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Updated: Feb 19 2022

Tillaux Fractures

Images tillaux.jpg
  • summary
    • Tillaux Fractures are traumatic ankle injuries in the pediatric population characterized by a Salter-Harris III fracture of the anterolateral distal tibia epiphysis.
    • Diagnosis can be made with plain radiographs of the ankle. CT scan may be required to further characterize the fracture pattern and for surgical planning. 
    • Treatment is closed reduction and casting if < 2mm displacement or operative management if > 2mm displacement.
  • Epidemiology
    • Incidence
      • accounts for 3-5% of pediatric ankle fractures
    • demographics
      • more common in girls
      • seen in children nearing skeletal maturity (12-14 years old)
        • typically occur within one year of complete distal tibia physeal closure due to pattern of progression of physeal closure
        • older than triplane fracture age group
  • Etiology
    • Pathophysiology
      • caused by an avulsion of the anterior inferior tibiofibular ligament
      • mechanism of injury
        • results from supination-external rotation injury
          • leads to avulsion of anterolateral tibia at the site of attachment of the anterior inferior tibiofibular ligament
          • lack of coronal plane fracture in the posterior distal tibial metaphysis distinguishes this fracture from a triplane fracture
    • Associated conditions
      • distal fibular fracture (usually SH I or II)
      • ipsilateral tibial shaft fracture
  • Anatomy
    • Physeal considerations
      • distal tibial physis
        • accounts for 35-40% of overall tibial growth and 15-20% of overall lower extremity growth
        • rate of growth is 3-4 mm/year
        • growth continues until 14 years in girls and 16 years in boys
        • closure occurs during an 18 month transitional period
          • Occurs in a predictable pattern: central > anteromedial > posteromedial > lateral
    • Ligaments
      • anterior inferior tibiofibular ligament (AITFL)
        • extends from anterior aspect of lateral distal tibial epiphysis (Chaput tubercle) to the anterior aspect of distal fibula (Wagstaffe tubercle)
  • Presentation
    • Symptoms
      • pain
      • inability to bear weight
    • Physical exam
      • inspection
        • slight swelling
        • focal tenderness at anterolateral joint line
        • deformity is rare
          • marked displacement is prevented by the fibula
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
        • mortise
          • best view to see tillaux fractures
      • findings
        • SH III fracture of the anterolateral distal tibia epiphysis
    • CT scan
      • indications
        • delineate fracture pattern
        • determine degree of displacement
        • identify intramalleolar or medial fracture variant patterns
  • Treatment
    • Nonoperative
      • closed reduction and casting
        • indications
          • < 2mm displacement following closed reduction (rare)
    • Operative
      • CRPP vs. ORIF
        • indications
          • > 2mm displacement remains after reduction attempt
  • Techniques
    • Closed reduction and casting
      • reduce by internally rotating foot
        • can also attempt by dorsiflexing the pronated foot then internally rotating
      • CT scans sometimes needed to determine residual displacement (confirm < 2mm)
      • long leg cast initially for 3-4 weeks to control rotational component of injury
        • follow early with radiographs to assess for displacement
      • immobilize an additional 2-4 weeks in a short leg cast or walking boot (to initiate ankle ROM)
    • CRPP
      • reduction
        • use k-wire or guidwire as joystick for reduction
        • assess reduction with flouroscopy or arthrogram in OR (if in doubt, open the joint and viusalize)
      • instrumentation
        • K-wire or cunnulated screw over guidwire can be final fixation
        • it is OK to cross physis with fixation as there is little growth remaining
      • outcomes
        • functional outcomes are good with a residual displacement of < 2.5mm
    • ORIF
      • approach
        • anterolateral approach
          • visualize joint line to optimize reduction
      • reduction
        • reduce with internal rotation
        • arthroscopically-assisted reduction has been described
        • indirect reduction with periarticular clamp and percutaneous fixation has also yielded good results
      • instrumentation
        • intraepiphyseal K wires or cannulated screws
          • transphyseal fixation can also be used as most patients are approaching skeletal maturity
      • post-op
        • long leg cast for 3-4 weeks then short leg walking cast for 2 weeks
  • Complications
    • Premature growth arrest
      • rare
        • physeal closure is already occuring
      • decreased risk with anatomic reduction
    • Early arthritis
      • increased risk with articular displacement
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