Abstract
Ankle sprains are common athletic injuries, with a peak lifetime incidence between the ages of 15 and 19 years, especially in young males. However, an unclear history, an imprecise physical exam, and unhelpful radiographies lead to frequent misdiagnosis of paediatric ankle traumas, and subsequently, inappropriate treatment. Improper management may lead to residual pain, instability, slower return to physical activity, and long-term degenerative changes. The purpose of this study was to evaluate the initial management and treatment of acute paediatric ankle sprains at our center, a tertiary care paediatric hospital. Our hypothesis was that the initial diagnosis is often incorrect, and treatment varies considerably amongst orthopaedic surgeons.
We conducted a retrospective study of all cases of ankle sprains and Salter-Harris one (SH1) fractures referred to our orthopaedic surgery service between May and August 2014. Exclusion criteria included ankle fractures other than SH1 types, and cases where treatment was initially undertaken elsewhere before referral to our service. Patients were evaluated on a clinical and radiographic basis. Primary outcome was the difference between initial and final diagnosis. Secondary outcome was variation in immobilisation duration for each diagnosis. The main variables we considered were age, sex, mechanism of trauma, referral delay, patient symptoms, physical exam findings, radiographic findings, type and duration of immobilisation, prescription of any medication, and referral to physical therapy.
A total of 3047 patients were reviewed and 31 cases matched our inclusion criteria, comprised of 17 girls and 14 boys, with a mean age of 10.4 years. Patients were seen at a mean of 10.3 days after injury. Initial diagnosis was SH1 fracture in 20 cases, acute ankle sprain in 8 cases, and uncertain in 3 cases. Final diagnosis was SH1 fracture in 11 cases, acute ankle sprain in 13 cases, uncertain in 5 cases, and other in 3 cases. During follow up, 48.5% of cases saw a change in diagnosis. Forty five percent (9/20) of cases initially diagnosed as SH1 fractures proved to be incorrect, with 55.5% (5/9) of these being ultimately diagnosed as acute ankle sprains. Amongst cases initially diagnosed as acute ankle sprains, 37.5% (3/8) received a different final diagnosis. Duration of immobilisation was significantly different between acute ankle sprain and SH1 fracture groups, with an average of 17.3 days and 26.1 days, respectively. Physical therapy was prescribed to 33.3% of acute ankle sprains and 9.1% of SH1 fractures.
Initial distinction between acute ankle sprains and SH1 fractures can be difficult in paediatric ankle trauma. Case management and specific treatments vary considerably, as there is neither an evaluation algorithm nor consensus on treatment of these paediatric pathologies. This study reinforces the need to develop a systematic diagnostic and treatment protocol for paediatric ankle sprains.
