Reliability and clinical utility of paediatric ankle fracture classifications : a systematic review.

Abstract

Despite the availability of various classification systems for paediatric ankle fractures, there is a lack of consensus regarding the reliability and utility of each classification, and the corresponding impact on clinical practice. This systematic review aimed to investigate current paediatric ankle fracture classification systems, by assessing their inter- and intraobserver reliability, and their clinical utility in guiding clinical decisions and outcomes. A systematic search was performed on PubMed, Embase, and Cochrane Library from inception until 31 October 2025. The inclusion criteria were studies which evaluated the reliability and clinical utility of different paediatric ankle fracture classification systems. Exclusion criteria were adult fractures, paediatric non-ankle fractures, and lack of classification usage. There were 42 studies covering 11 classification systems, including Salter-Harris, AO, Dias-Tachdjian, Lauge-Hansen, Gerner-Smidt, Ashhurst-Bromer, Carothers-Crenshaw, transitional fractures, atypical triplane fractures, Li-La, and Nenopoulos, in this systematic review. Salter-Harris, AO, Dias-Tachdjian, and transitional fracture classifications are among the more widely used systems in the current field of paediatric orthopaedic surgery. In terms of interobserver reliability, both the AO classification and the Dias-Tachdjian demonstrated substantial to almost perfect agreement for paediatric ankle fractures, followed by the Salter-Harris classification, which showed substantial agreement. Anatomical classification such as the Salter-Harris classification is better at predicting the rate of premature physeal closure. Mechanistic classification such as the Dias-Tachdjian classification is preferred for predicting the rate of angular deformity. Dias-Tachdjian classification demonstrated the greatest interobserver and intraobserver reliability among paediatric orthopaedic surgeons, while the Salter-Harris classification was the most commonly used and provided the highest predictive value for premature physeal closure. Combining anatomical (e.g. Salter-Harris) and mechanistic (e.g. Dias-Tachdjian or Carothers-Crenshaw) systems may improve prognostic accuracy and treatment planning.