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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?
Splinting and admit for observation for compartment syndrome
Short leg cast and discharge with outpatient follow up
Long leg cast and discharge with outpatient follow up
Percutaneous pinning with casting immobilization
CT scan of the ankle
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Based on the history and radiographs provided, this patient has a Tillaux fracture. After reduction and casting, the best thing would be to obtain a CT scan to assess residual intra-articular displacement.
Tillaux fractures of the distal tibia are transitional Salter Harris III fractures. Because of the sequence of closure of the distal tibial physis, rotational mechanisms of injury can cause avulsion of the anterolateral epiphysis, yielding the Tillaux fracture pattern. Residual displacement leads to articular surface incongruity, for which degenerative changes can be seen radiographically as early as 4 years after injury.
Horn et al. completed a cadaveric study to discern which imaging modality had better sensitivity for detection of displaced Tillaux fractures. They found that CT scans were more sensitive for detecting fractures with > 2 mm of displacement and recommend that CT scans should be the preferred imaging modality in evaluating patients with Tillaux injuries.
Figure A shows a Tillaux fracture. Illustration A shows an axial cut of the distal tibia demonstrating the residual displacement of the Tillaux fragment after an attempted closed reduction maneuver. The video provided shows a brief overview of Tillaux fractures of the pediatric distal tibial epiphysis
Answer 1: Splinting is generally not used to immobilize pediatric patients after reduction of Tillaux fractures. There is low risk of compartment syndrome and admission for observation is generally not warranted.
Answer 2, 3: While a long leg cast is preferred to a short leg cast to give increased stability to the reduced fracture, discharging the patient without obtaining a CT scan is not appropriate.
Answer 4: While a closed reduction and percutaneous pinning procedure may be warranted, a CT scan should be obtained to better evaluate the fracture displacement and articular surface incongruity.
Horn BD, Crisci K, Krug M, Pizzutillo PD, MacEwen GD
J Pediatr Orthop. 2002 Jan-Feb;22(1):31-5. PMID: 11242242 (Link to Abstract)
Horn, JPO 2001
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Average 3.0 of 13 Ratings
A juvenile Tillaux ankle fracture is caused by an avulsion injury involving which of the following structures?
Anterior-inferior tibiofibular ligament
Posterior-inferior tibiofibular ligament
Anterior talofibular ligament
Posterior talofibular ligament
A Tillaux fracture occurs when the anterior-inferior tibiofibular ligament (AITFL) avulses an epiphyseal fragment off the anterolateral tibia, typically from an external rotation mechanism. This creates a Salter-Harris III fracture. It occurs typically in adolescents during physeal closure (usually 12 to 15 yrs of age) because the distal tibia physis closes from medial to lateral, leaving the lateral physis vulnerable to this transitional fracture pattern. Because this fracture occurs in adolescents with relatively mature growth plates there is diminished potential for deformity due to growth plate injury. Displacement and articular incongruity help determine whether operative intervention is indicated.
The illustrations demonstrate the typical radiographic appearance of this fracture, coronal and sagittal CT images of a displaced Tillaux fracture, and a rendering of the AITFL as it attaches to the tillaux fragment.
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