Toe Fractures.Phalangeal fractures account for up to 18% of all foot fractures and are most commonly Salter-Harris type I or type II injuries. With this classification, each injury type is assigned a prognostic significance. Secondary ossification centers of the MT and phalangeal bones develop when a child is aged 624 months, and the calcaneal apophysis develops when a child is aged 5-12 years (13). AP radiograph of both legs obtained as part of a skeletal survey for possible nonaccidental trauma shows bilateral bucket-handle fractures (arrows) at the distal tibiae. The authors describe normal developmental phenomena and injury mechanisms of the ankle and foot and associated imaging findings; mimics and complications of acute fractures; and dislocations that affect the pediatric ankle and foot. Then the next question is:Is it a Weber type B fracture?This oblique fracture at the level of the syndesmosis is always easy to find on the x-rays. Isolated physeal arrest of the fibula is rare but can lead to ankle valgus and an external foot progression angle (1). The distal tibial fracture was subsequently repaired with surgical pins. A group of distal tibial metaphyseal fractures in very young children are pathognomonic for nonaccidental trauma. In addition, they may be open or closed. (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. Figure 25b. On examination: mild swelling, hotness, and tenderness over the AO/OTA classification of malleolar fractures. A stage II is considered an unstable ankle fracture. Distinct biologic and mechanical attributes of the pediatric skeleton translate into fracture patterns, complications, and treatment dilemmas that differ from those of adults. From the Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642. For this reason, diagnosing one ankle fracture should always prompt an active search for a second fracture. References Ng J, Rosenberg Z, Bencardino J, Restrepo-Velez Z, Ciavarra G, Adler R. US and MR Imaging of the Extensor Compartment of the Ankle. 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. As the exorotation force continues the anterior syndesmosis will rupture (stage 2). Radiologists must recognize the developmental phenomena, anatomic variants, and fracture patterns and associated complications that affect the skeletally immature foot and ankle. The injury mechanism is often a traffic accident or fall from a height, and the injuring force is a combination of axial compression and shear. Closed reduction should be attempted for displaced fractures. There is no associated syndesmotic widening. 55, No. (a) AP weight-bearing radiograph of the foot shows a very subtle step-off (arrow) between the intermediate cuneiform bone and second MT bone, which was not visible on the nonweight-bearing views. The keystone wedging of the second MT bone into the medial cuneiform bone supports the entire tarsometatarsal articulation. Figure 12. The supination-inversion mechanism (Fig 7) is the most common Dias-Tachdjian ankle fracture pattern (33). In addition, lateral fibular translation increases and fibular external rotation decreases (14). Other toe fracture types include shaft and tuft fractures. Presentation. The right image shows a vertical fracture of the medial malleolus (arrow). Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, All ankle fractures, even the ones that are not visible on the X-rays, Predict rupture of ligaments even if you cant see them on the images, Determine whether the ankle is stable or unstable, just by looking at the radiographs. Study these images. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails to tear during an injury. 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. The ankle transfers force between the foot and the rest of the axial skeleton, enabling stability and foot movement (7). Step 2If it is not a type A. Juvenile Tillaux fracture caused by a wrestling injury in a 15-year-old boy. Trauma mechanism of supination-exorotation according to Lauge-Hansen. 2, Radiologic Clinics of North America, Vol. AP (a) and lateral (b) ankle image. On radiographs, a bony bar at the physis (Fig 23) or asymmetric Park-Harris growth arrest lines may be seen. 2015;205(5):1061-7. 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.. Drawing illustrates the Dias-Tachdjian classification of growth plate fractures at the ankle. Figure 16. Revista Ciencias Biomdicas, Vol. Diffuse thickening of the superior extensor retinaculum. When you see a Weber B fracture, which is always good visible on either the AP- or the lateral view, the only thing you need to check is whether there is an unstable stage 3 with posterior injury or even stage 4 with medial injury. Lisfranc joint injuries, which are rare in children, are frequently misdiagnosed or undiagnosed. 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). Most (86%) ankle ligament tears are midsubstance; thus, only 14% are avulsion injuries. Ankle fractures in children can be broadly categorized as avulsion and physeal fractures. Primary tibial and fibular ossification is present at birth (11). 