[Ankle injury without fracture in children: cast immobilization versus symptomatic treatment. Impact on absenteeism and quality of life]

Avulsion fracture of the distal fibula is associated with recurrent sprain after ankle sprain in children

PURPOSE

The purpose of this study was to clarify radiographic and clinical outcomes, as well as their association, of ankle sprain in children.

METHODS

Patients who sustained a first-time ankle sprain were prospectively surveyed. Patients underwent radiography of the ankle in the mortise, lateral, anterior talofibular ligament (ATFL), and calcaneofibular ligament views at the first clinic visit to assess avulsion fractures of the distal fibula. Patients with avulsion fractures underwent radiography after 8 weeks to assess bone union. The treatment method was not standardized and was determined by the patient, their parents, and the treating physician. Recurrent sprain and quality of life were evaluated by using the Self-Administered Foot Evaluation Questionnaire and reviewing the medical records of patients. The association between avulsion fracture and recurrent sprain was assessed using univariate and multivariate analyses.

RESULTS

A total of 143 patients with a median age of 9 (range 6-12) years were analyzed. Avulsion fractures were present in 89 (62%) patients. The sensitivity of the ATFL view for the diagnosis of avulsion fractures was 0.94, whereas that for the anteroposterior and lateral views was significantly lower at 0.46 (P < 0.001). Only 17% of fractures united at 8 weeks. Of 114 (follow-up rate, 80%) patients who were followed up for a median period of 24 months, recurrent sprain occurred in 41 (36%) patients. The incidence rate was significantly higher in patients with avulsion fractures than in patients without the fractures (44 vs. 23%, P = 0.027). In multivariate logistic regression analysis, avulsion fracture was independently associated with recurrent sprain (P = 0.027).

CONCLUSION

More than one-third of patients experienced recurrent sprain. The presence of avulsion fracture was associated with an increased risk of recurrent sprain. Patients with avulsion fracture and their parents should be informed about the risk of recurrent sprain and subsequent ankle instability, and careful follow-up is needed for these patients.

LEVEL OF EVIDENCE

III.

Management of 'low-risk' ankle fractures in children: a systematic review

INTRODUCTION

This study aimed to review the literature to establish whether there is a best treatment for low-risk ankle fractures in children.

MATERIALS AND METHODS

A systematic review and meta-analysis of trials was undertaken, which compared interventions for 'low-risk' ankle fractures in children. A meta-analysis was performed using a random effects model.

RESULTS

Four trials were identified reporting outcomes from 256 patients. All trials reported results using a device that permitted ankle motion compared with more rigid immobilisation. Overall risk of bias was low for three trials and high for one trial. Two trials assessed time to return to normal function. Patients treated in a splint or with a bandage recovering 6-7.5 days sooner than those treated with rigid immobilisation. One trial demonstrated that children returned to school sooner if treated in a bandage rather than in a cast. Two trials found a higher Activity Scale for Kids performance score at four weeks for children treated with splint compared with rigid immobilisation. There was no clear advantage to any device in patient satisfaction, quality of life or total costs.

DISCUSSION

There is no clear best treatment for these injuries. Studies had significant limitations and outcomes were heterogeneous, limiting meta-analysis.

CONCLUSION

There is a need for a definitive trial to establish the best treatment for ankle fractures and a core outcome set to ensure study findings are consistent and can be analysed in future meta-analyses.