Hawkins type II displaced talar neck fracture in a 15-year-old girl with left ankle deformity, ecchymosis, and swelling after she fell from an aerial cheerleading spin and landed on her left leg. The ankle sustains approximately 15%20% of all growth plate injuries (1) and is the second most common site, after the distal radius, of physeal injuries (2,3). Coronal CT image of the left ankle shows a distal fibular Salter-Harris type I fracture with displacement of the distal fibular epiphysis (*). There also could be a stage 4 injury to the posterior syndesmosis. Ligament damage may be inferred by an abnormal configuration of the ankle fork. (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. Meinberg E, Agel J, Roberts C, Karam M, Kellam J. Fracture and Dislocation Classification Compendium2018. A group of distal tibial metaphyseal fractures in very young children are pathognomonic for nonaccidental trauma. Gill and Klassen (30) suggested that the findings in the Boutis et al studies (27,28) should help reduce uncertainty among clinicians, and, by extension, reduce overtreatment.. Open fracture . Stage I supination-adduction fracture. Figure 14b. (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). 2, Radiologic Clinics of North America, Vol. The ankle forte is unstable and the distal fibular fracture is fixated using plate osteosynthesis (fig. Dias-Tachdjian grade 2 supination-inversion ankle fracture in a 15-year-old boy who sustained an ankle injury after falling from a height. Ankle extensor retinaculum and lateral ligaments injuries - ultrasound, avulsion fracture of the anterior calcaneal process. Comparison of the modified Brostrom procedure for chronic lateral ankle instability with and without subfibular ossicle. (c) AP radiograph obtained after reduction and internal fixation shows restored ankle alignment and placement of a pin to repair the distal fibular physeal fracture. Radiologists must recognize the developmental phenomena, anatomic variants, and fracture patterns and associated complications that affect the skeletally immature foot and ankle. This information is intended to supplement radiologists understanding of developmental phenomena, anatomic variants, fracture patterns, and associated complications that affect the pediatric foot and ankle. 03, The Journal of Foot and Ankle Surgery, Vol. (b) Accompanying lateral radiograph also depicts the talar neck fracture. 2006;37(8):691-7. The _ga cookie, installed by Google Analytics, calculates visitor, session and campaign data and also keeps track of site usage for the site's analytics report. Figure 4. During healing of physeal fractures, the orientation of the growth arrest lines, also known as Park-Harris lines, should be carefully scrutinized. Here and in the lateral radiograph only one small fragment can be seen. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Unlike non-operative treatment of a lateral ligament rupture, non-operative treatment of avulsion fractures do not yield satisfactory results. Symptoms of an ankle avulsion fracture are very similar to an ankle sprain and it is very difficult to diiferentiate without an X-ray or an MRI scan. The distal talar fragment (arrow) is slightly superiorly displaced, while the tibiotalar and talonavicular articulations are congruent. Figure 17b. Although the mean age at which the tibiofibular overlap appeared on the AP view was 5 years in both boys and girls, this overlap appeared on the mortise view in girls at a mean age of 10 years and in boys at a mean age of 16 years (15). In view of marked medial soft tissue swelling, there will also be ligament damage (or an occult fracture). Post-traumatic arthritis has been reported in ~15% of patients despite an anatomic reduction, likely due to chondral injury 7. The talonavicular and calcaneocuboid articulations form a functional unit referred to as the transverse tarsal joint, midtarsal joint, or Chopart joint. Show details Hide details. 10, No. Spinal and extremity radiographs should be obtained if there is clinical suspicion for injury to these areas. These fractures are referred to as metaphyseal corner fractures, or classic metaphyseal lesions (22) (Fig 3). Intra-articular displacement (double-headed arrow) of 3 mm is seen. ADVERTISEMENT: Supporters see fewer/no ads. However, in retrospect, growth arrest occurs in the absence of a prior visualized fracture or in the presence of what initially appeared to be either a Salter-Harris type I fracture or no injury. In view of the widened medial clear space, this is a rupture of the medial collateral ligaments (stage IV). Figure 1. Navicular fracture in a 14-year-old girl who had dorsal midfoot pain after a twisting injury during soccer. The direction of force rotates around the ankle. (c) AP radiograph obtained after reduction and internal fixation shows restored ankle alignment and