Tillaux fractures

Cite this article as:
Tadgh Moriarty. Tillaux fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26111

Jenny is a 14-year-old girl who was at soccer training when she had an awkward injury to her left ankle. She was running for the ball when her foot caught in a clump of grass and she externally rotated her leg while her foot remained planted. While the pain was instantaneous, there was very little swelling. Her father has brought her in remarking that ‘it’s probably just a sprain’. But as you call her down to the cubicle to examine her, you think there might be more to it.

Incidence

Tillaux fractures are a type of ‘transitional’ ankle fracture which occur almost exclusively in adolescents. These occur during the unique closure pattern of the distal tibial physis. This closes over an eighteen-month period; first in the middle, then medially and finally laterally. During the closure, this area is vulnerable to these distinctive transitional fractures; the triplane fracture and the Tillaux fracture.

These fractures account for roughly 3% of paediatric ankle fractures. They are seen more commonly in females and tend to occur at slightly different ages depending on gender. It tends to occur later than a triplane fracture; between 12-14 years in girls and 15-18 years in boys.

Mechanism

This Salter-Harris 3 fracture occurs at the anterolateral distal tibial epiphysis. It tends to cause avulsion of the tibial fragment by the tibiofibular ligament; this strong ligament extends from the anterior aspect of the lateral distal tibial epiphysis to the anterior aspect of the fibula. The lack of a fracture through the coronal plane distinguishes this injury from that of a triplane fracture.

This injury pattern occurs usually through a combination of supination and external rotation of the foot in relation to the leg. It usually occurs through low-velocity trauma for example in skateboard accidents or sports with a sliding injury.

Presentation

These injuries are almost exclusively seen in adolescents. Similar to most ankle injuries there will be a history of trauma, symptoms of pain, swelling, and an inability (or painful) weight-bearing.

The clinical exam often reveals localised tenderness to the anterior joint line. This contrasts with a sprain where the tenderness is usually below the joint line. Marked displacement is prevented by the fibula.

Imaging

Do not be misled by lack of swelling – have a low threshold to image injuries which present with an inability to weight bear (at least four steps). When requesting an ankle x-ray AP and lateral views will be included as standard – if you have a high index of suspicion for a Tillaux fracture ask for an oblique or ‘mortise’ view – this can improve your detection by avoiding the obstructed view through the fibula and potentially making the subtle fracture more apparent.

This injury can sometimes have an associated ipsilateral tibial shaft fracture or a proximal fibular injury. During your clinical exam if you illicit tenderness proximal to the ankle, then include a full-length tibia/fibula x-ray with your request.

Does this injury require a CT? Perhaps! See the controversy section below for a more thorough explanation. CT is generally only required by the orthopaedic team to assist with surgical planning.

Image courtesy of Orthobullets.com

Image showing CT scan of same fracture with >2mm displacement courtesy of Orthobullets.com

This injury however often requires a CT scan to assist the orthopaedic team in deciding between conservative and operative management.

A study by Horn et al showed CT as being more sensitive than plain film at detecting fractures with greater than 2mm displacement (the cut-off point adopted for operative fixation).

Treatment

These fractures are important as they involve the weight-bearing surface and can lead to significant morbidity if missed. The treatment of these injuries is not uniform – different methods and cut-offs are described in different case reports and case series. Having that said the current marker for operative versus conservative treatment is the degree of displacement of the fracture fragment.

Those with < 2mm displacement can generally be treated conservatively. This usually involves an above-knee cast for up to 4 weeks (to control the rotational component) followed by either a walker boot or below-knee cast for a further 2-4 weeks. This conservative approach is well documented in having a satisfactory outcome.

Those with displacement >2mm generally require intervention to ensure articular congruity of the joint surface is restored. Intervention can occur in different forms; some may be suitable for a closed reduction under procedural sedation (or general anaesthetic). Different reduction techniques exist however longitudinal traction while the knee is flexed followed by internally rotating a maximally dorsiflexed ankle seems to achieve greater anatomic reduction. A review by Lurie et al concluded those left with a residual gap of more than 2.5mm led to worse functional outcomes. Therefore post-reduction radiological confirmation should show minimal displacement (the figure of <2mm tends to be favoured in the literature) otherwise operative intervention is required. Many orthopaedic surgeons favour CT as the post-reduction imaging modality of choice and then follow this reduction with serial radiographs to confirm maintenance of the reduction over time.

