 10 patients in groups 1 and 2,respectively.Statistical analysis revealed no significant differences in the functional outcomes,pain scores,or satisfaction between groups.No infections,non-unions,physeal arrest,or post-operative ankle deformities were reported.Two(4.8%)patients had difficulty returning to sports post-surgery due to pain.One was a dancer,and the other patient had pain while running,which led to hardware removal.Both patients had parallel fixation.Hardware removal for groups 1 and 2 were 4(23.5%)and 5(20.0%)patients,respectively.The reasons for removal was pain in 2 patients,and parental preference in the remaining.CONCLUSION This is the largest reported series of pediatric patients with Tillaux fractures comparing functional outcomes of different methods of screw fixation orientation to the physis,which showed no difference regarding functional outcomes.

Posterior ankle impingement–an underdiagnosed cause of ankle pain in pediatric patients

BACKGROUND Posterior ankle impingement syndrome(PAIS)is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot.The diagnosis is primarily made based on detailed history and accurate clinical examination.The delay in its diagnosis has not yet been described in the pediatric and adolescent population.AIM To identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients.METHODS This descriptive prospective study at a tertiary children’s hospital included patients≤18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS.Collected data included:Demographics,prior diagnoses and treatments,providers seen,time to diagnosis from presentation,and prior imaging obtained.Visual Analogue Scale(VAS)for pain and American Orthopedic Foot Ankle Society(AOFAS)ankle-hindfoot scores were noted at initial presentation and follow-up.RESULTS 35 patients(46 ankles)with average age of 13 years had an average 19 mo(range 0-60 mo)delay in diagnosis from initial presentation.25(71%)patients had previously seen multiple medical providers and were given multiple other diagnoses.All 46(100%)ankles had tenderness to palpation over the posterior ankle joint.Radiographs were reported normal in 31/42(72%)exams.In 32 ankles who underwent MRI,the most common findings included os trigonum(47%)/Stieda process(47%).Conservative treatment had already been attempted in all patients.Ankle impingement pathology was confirmed during arthroscopy in 46(100%)ankles.At an average follow-up of 13.1 mo,there was an improvement of VAS(pre-op 7.0 to post-op 1.2)and AOFAS scores(pre-op 65.1 to post-op 94).CONCLUSION This is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population;an increased awareness about this diagnosis is needed amongst providers treating young patients.