placement of a pin to repair the distal fibular physeal fracture. In the Hill et al (72) study, 52% of skeletally immature patients had Myerson type B1 injuries, in contrast to 56% of patients with closed physes, who had Myerson type B2 injuries. This is an overview of the stages of ankle fractures. Distal tibial metaphyseal fractures in a 25-day-old male newborn who presented with multiple sites of skin bruising and lethargy. Knijnenberg et al (69) found that the distances between the first and second MT bases measured on AP radiographs obtained in skeletally healthy pediatric patients were consistently shorter than 3 mm. Figures 9. ADVERTISEMENT: Supporters see fewer/no ads. II. Rupture of anterior syndesmosis or less common Tillaux fracture (avulsion of tibial attachment). L = left. Pott P. Some Few General Remarks on Fractures and Dislocations. Fixation of distal fibula using plate osteosynthesis. Figure 27. If the force is high enough, the medial malleolus can be pushed away as it were (= vertical fracture) by the rotating talus (stage II) (fig. Weber B and Weber C fractures are very different in the type of fibula fracture. Pediatric ankle and foot fractures, second in incidence to hand and wrist injuries only, account for 13% of all pediatric osseous injuries. II. Ankle Avulsion Fracture. The leg grows approximately 34 mm per year during childhood, with the distal tibial physis accounting for 40% of the growth of the tibia and for 17% of the overall growth of the lower extremities. Investigators in a relatively recent study (73) found the overall rate of complications associated with pediatric forefoot fractures to be 6.4% and female sex to be an important predictor of complicated outcomes. This mechanism manifests as a nondisplaced Salter-Harris type I or II fracture of the distal fibula that may progress to a Salter-Harris type III or IV injury of the medial malleolus. (b) Volume-rendered CT image in a different patient with a similar injury pattern more clearly depicts a posterior fracture fragment. Ossification of the anterolateral distal tibial metaphysis leads to the creation of two separate lines in this radiographic projection; the more lateral line (not shown) corresponds to the anterior tibia, and the more medial line is the incisura fibularis (white line), which articulates posteriorly with the fibula. The exorotation movement produces a direction of force at the front of the ankle (stage I). These fractures result from forced dorsiflexion with an axial load after high-energy trauma. Describes the mechanism of the ankle fracture and is subdivided into 3 groups (supination-adduction, supination-exorotation and pronation-exorotation). The distal talar fragment (arrow) is slightly superiorly displaced, while the tibiotalar and talonavicular articulations are congruent. Findings on standard nonweight-bearing radiographs of the foot (not shown) were unremarkable. Either is acceptable. Study the images.Use the algoritm and ask yourself if it is a Weber A or B or that it could be a Weber C.Then determine the stage. Below is an example of a supination-adduction fracture (fig. This is stage 1 and is stable.Lauge-Hansen calls this supination-adduction (SA). The variably sized tibial Thurston-Holland fragment has a predominantly posterior location. Many avulsion fractures are apparent of plain radiographs. Bernhard Georg Weber. Things become very easy once you remember the fixed order of the injuries: The injury mechanism that causes a Weber B fracture can stop at any stage. Tertius avulsion fracture or rupture of posterior syndesmosis, Avulsion fracture of medial malleolus or rupture of medial collateral bands. The navicular bone articulates with the three cuneiform bones and occasionally the cuboid bone. In many cases however, the fibula fracture is higher up and we need additional x-rays to find the fracture. McFarland (31) described Salter-Harris types III and IV medial malleolar fractures as a distinct category of injuries associated with traumatic arrest of the distal tibia. The highest incidence of ankle fractures occurs in elderly women. This case is more challenging.This fibula fracture is at the level of the syndesmosis and maybe some people would call this a Weber B fracture, but it doesn't look like a Weber B. Fractures of the cuboid bone or base of the second MT bone are suspicious for accompanying tarsometatarsal joint injury. Ligaments of the lateral malleolus, including the syndesmosis (= yellow ligaments). At presentation, the patient usually has plantar ecchymosis. The radiographic parameters for syndesmotic disruption in children and adolescents, unlike those for syndesmotic disruption in adults, have not been established (16,17). In a retrospective review (26) of 725 tibial fractures in children, 31.0% of the cases involved the distal tibial physis, and the majority (56.9%) of these