Operative intervention can involve K-wire insertion, use of lag screws or a novel technique involving percutaneously inserted wires with arthroscopic or radiological guidance. This new technique is seen as less invasive and as-effective but is technically complex and demanding. If this injury presents with a neurovascular compromise or critical skin then emergent surgery is indicated. This is, thankfully, rare.

What to tell the patient

Recovery: Both operative and conservative measures tend to require up to 8 weeks of immobilisation followed by a rehab phase. This phase will vary depending on the age of the patient. Most patients have a good outcome with 86% having complete recovery and no sequelae. Very few will have pain or limitation of ankle movement. Late presentation and a non-anatomical reduction will increase the risk of this.

Complications

These are less common than other ankle fractures; delayed or malunion, osteonecrosis of the distal tibial epiphysis, premature growth arrest and compartment syndrome are all very rare occurrences. Early-onset arthritis can occur, those with late presentations or missed fractures are more at risk.

Operative intervention carries the additional (albeit small) risk of physeal damage from direct pressure by blunt instruments and inadvertent damage to the superficial peroneal nerve.

Controversies

Radiological evaluation remains controversial. Plain x-ray usually identifies the transitional fracture, and the degree of displacement. However, CT (ideally with 3D reconstruction) is more accurate in estimating the degree of displacement and fracture separation.

Case courtesy of Dr Yasser Asiri, Radiopaedia.org. From the case rID: 64778

CT can help in identifying the number and position of fragments. The issue of whether CT or MRI alters treatment or prognosis when compared with plain X-ray has not been fully investigated. Limited research has been carried out on whether CT, with its greater accuracy, actually affects treatment or patient outcome. Liporace et al in 2012 found that interobserver and intra-observer agreements about primary treatment plans did not differ significantly between radiography alone and radiography plus CT. This showed that the addition of CT did not actually change the impression about the degree of displacement in each case. This raises the question as to whether CT really alters outcomes despite having perceived greater benefits.

Jenny is found to have significant tenderness about her distal tibia on exam and an x-ray confirms a Tillaux fracture which is minimally displaced. She is placed in an above-knee backslab and referred to the orthopaedic fracture clinic. She is left disappointed that she will miss this season’s matches, but thankfully you didn’t misdiagnose this as a sprain!

References

Orthobullets.com/paediatrics/4028/tillaux-fractures

Wheelers textbook of orthopaedics (updated 2015) Clifford J Wheeless Tintinnali 7th Ed

Tiefenboeck TM, Binder H, Joestil J et al. Displaced juvenile Tillaux fractures: surgical treatment and outcome. Wien Klin Wochenschr. 2017; 129 (5-6):169-175

Rosenbaum AJ, DiPreta JA, Uhl RL. Review of distal tibial epiphysis transitional fractures. Orthopaedics. 2012;35(12):1046-1049

Horn BD, Cristina K, Krug M, Pizzutillo PD, MacEwen GD. Radiologic evaluation of juvenile Tillaux fractures of the distal tibia. J Pediatr Orthopaedics. 2001; 21(2): 162-4

Cooperman DR, Spiegel PG, Laros GS. Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture. J Bone Joint Surg Am. 1978 Dec. 60 (8):1040-6

Panagopoulos A, van Niekerk L. Arthroscopic assisted reduction and fixation of a juvenile Tillaux fracture. Knee Surg Sports Traumatol Arthrosc 2007;15:415-417

Manderson EL, Ollivierre CO. Closed anatomic reduction of a juvenile tillaux fracture by dorsiflexion of the ankle. A case report. Clin Orthop Relat Res. 1992 Mar. (276):262-6.

