Tillaux Fractures: Anterior Tibia-Fibula Ligament Avulsion

By admin On Nov 15, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Kyle J. Cassas

Basics

Description

1st described by Paul Jules Tillaux in 1892 (1)
Avulsion fracture of the lateral distal tibia epiphysis
Occurs in adolescents with a partially closed physes (girls 13–15 and boys 15–17 yrs of age)
During the 18-mo period when the distal tibial physis has begun to fuse centrally
Results in either a Salter Harris type III or IV physeal avulsion fracture
Synonym(s): Juvenile Tillaux fracture; Transitional fracture of distal tibia

Epidemiology

2.9% (2)
Relatively uncommon
Should be considered in adolescents with ankle injuries

Risk Factors

Girls 13–15 yrs of age with a partially closed physis
Boys 15–17 yrs of age with a partially closed physis
Rapid, forceful external rotation of the foot

Diagnosis

History

Forceful external rotation of the foot or internal rotation of the lower leg on a firmly planted foot
Stress applied to the anterior tibiofibular ligament, which inserts on the anterolateral aspect of the distal tibial epiphysis

Physical Exam

Signs and symptoms:
- Acute anterolateral ankle pain
- May report difficulty bearing weight
- Swelling and ecchymosis: Generally mild
Physical examination:
- Inspection: Mild swelling and/or ecchymosis
- Limited active ankle range of motion (ROM)
- Pain with passive ankle motion
- Tenderness over the anterolateral ankle and syndesmosis region
- Usually unable to fully bear weight
- Palpate entire length of the fibula for associated injury
- Neurovascular examination

Diagnostic Tests & Interpretation

Imaging

Initial radiographs: Ankle anteroposterior (AP), lateral, and mortise views
Comparison films of the uninjured ankle to evaluate physeal closure and displacement

Diagnostic Procedures/Surgery

CT scan often needed to determine fracture pattern, amount of displacement, and need for surgery

Differential Diagnosis

Ankle sprain
Syndesmosis injury/sprain (high ankle sprain)
Triplanar fracture: More severe version of Tillaux fracture
Talar dome injury/osteochondritis dissecans
Distal fibular physeal injury

Treatment

Nondisplaced or minimally displaced fractures (1 mm) can be treated nonoperatively.
Analgesia:
- Immobilization, ice, elevation, acetaminophen/NSAIDs
- Narcotics for breakthrough pain
Reduction technique: Gently position the foot in internal rotation
Postreduction evaluation:
- Neurovascular check
- Radiography: Ankle AP, lateral, and mortise views
- CT scan may be needed to determine the fracture pattern and the amount of displacement, and assess the need for surgery (see “Surgical Criteria” below).
Immobilization:
- Consider posterior splint or fracture boot initially for significant swelling.
- A long-leg cast (owing to the intra-articular component) with knee partially flexed
- Non–weight bearing for 4 wks and weight bearing as tolerated for 2–4 wks in a cam walker or rigid shell boot
- Prognosis is good for those treated nonoperatively if displacement <2 mm (3).

P.599

Additional Treatment

Additional Therapies

Anatomic alignment of the articular surface is essential to minimize the risk of posttraumatic arthritis.
Physeal arrest typically is not a concern.
Evaluate for varus or valgus deformity.
Rehabilitation:
- ROM
- Strengthening of dynamic stabilizers
- Proprioception
- Sport-specific drills

Surgery/Other Procedures

Indicated if 2 mm of displacement or greater
Open reduction with internal fixation of fracture, typically using two cannulated screws
Successful treatment also described using percutaneous fixation assisted arthroscopically (4)
Good reported surgical outcomes (3,5)

Ongoing Care

Follow-Up Recommendations

For nonsurgically treated:

Follow-up with x-rays, typically every 2 wks.
After 4 wks of immobilization, progress to walking cast or cam walker for 2–4 wks.

Prognosis

Good
Most patients are able to return to full activity at 3 mos after injury.

References

1. Cassas KJ, Jamison JP. Juvenile Tillaux fracture in an adolescent basketball player. Phys Sportsmed. 2005;33:30–33.

2. Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of two hundred and thirty-seven cases in children. J Bone Joint Surg Am. 1978;60:1046–1050.

3. Pannier S, Odent T, Milet A, et al. [Tillaux fractures in teenagers: a review of nineteen cases.] Rev Chir Orthop Reparatrice Appar Mot. 2006;92:158–164.

4. Thaunat M, Billot N, Bauer T, et al. Arthroscopic treatment of a juvenile tillaux fracture. Knee Surg Sports Traumatol Arthrosc. 2006.

5. Kaya A, Altay T, Ozturk H, et al. Open reduction and internal fixation in displaced juvenile Tillaux fractures. Injury. 2006.

Additional Reading

Churchill JA, Mazur JM. Ankle pain in children: diagnostic evaluation and clinical decision making. J Am Orthop Surg. 1995;3:183–193.

Codes

ICD9

824.8 Unspecified fracture of ankle, closed

Clinical Pearls

Possible complications include posttraumatic arthritis and asymmetric physeal growth.
If the intra-articular fracture is treated nonoperatively, 4 wks non–weight bearing followed by 2–4 wks in a walking cast or cam walker is the rule. If the intra-articular fracture is stabilized with internal fixation, 3 wks non–weight bearing followed by 3 wks of weight bearing in walking cast is appropriate.
Return to sports in 12 wks at minimum is usual. Patient must be healed on x-ray, be pain-free with activity, and have full ROM and strength.
Peroneal strengthening and proprioception training are essential after this injury; proper mechanics in sport and proper shoe wear should be emphasized to prevent excessive stress to the anterior tibiofibular ligament. Consider use of an ankle support during early return-to-activity phase.