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.
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.
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.
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.
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.
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).
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.
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.
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.
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!
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