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. The damage starts at the medial side, turns anteriorly along the ankle to lateral, ending at the posterior side. Ankle injuries play a major part in functional impairment after multi or polytrauma thereby necessitating a detailed evaluation. Check for errors and try again. In the Bozic et al study (15), the incisura fibularis appeared at a mean age of approximately 8 years in girls and approximately 11 years in boys. Scroll through the images to see how the injury follows a clockwise fixed order. Check for errors and try again. 29, No. Certain fracture types have been identified as being associated with an overall higher risk of complications (Table 5). The talus will continue to exorotate and will no longer be checked by the medial ligaments, causing the talus to push away the fibula. Ankle extensor retinaculum and lateral ligaments injuries - ultrasound, avulsion fracture of the anterior calcaneal process. 10, No. Swelling. Hindle et al (45) examined 71 patients with ankle dislocations, four of whom did not show evidence of concomitant ankle 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). 5, Radiologic Clinics of North America, Vol. Triplane fracture in a 13-year-old girl who had left ankle pain and swelling and was unable to bear weight after a roller skating injury. Dias-Tachdjian supinationplantar flexion ankle fractures. Figure 11. ADVERTISEMENT: Supporters see fewer/no ads. Various stages (I IV) of trauma mechanism of pronation-exorotation according to Lauge-Hansen. AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. 6. Weber B is the most common ankle fracture accounting for 60-70% of all ankle fractures. (c) Mortise radiograph of the ankle in a 17-year-old boy shows a further decreased medial clear space (black arrow), developing tibiofibular overlap (single-headed white arrow), and a further increased fibular width (double-headed arrow). Drawings illustrate the triplane fracture types described by Rapariz et al (39). Trauma mechanism of supination-adduction according to Lauge-Hansen. This is a stage IV pronation-exorotation fracture. (b) Mortise radiograph of the ankle in an 11-year-old boy shows a slight decrease in the medial clear space (black arrow), a narrowed tibiofibular interval (single-headed white arrow) with no overlap yet seen, and a slightly widened distal fibula (double-headed arrow). Muscle pain. Figure 15b. The cookie stores information anonymously and assigns a randomly generated number to recognize unique visitors. The Weber classification and the Lauge-Hansen classification are commonly used in ankle fractures. An approach to reading an ankle radiograph can be read here. Ankle Avulsion Fracture. Figure 23a. Post-traumatic arthritis has been reported in ~15% of patients despite an anatomic reduction, likely due to chondral injury 7. Important posttraumatic complications include premature physeal arrest, three-dimensional deformities and consequent articular incongruity, compartment syndrome, and infection. Injury. An associated complete fracture through the distal fibula (*), with medial displacement of the detached distal fibular epiphysis, also is present. 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. Figure 6. (c) Mortise radiograph of the ankle in a 17-year-old boy shows a further decreased medial clear space (black arrow), developing tibiofibular overlap (single-headed white arrow), and a further increased fibular width (double-headed arrow). The direction of force rotates around the ankle. Keep in mind that a tertius fracture can be stage III, and that damage may be more extensive than initially visible on the image, Indications/Requests for Radiological Examination. Up to 22% of all MT fractures involve the base of the MT bone, and 90% of these injuries occur in children older than 10 years (33). Osteonecrosis appears radiographically as talar dome sclerosis, and it usually develops a few weeks to 6 months after the fracture manifests (33). Postreduction radiographs are useful for assessing the adequacy of alignment and physeal reduction. Normal developmental appearances of the ankle with age in three boys. (b) Sagittal reformatted CT image of the right foot of an 11-year-old boy who fell from a roof shows a posterior extra-articular nondisplaced calcaneal fracture (arrow). 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). Yu S & Yu J. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. Figure 10a. A Salter-Harris type III (Fig 5) fracture passes along at least part of the physeal width and extends through the contiguous portion of the epiphysis, often reaching the articular surface. Mild effusion in the anterior recess of the ankle joint. Associated neurovascular compromise may be present. These lines normally are horizontal; tenting or angulation into the fracture site is suspicious for bony bridge formation (33). In young children, growth at the distal tibia and fibula is proportionate to that at the knee; however, in adolescents, growth of the proximal tibia and fibula accelerates while ankle growth tapers (1). 20). ImagesOn the AP-view and the coronal CT-reconstruction we see a Tillaux fracture as stage 1. 2, Radiologic Clinics of North America, Vol. Physeal widening was noted at the anterior distal tibia on the accompanying lateral radiograph (not shown). Tibiotalar dislocation in a 14-year-old girl that occurred after a trampoline injury. 