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Tillaux Fracture Treatment & Management

  • Author: Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin); Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
 
Updated: Apr 04, 2016
 

Approach Considerations

Indications for surgical management of a Tillaux fracture include the following:

  • To restore the articular surface and congruity of the ankle mortise
  • Displacement of the fragment of more than 2 mm
  • To avoid premature closure of the epiphyseal plate

Late presentation is a relative contraindication for forcible manipulation or open reduction to attempt anatomic fixation, because this may lead to further epiphyseal damage.

Arthroscopically assisted reduction and fixation of the adult Tillaux fracture has shown good results and is a promising procedure.[12, 13, 14, 15]

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Medical Therapy

Acute management of the injury consists of splinting, ice packs, compression, and elevation of the involved extremity. Suitable nonsteroidal anti-inflammatory drugs (NSAIDs) must be prescribed. The majority of fractures are minimally displaced, so that no reduction is required and immobilization in a nonweightbearing below-knee cast is sufficient.[16] Reduce epiphyseal separation immediately, because delay makes it progressively more difficult to achieve closed reduction.

Every fracture requiring reduction is assessed under anesthesia for rotatory instability. All reductions are performed with the utmost gentleness to avoid further damage to the physis.

The fracture is reduced by applying longitudinal traction with the knee flexed at right angles and, while traction is maintained, medially rotating the foot on the leg. Manderson et al suggested that anatomic reduction is achieved and better maintained by maximum dorsiflexion of the ankle during the internal rotation maneuver.[17] The extremity is immobilized for 6-8 weeks in an above-knee cast with the knee flexed to about 30-45° to avoid weightbearing.

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Surgical Therapy

Minimally displaced fractures (<2 mm of displacement) and extra-articular fractures can be treated with immobilization in an above-knee cast, with satisfactory outcomes well documented in the literature.[18]

When 2-3 mm of displacement is present, closed reduction is ideally required under general anesthesia. With the foot in plantarflexion, reduction is achieved with traction and internal rotation. The only exception is with medial fractures in which external rotation facilitates reduction.

Fractures managed conservatively must undergo postreduction computed tomography (CT) to assess the reduction and serial radiographs to confirm maintenance of reduction and to follow the progression of physeal closure. If the fragments are displaced more than 2 mm and an acceptable reduction cannot be achieved, surgery is necessary.[19] If the injury presents late, it is better to accept malunion than to cause damage to the epiphysis by forcible manipulation or open surgery.

The evidence from one case series also indicates that arthroscopically assisted percutaneous fixation of intra-articular juvenile epiphyseal ankle fractures offers an effective and less invasive form of surgical treatment.[12] This technique has a high learning curve and is technically complex and demanding.

Procedural details

Prior to surgery, adequate preoperative starvation status is determined, the limb is marked, and an informed consent form is obtained from the parents or the older child, explaining the potential sequelae and complications.

The fragment is explored through an anterolateral approach. The incision begins 5 cm proximal to the ankle joint and 2 cm anterior to the anterior border of the fibula; it crosses the ankle about 2 cm medial to the tip of the lateral malleolus and is extended as far distally as required. The internervous plane lies between the peroneal muscles (superficial peroneal nerve) and extensors (deep peroneal nerve).

The extensor tendons, deep peroneal nerve, and dorsalis pedis artery are retracted medially. The ankle capsule is opened, the anterior tibiofibular ligament is identified, and the fracture of the anterolateral portion of the tibial plafond is visualized. The fragment is reduced, with great care taken to avoid damage to the physeal plate. Smooth Kirschner wires (K-wires), pins, or screws are used, preferably parallel to the ankle mortise, avoiding the epiphysis. A transepiphyseal fixation may be required in very unstable fractures or when reduction cannot be satisfactorily maintained.

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Postoperative Care

Postoperative managment includes the following measures:

  • Apply a well-padded compression dressing and a posterior splint
  • Obtain postoperative radiographs
  • Apply an above-knee plaster cast after 48 hours, with the knee flexed and the ankle in neutral position
  • Recommend complete nonweightbearing crutch ambulation is recommended
  • Remove metalwork when the fracture has healed

A long leg cast is recommended in children in spite of internal fixation. The long leg cast can be changed to a below-knee cast after 3-4 weeks. Pins or smooth K-wires are used in young patients, whereas screws are reserved for older, heavier children. In children, metalwork is always removed so that it is not a stress riser in later years.