Crawford AH Triplane and Tillaux fractres: is a 2mm residual gap acceptable. J Pediatr Orthop. 2012 Jun;32 Suppl1:S69-73

Schlesinger I, Wedge JH. Percutaneous reduction and fixation of displaced juvenile Tillaux fractures: a new surgical technique. J Pediatr Orthopaedics. 1993;13:389-391

Stefanich RJ, Lozman J. The juvenile fracture of Tillaux. Clin Orthopaedics Relat Res. 1986;210:219-227

Kaya A, Altay T, Ozturk H, Karapinar L. Open reduction and internal fixation in displaced juvenile Tillaux fractures. Injury 2007;38:201-205

Choudhry IK, Wall EJ, Eismann EA. Crawford AH, Wilson I. Functional outcome analysis of triplane and tillaux fractyres after closed reduction and percutaneous fixation. J Pediatr Orthop. 2014;34:139-43

Jennings MM, Layaway P, Schubert JM. Arthroscopic assisted fixation of juvenile intra-articular epiphyseal ankle fractures. J Foot Ankle Surg 2007;46: 376-386

Rockwood and Wilkin’s fractures in children. 6th Edition.2006

Kim JR, Song KH, Song KJ, Lee HS. Treatment outcomes of triplane and Tillaux fractures of the ankle in adolescence. Clin Orthop Surg. 2010 Mar. 2 (1):34-8

Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol. 2004 Sep. 183 (3):615-22

Charlton M, Costello R, Mooney JF et al. Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia. J Pediatr Orthopaedics. 2005;25: 635-640

Liporace FA, Yoon RS, Kubiak EN, Parisi DM, Koval KJ, Feldman DS, et al. Does adding computed tomography change the diagnosis and treatment of Tillaux and triplane pediatric ankle fractures?. Orthopedics. 2012 Feb 17. 35 (2):e208-12

Lurie B, Van Rysselberghe N, Pennock AT, Upsani VV. Functional outcomes of Tillaux and triplane fractures with 2-5millimetres of intra articluations gap. J Bone Joint Surg Am. 2020;102:679-686

Rapariz AJ, Avocets G, Gonzalez-Herman P, Texas et al. Distal tibial triplane fractures: long term follow up. J Pediatr Orthopaedics. 1996; 16: 113-118.

Minor injuries – ankle injuries

Cite this article as:
Tessa Davis. Minor injuries – ankle injuries, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9990

This is part of a DFTB minor injuries series. Today’s post is about ankle injuries.

When should I x-ray an ankle?

The Ottawa ankle rules are a decision tool for x-ray in patients with an ankle injury.

If there is pain in either malleolar region, and one of the following then an x-ray is indicated:

  • Inability to bear weight (walk four steps) immediately after the injury and when examined.
  • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
  • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.

The Ottawa ankle rules are very sensitive – so if your patient does not meet the criteria for x-ray, it is very unlikely that your patient has a fracture.

There is no evidence for CT or MRI in acute ankle sprain.

Can we use the Ottawa ankle rules in children?

The rules were originally validated in adults, but the analysis since shows that they can be used in children too. The introduction of the Ottawa ankle rules in one hospital in the UK reduced the number of x-rays ordered by 7% and showed no increase in the number of missed fractures.

It should be noted that these rules are meant to be applied to those patients who have the ability to walk prior to their injury, and can localise pain with verbal communication. For every 1000 patients that exhibit negative Ottawa ankle rules, 14 will actually have fractures.

What is a sprain?

A sprain is where you stretch or tear a ligament by applying abnormal force. Sprains usually occur in ankles, knees, wrists or thumbs.

Symptoms are usually pain, swelling, bruising, tenderness, difficulty using the joint functionally and even mechanical instability if severe.

Sprains can be classified according to severity:

  • Grade I – mild stretching of the ligament complex without joint instability.
  • Grade II – partial rupture of the ligament complex without joint instability.
  • Grade III – complete rupture of the ligament complex with instability of the joint.

How do we assess ankle stability?

There are two tests to assess this – the anterior drawer test and the talar tilt test.

Anterior drawer test: hold the leg with one hand and use the other hand on the back of the foot to gently pull it forward. If there is excessive forward movement of the foot then the test is positive.

Talar tilt test: hold the leg with one hand and use the other hand to hold the foot and gently invert it. If there is excessive tilting then the test is positive.

They are much more clearly explained in these videos:

How do we best manage a sprain?

Simple management includes analgesia, and PRICE (protect, rest, ice, compression, elevation).

  1. Protect from re-injury – this can include using a supportive shoe
  2. Rest the ankle for up to 72 hours
  3. Wrap some ice in a towel and hold it against the ankle for 15 mins every few hours for the first 72 hours
  4. Use a simple tubigrip or elasticated bandage (it helps with the swelling and offers support) but take it off at night
  5. Elevate the ankle on a pillow until the swelling settles

Do I immobilise it or encourage them to walk?

