Review Question - QID 4583

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

Incorrect Answers:
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.