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Basics ⬇

Author(s): DavidJohnson, MD and Michael Y.Yang, MD

Description

  • Salter-Harris (SH) type III avulsion fracture of the lateral distal tibial epiphysis
  • Occurs with traumatic external rotatory force pulling on the anterior inferior talofibular ligament
  • Transitional fracture, classically seen in adolescent girls ages 13 to 15 yr and boys ages 15 to 17 yr with a partially closed physis
  • Synonyms: Tillaux-Chaput fracture; juvenile Tillaux fracture; transitional fracture of distal tibia
  • Described by Paul Jules Tillaux in 1892 (1)

Epidemiology

  • Relatively uncommon—15% of all juvenile injuries of the long bones involve the epiphyseal growth plate, and 2.9% of these injuries are juvenile Tillaux fractures (2)
  • Adolescent ankle injuries typically within 1 yr from physeal closure. The anterior-lateral portion of the plate closes last.
  • Tensile stress applied to the anterior tibiofibular ligament, which inserts on the anterolateral aspect of the distal tibial epiphysis

Risk-Factors

  • Peak incidence: girls 13 to 15 yr of age and boys 15 to 17 yr of age during the 12- to 18-mo mo period when the distal tibial physis is fusing centrally but not yet laterally
  • Traumatic, forceful external rotation of the foot

Diagnosis ⬆ ⬇

History

  • Forceful supination and external rotation with compression stress
  • Also seen with internal rotation of the lower leg on a firmly planted foot
  • Acute anterolateral ankle pain
  • Reported pain with bearing weight

Physical Exam

  • Mild swelling and/or ecchymosis
  • Tenderness over the anterolateral ankle and syndesmosis region
  • Limited active ankle range of motion (ROM)
  • Pain with passive ankle motion
  • Weight-bearing—limited
  • Examine for concurrent fibular injury.
  • Extremity neurovascular examination

Differential Diagnosis

  • Ankle or syndesmosis injury/sprain
  • Triplanar fracture: more severe transitional fracture (SH IV) that fractures through the posterior distal tibial metaphysis
  • Talar dome injury/osteochondritis dissecans
  • Distal fibular physeal injury

Diagnostic Tests & Interpretation

  • Radiography: ankle anteroposterior (AP), lateral, and mortise views
  • Consider comparison of uninjured ankle to assess physeal closure.
  • Computed tomography (CT): Patients with transitional distal tibial fractures as well as patients with displaced SH III and SH IV fractures may benefit from CT to better determine fracture pattern, amount of displacement, and need for surgery (3)[C].

Treatment ⬆ ⬇

Nonsurgical:

  • Initial: immobilization, non–weight-bearing, ice, elevation, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Nondisplaced or minimally displaced fractures (<2 mm) can be treated nonoperatively (4)[B].
  • Closed reduction by positioning foot in internal rotation and slight inversion sufficient if postreduction interfragment gap is <2 mm (5)[B]
  • Postreduction evaluation: neurovascular exam and repeat radiographs: ankle AP, lateral, and mortise views
  • Immobilization:
    • Initial—compressive bulky dressing or fracture boot
    • 4-wk non–weight-bearing in a long leg cast with knee partially flexed stabilizes intra-articular rotational component (4)[B].
    • After initial 4 wk, may bear weight as tolerated for 2 to 4 wk in a short leg cast, cam walker, or rigid shell boot

Surgery/Other Procedures

  • Indicated if ≥2 mm of displacement
  • Open reduction with internal fixation of fracture (5)[C]
  • Successful treatment also described using percutaneous fixation assisted arthroscopically (4)[C]
  • Overall good reported surgical outcomes (5,6)
  • Prognosis uniformly good after closed reduction and percutaneous fixation techniques if residual displacement is <2.5 mm (6)[C]

Additional Therapies

Rehabilitation:

  • Sport-specific drills
  • Strengthening of dynamic stabilizers
  • Proprioception training
  • Proper shoe wear

Ongoing Care ⬆ ⬇

Follow-up Recommendations

For nonsurgically treated:

  • Follow-up with x-rays, typically every 2 wk
  • Evaluate for varus or valgus deformity.
  • After 4 wk of immobilization, progress to walking cast or cam walker for 2 to 4 wk.

Prognosis

  • Generally good outcomes if treated
  • Early arthritis: risk based on displacement
  • Physeal arrest rare and typically of low concern given patients are near physeal closure
  • Many patients are able to return to full activity after 3 mo postinjury.

Additional Reading ⬆ ⬇

Habusta SF, Griffin EE. Fractures, Tillaux. Treasure Island, FL: StatPearls Publishing; 2018.

References ⬆ ⬇

  1. Cassas KJ, Jamison JP. Juvenile Tillaux fracture in an adolescent basketball player. Phys Sportsmed. 2005;33(2):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(8):1046–1050.
  3. Nenopoulos A, Beslikas T, Gigis I, et al. The role of CT in diagnosis and treatment of distal tibial fractures with intra-articular involvement in children. Injury. 2015;46(11):2177–2180.
  4. Tiefenboeck TM, Binder H, Joestl J, et al. Displaced juvenile Tillaux fractures: surgical treatment and outcome. Wien Klin Wochenschr. 2017;129(5–6):169–175.
  5. Choudhry IK, Wall EJ, Eismann EA, et al. Functional outcome analysis of triplane and Tillaux fractures after closed reduction and percutaneous fixation. J Pediatr Orthop. 2014;34(2):139–143.
  6. Feng SM, Sun QQ, Wang AG, et al. “All-Inside” arthroscopic treatment of Tillaux-Chaput fractures: clinical experience and outcomes analysis. J Foot Ankle Surg. 2018;57(1):56–59.

Clinical Pearls ⬆

  • Possible complications include posttraumatic arthritis and asymmetric physeal growth.
  • If treated nonoperatively, 4 wk non–weight-bearing followed by 2 to 4 wk in a walking cast or cam walker. If stabilized with internal fixation, consensus is >4 wk non–weight-bearing and cast immobilization 4 to 12 wk (4)[C].
  • Return to sports after >12 wk if well-healed on x-ray, pain-free with activity, and have full ROM and strength.
  • Peroneal strengthening and proprioception training are essential rehab components.
  • Proper mechanics and proper shoe wear