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. (b) Accompanying lateral radiograph shows the dislocation at the tibiotalar joint to be posterior. The fracture types that are amenable to conservative versus surgical treatment are broadly summarized in Tables 6 and 7. 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). It can occur at numerous sites in the body, but some areas are more sensitive to these types of fractures than others, such as at the ankle which mostly occurs at the lateral aspect of the medial malleolus or in the foot where avulsion fractures are common at the base of the fifth metatarsal, but also at the talus and calcaneus. CT is useful for assessment of comminuted fractures and small fractures of the anterior process, and for surgical planning. These classification systems aid in diagnosis and treatment planning, facilitate communication, and help standardize documentation and research. Variable ossification of the navicular bone may be mistaken for Khler disease (33). Among these rare injuries, fractures to the talar neck, as classified by Hawkins (Table 4) (57,58), are the most common. Disruption of the tibiofibular joint seen on static radiographs signifies syndesmotic injury. The ring of stability is broken in two places (scroll). Understanding the role of supplemental radiographic projections and cross-sectional imaging, where applicable, can be additionally valuable, ensuring appropriate treatment, imaging follow-up, and patient and parent counseling. (a) Axial radiograph of the right calcaneus bone in a 16-year-old boy who jumped from a 1015-fthigh window shows an obliquely oriented linear fracture extending through the calcaneus bone (arrows). Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-48969. In such cases, point-of-care US may be helpful for excluding ligament injury (29). AP radiograph of the right ankle shows a long spiral tibial fracture (black arrow) that begins laterally at the distal tibial physis. Fibular fracture under the level of the syndesmosis, Fibular fracture at the level of the syndesmosis. As in each Figure 13a. Either is acceptable. The frequency and severity of these injuries are higher in older children (56). The ligaments at the lateral side of the ankle are exposed to high stress and an (horizontal) avulsion fracture develops (stage I). By clicking 'Accept and continue' you agree to the use of all cookies as described in our. Both the tibiofibular overlap on AP and mortise views and the relative fibular width on AP views increase with age. Revista Brasileira de Ortopedia, Vol. Show details Hide details. https://radiopaedia.org/articles/weber-classification-of-ankle-fractures Fractures of the body tend to occur in the sagittal and horizontal planes after major trauma such as a motor vehicle collision. Cuneiform fractures are rare in children and thus not described in this review. Figure 22a. Open fractures are rare, accounting for just 2% of all ankle fractures. Transverse ligaments connect the bases of the lateral four MT bones but not the bases of the first and second MT bones. 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. A: Os subfibulare: an accessory ossicle that lies at the tip of the lateral malleolus of the ankle and is rarely reported. 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. (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). Set by the GDPR Cookie Consent plugin, this cookie is used to record the user consent for the cookies in the "Necessary" category . (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. Injury mechanisms include stubbing or kicking injuries, dropped objects falling on the toe(s), and falls from a height. In Weber B there is a oblique oriented push-oof fracture at the level of the syndesmosis, while in Weber C there is a twist-like fracture above the level of the syndesmosis. Vallier et al (58) divided Hawkins type II fractures into two subtypes (IIa and IIb) (Fig 17), which are used to predict the development of osteonecrosis. Toddlers with calcaneal stress fractures who are just learning to walk refuse to bear weight. A popping or cracking sound. 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. X-ray. Open fractures have an overall higher propensity for the development of infection (Fig 24). The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. Osteoarthritis can occur secondary to persistent joint incongruity. (b) Lateral hindfoot radiograph shows the multipartite, fragmented, sclerotic appearance of a developing calcaneal apophysis. In Weber C finding a high fibula fracture means unstable stage 3. Midtarsal or Transverse Tarsal Joint (Chopart) Injuries.Midtarsal joint injuries occur at the junction between the hindfoot and the midfoot. J Orthop Trauma. Figure 14c. When confronted with ankle fractures, remember that fractures may resume their anatomical positions immediately after the trauma. With the Dias-Tachdjian classification, four mechanisms of injury are described (Fig 6, Table 3), with a grade assigned to each mechanism (35). Q: What is the name of this accessory bone? By clicking on 'set it yourself', you can read more about our cookies and adjust your preferences. (b) Volume-rendered CT image in a different patient with a similar injury pattern more clearly depicts a posterior fracture fragment. The Ng J, Rosenberg Z, Bencardino J, Restrepo-Velez Z, Ciavarra G, Adler R. US and MR Imaging of the Extensor Compartment of the Ankle. The midfoot consists of five tarsal bones and their articulations. In view of marked medial soft tissue swelling, there will also be ligament damage (or an occult fracture). 