Tillaux Fractures - Pediatrics

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

Action	Numeric Key	Letter Key	Function Key
Show Bullets		S	Enter (frontside only)
20%	1	N
40%	2	H
60%	3	F	Enter (backside only)
80%	4	E
100%	5	M
Toss	0	T