Tillaux Fracture Treatment & Management

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

• Restoration of the articular surface and congruity of the ankle mortise
• Fragment displacement exceeding 2 mm ^{[15, 16]}
• Avoidance of 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 adult as well as juvenile Tillaux fracture has shown good results and is a promising procedure. ^{[17, 18, 19, 20, 21]}

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. ^[22] Epiphyseal separation must be reduced 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. ^[23] The extremity is immobilized for 6-8 weeks in an above-knee cast with the knee flexed to about 30-45° to avoid weightbearing.

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. ^[24]

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 radiography 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. ^[25] If the injury presents late, it is better to accept malunion than to cause damage to the epiphysis by forcible manipulation or open surgery.

Evidence from one case series indicated that arthroscopically assisted percutaneous fixation of intra-articular juvenile epiphyseal ankle fractures offers an effective and less invasive form of surgical treatment. ^[17] This technique has a high learning curve and is technically complex and demanding.

Operative details

Before 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. ^[26] A transepiphyseal fixation may be required in very unstable fractures or when reduction cannot be satisfactorily maintained; clinical and functional outcomes appear to be comparable to those of all-epiphyseal fixation. ^[27]

Feng et al retrospectively evaluated an "all-inside" approach to Tillaux-Chaput fractures in 19 patients (12 male, 7 female; mean age, 28.1 years [range, 10-55]), in which anterolateral and anteromedial ankle arthroscopy was used for closed reduction and internal fixation with one or two Herbert screws. ^[28]  At the last follow-up, patients had no restrictions in ankle function or range of motion (ROM) and no ankle or walking pain. The American Orthopaedic Foot and Ankle Society (AOFAS) score rose from 52.8 points to 91.7, with an excellent/good rate of 100%.

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
• 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.

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 arthroscopic surgery; many of these cases are probably a result of articular cartilage scuffing/damage