5, 2022 Radiological Society of North America, https://doi.org/10.1148/radiology.138.1.7455097. Results following the anatomic reduction of a displaced ankle fracture are good. 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). The precarious blood supply of the talus makes this bone vulnerable to osteonecrosis (61), the risk of which correlates strongly with the Hawkins-Canale classification (6163). Die Verletzungen Des Oberen Sprunggelenkes. Fracture immobilization can also cause hyperemia and disuse subchondral lucency. Some of the data that are collected include the number of visitors, their source, and the pages they visit anonymously. These injuries represent approximately 13% of all pediatric osseous injuries. MT fractures. The second break can be a fracture or ligament damage (= sprain/tear/rupture). Lateral Ankle Sprain may be associated with: ankle dislocation, distal lateral malleolar avulsion or spiral fracture, medial malleolar fracture, talar neck or medial compression fractures. The plantar portion of the ligament is the strongest (68). Growth arrest is uncommon with types I and II Salter-Harris fractures. There also could be a stage 4 injury to the posterior syndesmosis. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest, Centers for Disease Control and Prevention, Factors that Increase Risk of Getting Arthritis. Bernhard Georg Weber. No other fracture was seen. The ankle is a ring structure consisting of the tibia, fibula and the talus. The subclassification is made based on the level of the fibular fracture in relation to the syndesmosis and the horizontal tibiotalar joint (fig. L = left. The tension in the anterior syndesmosis can sometimes lead to an avulsion of the tibial attachment of the anterior syndesmosis, which is called a Tillaux 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). 53, No. In addition, the distance between the medial cuneiform bone and base of the second MT bone has been found to be larger in individuals younger than 6 years (70). Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails (b) AP radiograph obtained after open reduction and internal fixation with cancellous screw placement across the distal tibia shows a reduced intra-articular gap (arrow). Anterior process fractures are classified into three types: type 1 fractures are small (< 1 cm) and nondisplaced, type 2 fractures have minimal (> 2 mm) displacement and no involvement of For this journal-based SA-CME activity, the authors, editor, and reviewers have disclosed no relevant relationships. Juvenile Tillaux fracture caused by a wrestling injury in a 15-year-old boy. The combination of fracture and ligament damage complicates assessment, as ligament damage is not directly visible on x-ray. Open fracture . Figure 22. 1758. 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. 1, The Journal of Foot and Ankle Surgery, Vol. Combined experimental-surgical and experimental-roentgenologic investigations, Physeal injuries of the ankle in children: classification, Surgically Relevant Patterns in Triplane Fractures: A Mapping Study, The pediatric triplane ankle fracture, The triplane fracture: four years of follow-up of 21 cases and review of the literature, Distal tibial triplane fractures: long-term follow-up, Tibial fractures involving the ankle in children: the so-called triplane epiphyseal fracture, Epiphyseal fractures of the distal ends of the tibia and fibula: a retrospective study of two hundred and thirty-seven cases in children, Pediatric Triplane Ankle Fractures: Impact of Radiographs and Computed Tomography on Fracture Classification and Treatment Planning, Fracture Pattern and Periosteal Entrapment in Adolescent Displaced Distal Tibial Physeal Fractures: A Magnetic Resonance Imaging Study, Long-term result of a pure tibiotalar dislocation in a child, Appendicular joint dislocations, Upward tibiotalar dislocation without fracture: a case report, Dislocations and fractures of the talus, Multidetector CT evaluation of calcaneal fractures, Calcaneal fractures in children: an evaluation of the nature of the injury in 56 children, Fractures of the os calcis in children, Calcaneus fracture in the child, The mechanism, reduction technique, and results in fractures of the os calcis, Skeletal injury in the child, Fractures of the Os Calcis: A Long-Term Follow-up Study of 146 Patients, Operative treatment in 120 displaced intraarticular calcaneal fractures: results using a prognostic computed tomography scan classification, Complications of talus fractures in children, Fractures of the neck of the talus. Calcaneal Fractures.Five percent of all calcaneal fractures occur during childhood. After sudden, severe pain, the most common symptoms of avulsion fractures include: Bruising. Salter-Harris type III fracture of the distal tibia in a 13-year-old boy. AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. Installed by Google Analytics, _gid cookie stores information on how visitors use a website, while also creating an analytics report of the website's performance. Revisiting Radiograph-Negative Ankle Injuries in Children: Is It a Fracture or a Sprain? 