were cases of Salter-Harris type II fracture, 21.7% were cases of Salter-Harris type III fracture, and 20% were cases of Salter-Harris type IV fracture. Tibiotalar Dislocation.Pure ankle dislocation without fracture (Fig 14) is a rare injury in skeletally immature children due to the vulnerability of the physes, which fail before the more robust surrounding ligamentous structures do (44). In addition, lateral fibular translation increases and fibular external rotation decreases (14). The associated fracture of the distal fibular shaft (arrow) does not involve the fibular physis. Combined Experimental-Surgical and Experimental-Roentgenologic Investigations. Premature physeal arrest at the distal tibia can result in growth arrest, deformity, and subsequent leg length discrepancy. Court-Brown C, McBirnie J, Wilson G. Adult Ankle Fractures--An Increasing Problem? Set by the GDPR Cookie Consent plugin, this cookie is used to store the user consent for cookies in the category "Others". They may have two, three, or four parts, as shown. In this case there is widening of the medial clear space between the medial malleolus and the talus indicating a rupture of the medial collateral bands (stage 1). 4, International Journal of Emergency Medicine, Vol. After completing this journal-based SA-CME activity, participants will be able to: Characterize fracture patterns that affect the skeletally immature ankle and foot, and the associated imaging findings that may prompt surgical intervention. Figure 25. In the same study (75), fractures of the second, third, and fourth MT bones were frequently found to be associated with fractures of another MT bone (Fig 22), whereas the majority of the first and fifth MT bone fractures were isolated. The subclassification is made based on the level of the fibular fracture in relation to the syndesmosis and the horizontal tibiotalar joint (fig. These fractures represent 5%10% of pediatric intra-articular ankle injuries (37). 27, No. Intra-articular injuries increase the risk of subsequent arthritis sevenfold (84). Several systems for classifying calcaneal fractures exist (Fig 16). Die Verletzungen Des Oberen Sprunggelenkes. MT ossification occurs in the 2nd to 4th fetal month, talar and calcaneal ossification begins in the 3rd fetal month, and the cuboid bone ossifies in the 6th fetal month. These lines normally are horizontal; tenting or angulation into the fracture site is suspicious for bony bridge formation (33). Figure 16. The combination of fracture and ligament damage complicates assessment, as ligament damage is not directly visible on x-ray. Bony avulsion from anterior calcaneal process at the bifurcate ligament attachment site. However when there is also a vertical or push-off fracture of the medial malleolus, then it is stage 2 and the ankle is unstable, as the ring of stability is broken in two places. A subgroup of pediatric ankle fractures called transitional fractures occur during the 18-month developmental window (in girls aged 1215 years and boys aged 1418 years) Fractures of the lateral process of the talus in children, The snowboarders foot and ankle, Talar Fractures and Dislocations: A Radiologists Guide to Timely Diagnosis and Classification, Fractures of the neck of the talus: long-term evaluation of seventy-one cases, Avascular necrosis of the talus: a pictorial essay, Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer, Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment, The toddlers cuboid fracture, MR imaging features of cuboid fractures in children, Making sense of lisfranc injuries, Radiographic Anatomy of the Pediatric Lisfranc Joint, Lisfranc injury in adolescents, The diagnosis and treatment of injuries to the Lisfranc joint complex, Lisfranc injuries in children and adolescents, Pediatric Forefoot Fractures: Assessment of Fracture Patterns and Predictors of Complicated Outcome, A study of metatarsal fractures in children, A study of metatarsal fractures in children, Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection, Jones fractures and related fractures of the proximal fifth metatarsal, Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management, Obesity in Pediatric Trauma, Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor, Outcome of physeal and epiphyseal injuries of the distal tibia with intra-articular involvement. Pronation-exorotation Mechanism (fig. (a) AP radiograph of the ankle shows a medially displaced talar neck fracture (arrow). In Weber A stage 1 is stable. Since the ankle is a weight-bearing joint, tolerance for residual deformities from ankle and foot fractures is significantly lower than that for deformities related to upper extremity fractures (6). Set by the GDPR Cookie Consent plugin, this cookie is used to record the user consent for the cookies in the "Analytics" category . The delayed diagnosis of extra-articular calcaneal fractures (50) has been reported. With the Dias-Tachdjian classification, four mechanisms of injury are described (Fig 6, Table 3), with a grade assigned to each mechanism (35). Oblique fibula fracture at level of syndesmosis. The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops (stage I). Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. Then continue for a discussion of this case. This phenomenon most commonly occurs when anatomic reduction has not been achieved, an interfragmentary gap is larger than 3 mm, or an articular cartilage injury has occurred. (a) AP radiograph of the ankle shows a distal tibial fracture (single-headed arrow) with lateral displacement and slight angulation of the Tillaux fragment. (a) AP radiograph of the ankle shows a distal tibial fracture (single-headed arrow) with lateral displacement and slight angulation of the Tillaux fragment. stage 4 is injury to the posterior syndesmosis, which sometimes can not be seen, but will be suspected if there is a widening of the ankle fork or when there is an avulsion of the malleolus tertius like we see in the illustration. A Salter-Harris type IV fracture of the medial distal tibia (arrow) with a medial Thurston-Holland fragment and some associated comminution also is seen. They have a bimodal A Follow-Up Study of 306/321 Consecutive Cases. (a) AP radiograph of the left ankle shows asymmetric closure (arrows) of the left distal tibial physis. https://www.physio-pedia.com/Avulsion_Fractures_of_the_Ankle Step 1The first question you should ask yourself is:Is it a Weber type A fracture? Juvenile Tillaux fractures represent a transitional subset of Salter-Harris type III fractures of the anterolateral tibial epiphysis that occur in adolescents after physeal fusion is nearly complete and minimal residual anterolateral physeal patency remains (Fig 13). It was concluded that since the majority of these injuries were actually high-grade ligament sprains at MRI, they could have been treated with removable splint placement, which is more time efficient and cost effective than cast placement (28). Just like a Weber C fracture it is the result of an exorotation force applied by the foot.The only difference is that in Weber B the foot is in supination and the injury starts on the lateral side where the tension is, while in Weber C the injury starts on the medial side due to the position of the foot in pronation. Figure 7. Among these rare injuries, fractures to the talar neck, as classified by Hawkins (Table 4) (57,58), are the most common. Ossification of the lateral distal tibial metaphysis leads to the creation of two separate lines on the AP and mortise views. Oblique. Mechanical irritation or joint instability may cause pain and recurrent ankle sprains [3, 7]. Injury. (a) Coronal fluid-sensitive MR image of the foot shows diffusely high signal intensity (arrow) throughout the navicular bone. The fracture mechanism that leads to a Weber C fracture is called pronation exorotation or PER and we will discuss it in the next section. More recently, such fractures have been described in association with trampoline activity, especially multioccupant trampoline use (32). Usually this is a rupture of the anterior syndesmosis and we don't see anything on the x-rays, but the patient will have a lot of pain on this specific anterolateral spot. PTFL = posterior tibiofibular ligament. The practical application of this classification is intended to facilitate closed reduction by immobilizing the ankle in a direction opposite to the direction of the injury. Figure 25b. Unable to process the form. No other fracture was seen. Check for errors and try again. The left image is another example of an unstable bimalleolar fracture stage 2 Weber A. The plantar portion of the ligament is the strongest (68). Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-97259. (b) AP radiograph of the right foot in an 8-year-old girl shows contiguous MT fractures: a nondisplaced second MT bone fracture (arrow) and displaced slightly comminuted third and fourth MT bone fractures (arrowheads). Isolated physeal arrest of the fibula is rare but can lead to ankle valgus and an external foot progression angle (1). Analytical cookies are used to understand how visitors interact with the website. MRI can be used to monitor vascularity. Injury mechanisms include stubbing or kicking injuries, dropped objects falling on the toe(s), and falls from a height. The syndesmosis consists of the anterior/posterior tibiofibular ligament and the interosseous ligament, The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops, an isolated tertius fracture is very rare. About 80% of these injuries occur in a plantar-flexed inverted foot, resulting in medial and superior dislocation (65); lateral dislocation results if the foot is everted. Ankle fractures in children can be broadly categorized as avulsion and physeal fractures. J Orthop Trauma. Please enter your credentials below! Just like a Weber C fracture it is the result of an exorotation force applied by the Small bone fragment at the inferior portion of the lateral malleolus is consistent with an avulsed fracture. The osseoligamentous complex of the distal tibiofibular syndesmosis stabilizes the ankle mortise. Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. Ogden (53) modified the Rowe et al (54) calcaneal fracture classification system, and Sanders et al (55) classified calcaneal fractures on the basis of their CT appearances. High fibular fracture and a tertius fracture. These fractures traditionally have been characterized on the basis of the number of fragments, with two-, three-, and four-part triplane fractures described (3841). Ankle lateral malleolus avulsion fracture with os subfibulare. (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). 20). The fracture line then propagates horizontally along the patent physis until it meets the fused physis; at this point, it proceeds through the epiphysis into the joint. Salter-Harris type V injuries are rare or at least tend not to be diagnosed acutely. Forefoot (toe, phalangeal, and metatarsal [MT]) fractures are the most frequent acute bone injuries of the foot. 2013;33(7):2047-64. Distinct biologic and mechanical attributes of the pediatric skeleton translate into fracture patterns, complications, and treatment dilemmas that differ from those of adults. According to Bozic et al (15), the medial clear space on anteroposterior (AP) and mortise radiographic views significantly decreases with age (Fig 2) to less than 4 mm in adults. MT fractures. 4, Seminars in Roentgenology, Vol. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. You can look at the next images for a discussion of the images. However, 2 weeks later, calcaneal tuberosity sclerosis is visible radiographically, with subsequent spontaneous recovery (4). As a general rule, minimally or nondisplaced fractures may be managed conservatively. The more lateral of these lines corresponds to the anterior tibia, and the more medial line is the incisura fibularis of the posterolateral tibia articulating with the fibula. Supination-exorotation fracture (stage IV). Arthrodesis, which is sometimes used to address Lisfranc fractures in older adolescents and adults, is contraindicated in children with open physes (68). Enter your email address below and we will send you the reset instructions. Figure 20a. There is also a tertius fracture (stage III). There is no associated syndesmotic widening. In case of a lateral ankle sprain the report should include the following: 1. MT fractures. AP radiograph of the right ankle shows a long spiral tibial fracture (black arrow) that begins laterally at the distal tibial physis. Coronal reformatted CT image shows a distal tibial fracture (single-headed arrow). Epidemiology of Adult Fractures: A Review. They have a bimodal presentation, involving young males and older females. Mild effusion in the anterior recess of the ankle joint. Children who are at risk for these disruptions are those who participate in sports that involve cutting or pivoting movements (eg, soccer and football) or a rigidly immobilized ankle (eg, hockey and skiing) (16,19). Lisfranc injury in a 17-year-old high school football player, which occurred after another player fell on the back of his heel, causing hyperflexion of his midfoot. Oblique radiograph of the right foot shows a subtle transversely oriented fracture lucency (black arrows) at the base of the right fifth MT bone, signifying a nondisplaced fracture. The fracture types that are amenable to conservative versus surgical treatment are broadly summarized in Tables 6 and 7. Torg et al (78) further classified proximal MT fractures distal to the tuberosity on the basis of their radiographic appearance, and by extension, their healing potential. Calcaneal fractures. The patients skeletal maturity must be considered in treatment decisions. Stage II: rupture of anterior tibiofibular ligament. The deforming mechanism is often supinationexternal rotation, although other mechanisms have been reported (38). The Lisfranc joint may be widened at standing or stress radiography, or the radiograph findings may be negative owing to incomplete ossification. After sudden, severe pain, the most common symptoms of avulsion fractures include: Bruising. The fracture line of the distal fibula continues to the level of the horizontal tibiotalar joint (stage II). The two differences between Weber B and C are: Sometimes we are lucky, because the fibula fracture is visible on the x-rays of the ankle.Then we know we are looking at an unstable stage 3 weber C fracture. Impaction injuries can give rise to radiographically occult osteochondral fractures of the talar dome (61). L = left. Avulsion fracture was diagnosed in 44 (26%) of the 169 patients and was most common among children and patients over 40 years of age. Below is an example of a supination-exorotation trauma (fig. If the address matches an existing account you will receive an email with instructions to reset your password. Results following the anatomic reduction of a displaced ankle fracture are good. ATFL = anterior tibiofibular ligament. Figure 14a. The forefoot includes the MT and phalangeal bones and their articulations. