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Introduction
  • Overview
    • tillaux fractures are a traumatic condition characterized by a Salter-Harris III fracture of the anterolateral distal tibia epiphysis
      • caused by an avulsion of the anterior inferior tibiofibular ligament  
      • treatment is closed reduction and casting if < 2mm displacement or ORIF 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
  • Pathophysiology
    • 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 fracture in the posterior distal tibial metaphysis in the coronal plane 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
        • pattern of closure 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
    • common 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)
      • technique
        • 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 4 weeks to control rotational component of injury, then short leg cast for 2-3 weeks
  • Operative
    • ORIF
      • indications
        • > 2mm displacement remains after reduction attempt 
Techniques
  • ORIF
    • techniques
      • closed reduction (by internal rotation) can be attempted under general anesthesia first
        • percutaneous K wires or cannulated screws can be placed if adequate reduction obtained
      • arthroscopically-assisted reduction has been described
    • approach
      • anterolateral approach
        • visualize joint line to optimize reduction
    • instrumentation
      • intraepiphyseal K wires or cannulated screws
        • transphyseal fixation can also be used as most patients are approaching skeletal maturity
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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(OBQ12.223) A 12-year-old sustains a twisting injury to his ankle while playing soccer. His skin is intact and he has no evidence of neurovascular compromise. An injury radiograph is shown in Figure A. A closed reduction is attempted to improve alignment. What is the next best step after reduction to optimize this patient’s outcome? Review Topic

QID: 4583
FIGURES:
1

Splinting and admit for observation for compartment syndrome

1%

(38/3456)

2

Short leg cast and discharge with outpatient follow up

3%

(105/3456)

3

Long leg cast and discharge with outpatient follow up

2%

(85/3456)

4

Percutaneous pinning with casting immobilization

14%

(479/3456)

5

CT scan of the ankle

79%

(2733/3456)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ08.102) A juvenile Tillaux ankle fracture is caused by an avulsion injury involving which of the following structures? Review Topic

QID: 488
1

Anterior-inferior tibiofibular ligament

89%

(1555/1745)

2

Posterior-inferior tibiofibular ligament

4%

(66/1745)

3

Anterior talofibular ligament

5%

(91/1745)

4

Posterior talofibular ligament

1%

(12/1745)

5

Calcaneofibular ligament

1%

(11/1745)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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