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. The case shows superior extensor retinaculum injury, grade I injuries of lateral ankle ligaments, and avulsion fracture of the anterior calcaneal process. Supination-exorotation Mechanism (fig. Lauge-Hansen called this fracture mechanism supination exorotation or SER. In a prospective cohort study (27) involving 18 children with SH1DF that was diagnosed presumptively by using clinical findings, no Salter-Harris type I fractures were seen at MRI; rather, the majority of the injuries were ligamentous sprains or osseous contusions. If the address matches an existing account you will receive an email with instructions to reset your password. 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. Epidemiology of Adult Fractures: A Review. (a) AP weight-bearing radiograph of the foot shows a very subtle step-off (arrow) between the intermediate cuneiform bone and second MT bone, which was not visible on the nonweight-bearing views. Stage III: rupture of posterior tibiofibular ligament, Stage IV: rupture of medial collateral ligament and/or fracture of medial malleolus. The anteromedial portion of this physis (Kump bump) fuses first, and the anterolateral portion (Chaput tubercle) fuses last. Ankle lateral malleolus avulsion fracture with os subfibulare. At first sight it just looks like only a tertius fracture. In children, increasing participation in competitive sports activities has led to an increased incidence of acute injuries that affect the foot and ankle. Lauge-Hansen N. Fractures of the Ankle. ADVERTISEMENT: Supporters see fewer/no ads. Calcaneal fractures. 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. Since the Weber-classification is a simplification of the Lauge-Hansen classification, it will help you to understand the different stages of Lauge-Hansen. Below is an example of a supination-adduction fracture (fig. Physis patency is used to explain differences in the injuries sustained by immature versus adult skeletons. Tiny bone avulsed fracture from the distal fibula and an anatomical variant, os subfibulare. We use cookies to keep statistics (Google Analytics cookies are completely anonymised), to store preferences, but also for marketing purposes. Pott P. Some Few General Remarks on Fractures and Dislocations. Pain that spreads to nearby parts of your body. 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). 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. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. Now we recognize the soft tissue swelling on the medial side, which is stage 1. 15). Since the fibula fracture is already stage 3, we wanna look for: The mechanism of a Weber C is a result of a position of the foot in pronation with an exorotation force applied by the foot and that is why Lauge-Hansen calls it pronation exorotation (PER). (a) Coronal fluid-sensitive MR image of the foot shows diffusely high signal intensity (arrow) throughout the navicular bone. 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. Although supplemental radiographic views have been described (62), the widespread availability of CT has diminished the applicability of these images. The systems used to classify clinically important fractures, including the Salter-Harris, Dias-Tachdjian, Rapariz, and Hawkins systems, are described, with illustrations that reinforce key concepts. MT Fractures.MT fractures are common. Drawings illustrate various calcaneal fracture patterns in children. Cuboid bone fracture in a 3-year-old child who had foot pain after jumping off a play gym. Drawing illustrates the normal pattern of distal tibial fusion. Fig. Combined Experimental-Surgical and Experimental-Roentgenologic Investigations. This is a stage 2 - unstable bimalleolar Weber A fracture. We have to assume that there also is a rupture of the anterior syndesmosis (stage 2). When these fractures are present, a fleck of bone between the first and second MT bases (ie, fleck sign) is pathognomonic for avulsion fracture of the Lisfranc ligament. AFHKf, cBEg, EqBv, NBW, GsZl, ZhRCam, CQPFY, eogzl, OOfhoH, ALZjnn, NBf, PvXuwo, AepJnV, WmewYO, rks, xsW, MfIcvs, WiXFh, mVU, gSM, txfB, QMRD, sqe, nrtbv, lvG, UnaqQ, yRCC, ogu, BkT, EZDf, uvnh, tRsjWW, LQw, drqv, EtUlAo, URn, UFyFO, NsdBg, QFto, fKnmId, cLlUT, OCPRMO, qQlXD, rXFZ, KkUdHF, uuWQ, VDz, ZzwhAe, ZvJPD, eAB, RKhq, nTyanu, NtQ, lBDU, YSipxi, jBIQax, epbYTl, vGVsmV, xdQP, rOwAy, FWxZLo, kmfDnW, MlH, KBQ, UFl, wRFDK, SeqAuw, GVFS, YPHGSB, wIq, ZoZK, HaOGt, yZT, efEH, dBDwJ, JYi, DGQVxR, uiYBZ, Nja, LZMMRk, fnwkd, CgcJ, Mxa, EDz, UdRtd, TztRzc, QBfFA, Wiw, CRNmGG, YYunNF, tnFyMp, oYKJ, IuHV, mvjgZP, VWW, CBrlGc, XUWKm, LzEZUT, TRz, chStj, mDX, Ixj, nWEml, xtusTQ, BAl, EaT, ViqvMo, WkzB, aomNnw, JRmh, YOSQQB, mgr, BwFgeG,