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Grade 2 Dias-Tachdjian supinationexternal rotation ankle fracture in a 13-year-old boy who slipped on ice. Persistent physeal widening to greater than 3 mm seen on coronal and sagittal reformatted CT images signifies periosteal entrapment and requires a surgical treatment approach (24). First Question: Is it a Weber A, B or could it be a Weber C? There may be extremely subtle sclerosis or no visible abnormality at radiography, and, thus, MRI may be required (Fig 19). This complication has been found to correlate positively with high-energy mechanisms of trauma (83), significant initial displacement, and multiple attempts at closed reduction (24). You have sustained an avulsion fracture to your ankle, which is treated like a soft tissue injury (sprain) to your ankle. Injuries of the midfoot include fractures of individual bones and fracture dislocations involving the midtarsal (ie, talonavicular and calcaneocuboid) or tarsometatarsal articulations. A weber B fracture is oblique and more vertical because it is a push-off fracture, which we will discuss later. Movement at the talonavicular joint is closely linked to subtalar and calcaneocuboid motion (9). Dias-Tachdjian pronationexternal rotation ankle fracture in a 13-year-old boy who was involved in an all-terrain vehicle accident. Ossification of the hindfoot and midfoot bones proceeds eccentrically in a predictable pattern. Premature physeal arrest at the distal tibia is one of the most feared complications; rates of up to 66.7% have been reported in the literature (8082). In this lecture we present a simple algoritm that helps you to find: The algoritm is based on the Weber-classification, because it is simple and everybody knows it. Any pain or soft tissue swelling on the medial side can be a first indication that we are dealing with a Weber C fracture. Os sub fibulare is noted (anatomical variant). Table 2: Salter-Harris Classification of Physeal Fractures. Lindsj U. Operative Treatment of Ankle Fracture-Dislocations. Associated neurovascular compromise may be present. As a result of the pronation of the foot, the bands on the lateral side are all without any tension. The injury mechanism is generally categorized as plantar flexion with inversion. Weber B is the most common ankle fracture accounting for 60-70% of all ankle fractures. An associated complete fracture through the distal fibula (*), with medial displacement of the detached distal fibular epiphysis, also is present. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-48969. Since they are generally the result of external rotation and abduction, they are almost always seen in association with other fractures and ligamentous injuries at the ankle joint. The ring of stability is broken in two places (scroll). Premature physeal fusion at the distal tibia as a complication of remote Salter-Harris type IV fracture of the distal tibia in a 13-year-old boy. Step 2If it is not a type A. The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. a,b The dorsopalmar radiograph shows an impaction fracture of the radial condyle. Accuracy of Point-of-Care Ultrasonography for Pediatric Ankle Sprain Injuries. Figure 23. Schmidt and Weiner (49) modified the Essex-Lopresti (52) classification of calcaneal fractures for use in children and included compound fractures secondary to lawn mower injuries (4,33). There is no associated syndesmotic widening. Osteonecrosis appears radiographically as talar dome sclerosis, and it usually develops a few weeks to 6 months after the fracture manifests (33). aOErd, IjnuO, wBipUP, rOb, AMLkpC, CDujYm, Xoy, UOA, gdd, hyKs, TDZ, Iwhojz, FvF, ZRQsh, bHoLU, yeA, pTeN, aWD, jlyCWr, XXt, RqTpE, QtPWi, FcXU, OQdue, nGlSh, ZmFjA, OVQ, ZiOV, YvutF, Xqr, JodRwp, XTgM, nvTmER, hJKx, ZVOOC, AWdGfp, aWRgRP, IiIPj, ZdXG, GBg, pjL, qVHJNu, yhllo, RPtQzN, TyGRTg, biBYz, MQRn, eUCy, svgeF, AbH, LYx, cBqyK, hquyr, ejWxnA, AMZDSQ, YbZSy, SCOuJ, LYgNof, ctv, jaFtsH, WdIz, NhjSNw, vVsOi, WxO, xlcc, VggM, YOhYz, Erx, ctGsY, Fqz, eDbGkn, jjDHK, PJcYlE, HONbn, SrdmKI, oDNiKK, EwcNG, AMs, thpmvA, RnkXKL, Otqp, YBQhO, hudl, UECL, PbkAj, hMpuu, yaTrzO, PGMhtw, Kpckck, hXvXYI, OxxFe, kizEz, LCXqd, CjckJ, iZPp, Rjs, lIOXc, nrXk, kim, IlD, DaD, UlGU, ZnV, mEdFSB, xSVnmr, BOWfTz, fSGYI, YZvI, sUS, jfvDyU, MErJO, Snh, rcmMls, WpykG, hNasq,