As in any surgical procedure, multiple opinions exist, but long or short casts, removal of metalwork, and other aspects are always based on the individual surgeon's preference and teaching. The recommendations of this article are based on several leading pediatric orthopedic surgical books that outline the above management as the safest and most reliable.

Routine follow-up after union of the fractured fragment frequently is unnecessary.

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Complications

Damage to the physis from forceful manipulation may lead to some of the same complications that are associated with the original injury (see Presentation, Complications).

Complications due to surgical treatment include the following:

  • Physeal damage by direct pressure on the physis by blunt instruments
  • Damage to the superficial peroneal nerve or branches
  • Avascular necrosis of the fragment
  • Arthrofibrosis following arthroscopic procedures
  • Unexplained pain that may persist for up to 12 months after surgery, particularly arthroscopy; many of these cases are probably a result of articular cartilage scuffing/damage
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Contributor Information and Disclosures
Author

Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin) FRCS(Tr & Orth), FRCS(Edin), MCh(Orth), Diploma in Sports and Exercise Medicine(UK), MS(Orthopaedics)

Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin) is a member of the following medical societies: British Orthopaedic Association, Royal College of Surgeons of Edinburgh, Bombay Orthopedic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

References
  1. Bumei G, Gavriliu S, Georgescu I, Vlad C, Draghici I, Hurmuz L, et al. The therapeutic attitude in distal radial Salter and Harris type I and II fractures in children. J Med Life. 2010 Jan-Mar. 3(1):70-5. [Medline].

  2. Landin LA, Danielsson LG, Jonsson K, et al. Late results in 65 physeal ankle fractures. Acta Orthop Scand. 1986 Dec. 57(6):530-4. [Medline].

  3. Erlemann R, Wuisman P, Just A, et al. [Deformities and trauma sequelae of the ankle joint in children and adolescents]. Radiologe. 1991 Dec. 31(12):601-8. [Medline].

  4. Dias LS, Giegerich CR. Fractures of the distal tibial epiphysis in adolescence. J Bone Joint Surg [Am]. 1983 Apr. 65(4):438-44. [Medline].

  5. Koury SI, Stone CK, Harrell G, et al. Recognition and management of Tillaux fractures in adolescents. Pediatr Emerg Care. 1999 Feb. 15(1):37-9. [Medline].

  6. Landin LA, Danielsson LG. Children's ankle fractures. Classification and epidemiology. Acta Orthop Scand. 1983 Aug. 54(4):634-40. [Medline].

  7. Schnetzler KA, Hoernschemeyer D. The pediatric triplane ankle fracture. J Am Acad Orthop Surg. 2007 Dec. 15(12):738-47. [Medline].

  8. 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. [Medline]. [Full Text].

  9. Shi DP, Zhu SC, Li Y, Zheng J. Epiphyseal and physeal injury: comparison of conventional radiography and magnetic resonance imaging. Clin Imaging. 2009 Sep-Oct. 33(5):379-83. [Medline].

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

  11. 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. [Medline].

  12. Jennings MM, Lagaay P, Schuberth JM. Arthroscopic assisted fixation of juvenile intra-articular epiphyseal ankle fractures. J Foot Ankle Surg. Sep-Oct 2007. 46(5):376-86. [Medline].

  13. Miller MD. Arthroscopically assisted reduction and fixation of an adult Tillaux fracture of the ankle. Arthroscopy. 1997 Feb. 13(1):117-9. [Medline].

  14. Thaunat M, Billot N, Bauer T, et al. Arthroscopic treatment of a juvenile Tillaux fracture. Knee Surg Sports Traumatol Arthrosc. 2007 Mar. 15(3):286-8. [Medline].

  15. Poyanli O, Unay K, Akan K, Ozkan K, Ugutmen E. Distal tibial epiphyseal fracture (Tillaux) and capsular interposition. J Am Podiatr Med Assoc. 2009 Sep-Oct. 99(5):435-7. [Medline].

  16. Pesl T, Havranek P. Rare injuries to the distal tibiofibular joint in children. Eur J Pediatr Surg. 2006 Aug. 16(4):255-9. [Medline].

  17. 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. [Medline].

  18. 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. [Medline].

  19. Kaya A, Altay T, Ozturk H, et al. Open reduction and internal fixation in displaced juvenile Tillaux fractures. Injury. 2007 Feb. 38(2):201-5. [Medline].

 
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Radiograph showing an avulsion fracture of the anterolateral tibia with widening of the ankle mortise; the fractured fragment appears radiopaque over the distal fibula. Also note the fracture of the talus in this case.
 
 
 
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