FIGURE 111.52 Classic Tillaux fracture of the distal tibia in a 14-year-old boy The fracture line runs vertically through the epiphysis (small arrow ) and then laterally along the physis (large arrow ) The lateral portion of the physis is widened JUVENILE TILLAUX FRACTURES This is a Salter–Harris type III fracture that extends horizontally through the physis and vertically through the epiphysis and then exits intra-articularly The anterior tibiofibular ligament avulses the lateral epiphysis from the medial malleolus during external rotation ( Fig 111.52 ) Minimally or nondisplaced fractures may be immobilized with a posterior leg splint with outpatient orthopedic referral for casting For fractures with >2-mm displacement, CT evaluation is recommended for defining fracture displacement and for surgical planning as open reduction and internal fixation will be necessary TRIPLANE FRACTURES Triplane fractures are a subgroup of Salter–Harris type IV injuries as it is a combination of a Tillaux fracture and a Salter–Harris type II fracture of the distal tibia ( Fig 111.53 ) These fractures result in significant growth plate damage and should have emergent orthopedic consultation Suspected triplane fractures should be further evaluated by CT for assessing the fracture configuration and surgical planning for fractures displaced >2 mm Clinical indications for discharge or admission Children with ankle sprains may be discharged with appropriate immobilization and crutches For children with nondisplaced fractures and minimal swelling, the extremity should be immobilized with a posterior splint They can be discharged with urgent outpatient orthopedic follow-up Those with significantly displaced physeal fractures, open fractures, substantial distal lower extremity swelling and pain, and concern for development of compartment syndrome should be admitted for inpatient orthopedic management FIGURE 111.53 Triplane fracture The fracture line traverses the distal tibia in the transverse, coronal, and axial planes On radiographs (A ) mortise, (B ) lateral: the triplane fracture appears as a Salter–Harris type or fracture on the AP view and a Salter–Harris type or fracture on the lateral view Images (C ), (D ), and (E ) show CT images of the triplane fracture in the coronal, axial, and sagittal planes, respectively CT best defines the fracture pattern (Reprinted with permission from McCarthy JJ, Drennan JC Drennan’s the Child’s Foot and Ankle 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2009.) Injuries of the Foot CLINICAL PEARLS AND PITFALLS Calcaneal fractures typically occur after a fall from a height, so the spine should also be evaluated for possible compression fracture Snowboarders are at risk of fractures of the lateral process of the talus Avascular necrosis of the body of the talus is a serious complication that can develop depending on the location of the fracture and extent of displacement CT is recommended for the evaluation of tarsometatarsal injuries and calcaneal and talar fractures, and it may also diagnose occult fractures If a fracture of the second metatarsal is present, a tarsometatarsal dislocation should be considered or a Lisfranc injury should be suspected if there is also a cuboid fracture present Compartment syndrome of the foot can involve any of the nine compartments and should be considered in the presence of swelling and increasing pain, especially after elevation Hindfoot and Midfoot Fractures In general, fractures of the hindfoot involving the talus or calcaneus are relatively uncommon in children Fractures of the lateral process of the talus can be misdiagnosed as ankle sprains due to the articulation of the talus and the lateral malleolus Nondisplaced fractures of the hindfoot may be treated with a bulky posterior splint and crutches with no weight-bearing and referral to an orthopedic surgeon Displaced talus fractures will require reduction under anesthesia Fractures of the midfoot involving the navicular, cuboid, and first, second, third cuneiforms and tarsometatarsal injuries are uncommon in children They are usually caused by blunt trauma that can result in significant soft tissue damage and potential neurovascular compromise with compartment syndrome ( Fig 111.54 ) Nondisplaced fractures may be treated in a short leg cast Displaced injuries of the tarsometatarsal joint will require reduction under anesthesia