The patient should avoid heat, massage or running for the first 72 hours after the injury.

If the sprain is severe, then immobilising it for a short time can help their symptoms, but they need to be encouraged to begin mobilising after a day or two to avoid stiffness. If the sprain is mild then advise the patient not to immobilise the ankle. They should encourage gentle movement as soon as they can tolerate it.

What is the recovery time?

The usual recovery period, if the sprain is uncomplicated, is for the patient to be able to walk in 1-2 weeks, run in 6-8 weeks and return to their regular sporting activity in 8-12 weeks.

If in 7 days they still have difficulty walking or worsening symptoms, they should get a review.

Ankle x-rays

Cite this article as:
Tessa Davis. Ankle x-rays, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9992

The ankle joint consists of three bones – the tibia, the fibula, and the talus.

The ankle also consists of two joints – the ankle joint (where the tibia, fibula and talus meet) and the syndesmosis joint (the joint between the tibia and fibula which is held together by ligaments).

There are three main sets of ligaments:

  • Medial: deltoid ligament
  • Lateral: posterior talofibular, anterior talofibular and calcaneofibular ligaments
  • Syndesmotic ligament

Ankle views

An x-ray of the ankle will have three views – AP, mortise, and lateral. It should be noted though, that in some countries, including the UK, only the mortise and lateral are used. See the annotated images below from WikiFoundry, and thanks also to Radiopaedia:

In the AP view:

  • The distal fibula should be slightly superimposed on the tibia
  • The lateral and medial malleoli should be in profile
  • The tibiotalar space should be open (although the full mortise isn’t visible)

In the mortise view:

  • This aims to assess the articulation of the ankle joint
  • The lateral and medial malleoli should be in profile
  • The mortise should be uniformly visible
  • The base of the fifth metatarsal should be included in the view

In the lateral view

  • The following bones can be assessed: tibia, fibula, talus, cuboid, navicular, calcaneus, and fifth metatarsal
  • The distal fibula should be superimposed by the posterior part of the distal tibia
  • The talar domes should be superimposed
  • The joint space between the tibia and the talus should be uniform

N.B. Assess each bone individually, and if you see a break in one, then look for a second break.

1. Trace around the tibia and fibula in both views.

Be mindful that an ankle fracture can be unstable and therefore it’s important not to miss them.

2. Pay particular attention to the fibula on the lateral view for an oblique fracture.

Oblique fracture (from Radiology Key)

3. Look at the mortise and the talar dome.

Make sure the space is uniform, and that the talar dome surface is smooth.

Osteochondral fracture (from Radiopaedia)

4. Look at the interosseous ligament.

Measure the gap between the tibia and the fibula 1cm proximal to the tibial plafond. It should be less than 6mm, otherwise consider a ligament rupture which could be associated with a fracture.

Image result for interosseous ligament rupture xray
Widened gap between tibia and fibula

5. On the lateral view trace the lateral and medial malleolus, the posterior tibia, the calcaneus, and the base of the 5th metatarsal.

6. Assess the Bohler’s angle

  • Draw two lines at tangents to the anterior and posterior aspects of the calcaneus
  • The angle should be 20-40°
  • If it’s less than 20° then consider a calcaneus fracture
Calcaneus fracture (from Radiopaedia)

7. Do a final check around the bones to make sure you haven’t missed anything the first time around.

8. Remember about accessory ossicles – they aren’t fractures!

  • There are three common accessory ossicles in the ankle: os trigunum (usually forms at 7-13 years old); os subtibiale (when the medial malleolus epiphysis fails to fuse with the tibia in the later teenage years); os subfibulare (can also be an unfused ossification centre or an avulsion fracture).

Common fractures and their management

The level of the fracture directs the treatment – fractures can be classified according to the Salter-Harris classification.

Lateral malleolus fracture

In children, a fibula fracture usually requires a short leg cast and six weeks of non-weight bearing. Salter-Harris I distal fibula fractures can be diagnosed if there is tenderness directly on the lateral malleolus (rather than the ligaments) and many recommend treating as a fracture even if no radiographic fracture is noted.

However, a study in JAMA carried out MRI scans on 135 children with presumed SH1 distal fibula fractures. All children were treated with a removable leg brace and advised to continue regular activities as tolerated. 4 of the children had an SH1 on MRI, 38 had an avulsion fracture, and the rest showed ligamentous injury or bony contusion. By 1 month, 72.1% had full weight-bearing activity and by 3 months 96.9% had returned to normal activities (it didn’t matter which type of injury they had on MRI). Therefore, a removable brace may be appropriate for a Salter Harris I, if your department stocks them. (See a full summary of this article on ALiEM).

Medial malleolus fracture

An undisplaced distal tibia (Salter-Harris I or II) can be managed with a long leg cast and non-weight bearing. SH3 or 4 needs discussion with ortho. All will have a fracture clinic follow up in a week or so.

Salter-Harris I distal tibia fractures can be diagnosed if there is tenderness directly on the medial malleolus (rather than the ligaments) and many recommend treating as a fracture even if no radiographic fracture is noted.

The most common distal tibial epiphysis injury is a Salter Harris II

The high occurrence of Salter-Harris III and IV fractures is because the lateral and deltoid ligaments insert here and they are stronger than the physis itself.

A Tillaux fracture is a Salter-Harris III but with avulsion of the anterolateral corner of the distal tibial epiphysis. If there is <2mm displacement then the patient can have a long leg cast, and be non-weight bearing, with ortho discussion and follow-up. If there is >2mm displacement then an ortho review will be required as typically this need operative management.

Pilon fracture

A pilon fracture is where there is an axial load on the tibia and the talus is pushed into the tibia plafond.

If the fracture is non-displaced or very distal, it is unlikely to require surgery. It would usually be treated with a short leg cast, and weight bearing would be avoided for six weeks.

If it is displaced or the ankle is unstable, then surgery may be required to avoid non-union, so speak to the ortho team.

Posterior malleolus fracture

Posterior malleolus fracture (from Wikiradiography)

Usually when this has happened, there is also a lateral malleolus fracture (because they share ligament attachments). The ankle can be unstable if a large piece is broken and therefore surgery may be indicated – so speak to the ortho team.

An untreated posterior malleolus fracture can lead to arthritis because of the disruption to the cartilage surface.

If the fracture is not displaced then it would usually be treated with a short leg cast, and weight-bearing would be avoided for six weeks.

Talar neck fracture

Talar neck fracture

This fracture carries a high risk of avascular necrosis.

If the fracture is non-displaced then it can be managed with a short leg cast or a boot. If it is displaced then surgery will be required.

Bimalleolar fracture

Bimalleolar fracture (from Radiopaedia)

If two parts of the malleoli are broken then the ankle is not stable and surgery is usually needed.

Trimalleolar fracture

Trimalleolar fracture (from Radiopaedia)

If all three malleoli are broken then there can be associated dislocation. The ankle will be unstable and will require ortho input.

Maisonneuve fracture

This fracture is uncommon in children but can occur. It is where there is a spiral fracture of the proximal fibula along with ankle instability. On x-ray there can be syndesmotic widening.

mason1
From Wheeles Online

In adults this can be managed with a long leg cast, but in children it will require operative fixation.

Syndesmotic injury

Overlap between the tibia and fibula in a syndestomic injury (thanks to Bone School)

The joint between the tibia and fibula are held together by ligaments. If this ligament is sprained then this is a syndesmotic injury.

As mentioned above, there can be widening of the clear space between the medial border of the fibula and the lateral border of the posterior tibia (>5mm). You can also get an overlap of the fibula and the anterior tibial tubercle (>6mm on the AP views, >1mm on the mort

When do I need an orthopaedic review immediately?

  • Open fracture
  • Salter-Harris III or IV
  • Neurovascular injury
  • Compartment syndrome
  • Unable to reduce the fracture

Ref: RCH

Should we be worried about growth plates?

Growth arrest doesn’t occur immediately after the injury, and can even occur in seemingly benign fractures. It can be delayed for up to 6 months and so it is important to follow up ankle fractures post-injury.

References:

Wheeles Online

Radiopaedia

Royal Children’s Hospital, Melbourne

Radiology Masterclass

(Ed: Thanks to Eyston Vaughan-Huxley for his input too).