You are in: eMedicine Specialties > Orthopedic Surgery > FOOT AND ANKLE Tillaux FractureArticle Last Updated: Apr 3, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Satishchandra Kale, MD, FRCS(Edin), FRCS Ed(UK), Dip Sports Med, Honorary Assistant Professor of Trauma and Orthopedics, University of Bombay; Consultant, Department of Orthopedics, Dr R N Cooper Hospital, Brahmakumaris Global Hospital, India Satishchandra Kale is a member of the following medical societies: British Orthopaedic Association Editors: James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St. Luke's Hospital, Jacksonville, Florida; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: Kleiger fracture, Kleiger's fracture, Tillaux' fracture, anterolateral tibial epiphysis fracture, Tillaux lesion, ankle injury, ankle lesion, distal tibia fracture, fracture of Tillaux-Chaput, Tillaux-Chaput fracture, Tillaux-Chaput lesion, distal tibial physis fracture, Salter-Harris type III epiphyseal injury INTRODUCTIONSection 2 of 12
  The term Tillaux fracture is an eponym describing a fracture of the anterolateral tibial epiphysis that is commonly seen in adolescents. The fragment is avulsed due to the strong anterior tibiofibular ligament in an external rotation injury of the foot in relation to the leg. This injury is rarely seen in adults, because the ligament gives way instead of avulsing the tibial fragment from its epiphyseal attachment, resulting in a ligament injury known as a Tillaux lesion. History of the ProcedureSir Astley Cooper first described a fracture of the lateral aspect of the distal tibia in the adult. Paul Jules Tillaux partially described an avulsion fracture of the lateral tibia in 1892, following his experiment on cadavers. A similar injury to the posterolateral tibia was later described by Chaput and has been called the fracture of Tillaux-Chaput. In 1964, following their extensive work on distal tibial fractures, Kleiger and Mankin described an isolated fracture of the lateral portion of the distal tibial physis in adolescents. This is a Salter-Harris type III epiphyseal injury. Initially, these fractures were treated conservatively with mediocre results. Mankin recommended internal fixation of these fractures, followed by plaster management to ensure good union. Internal fixation eliminates the instability arising from the avulsion of the anterior tibiofibular ligament. Currently, common practice is to internally fix these fractures, allowing for a high proportion of good results. ProblemTillaux fractures can cause pain or stiffness for up to 2 years after the injury, with joint incongruity resulting in degenerative arthritis, varus deformity, rotational deformity (rare), tibiotalar slant, nonunion, delayed union (rare), and leg-length inequality (extremely rare).1 FrequencyFractures involving the distal tibia constitute about 11% of all epiphyseal injuries and about 4% of all ankle injuries. The common age of incidence is 11-15 years, with a median age of 14 years in males and 12 years in females. The Tillaux fracture is more common in females, although the majority of ankle injuries generally occur in males.2, 3 Increased participation in sporting activities for adolescents has contributed to increasing incidence since the latter part of the 20th century. EtiologyTillaux fracture usually is caused by low-energy trauma. It commonly is associated with skateboard and baseball (sliding) injuries. Around age 12-14 years, a forced lateral rotation of the foot in neutral or supination or a medial rotation of the leg on the fixed foot usually is responsible for an avulsion injury to the lateral epiphysis.4, 5 The anterior tibiofibular ligament is attached to the lateral epiphysis, the fragment being displaced anteriorly and laterally. As the foot is externally rotated, the talus appears to exert a compression-torque stress that propagates a crack through the articular surface up to the growth plate, which then shears off. The injury may be accompanied by a separate posterior metaphyseal fragment as a variant of the triplane fracture. Ligamentous injuries are rare in children because ligaments are stronger than is the growth plate that frequently is injured. In adults, the distal tibial tubercle is avulsed off the anterolateral aspect of the distal tibia (Tillaux fracture) or the anterior tibiofibular ligament may rupture (Tillaux lesion). A radiograph showing an avulsion fracture of the anterolateral tibia with widening of the ankle mortise can be seen in Image 1. PathophysiologyThe ossific nucleus of the distal tibial epiphysis appears from age 6-10 months. By age 14-15 years, the entire lower end of the tibia is completely ossified. It unites with the diaphysis at about age 18 years. The lower epiphysis contributes to about 45% of the growth of the tibia. Kleiger and Mankin reviewed children undergoing skeletal closure. They showed that fusion in the distal tibial epiphysis occurs first in the middle third of the epiphysis, next in the medial side, and finally in the lateral portion, the entire process taking about 12-18 months.6 Closure also appears to start posteriorly in the epiphysis and then to progress anteriorly. A Tillaux fracture occurs after the medial part of the physis has fused but before the lateral part closes. The fracture line passes proximally in a vertical direction through the epiphysis and then exits laterally on the lateral cortex of the tibia. The fracture fragment rotates anterolaterally; the displacement usually is minimal but occasionally is marked. The more skeletally mature the child, the more lateral is the vertical fracture line. Therefore, the physeal injury is a Salter-Harris type III of the lateral part of the distal tibial epiphysis. The fibula, which is pliable, usually does not fracture. The anterior and the posterior tibiofibular ligaments remain intact. ClinicalTillaux fracture is common in adolescents (age 12-15 y) and rare in adults. A history of low-velocity trauma or sporting activities with external rotation of the foot in relation to the leg is common. Symptoms
Signs
The lateral aspect of the leg and the entire fibula must be palpated for tenderness to exclude a high fibular fracture. Distal neurovascular status of the limb must be assessed and usually is normal. Checking for instability of the anterior tibiofibular ligament is difficult in the acute setting and must be attempted only under a general anesthetic in the operating room. INDICATIONSSection 3 of 12
Indications for surgical management include the following:
RELEVANT ANATOMYSection 4 of 12
Stability of the ankle is due to a combination of its bony architecture, joint capsule, and ligaments. The syndesmosis is stabilized by 4 ligaments, namely the anterior and posterior tibiofibular ligaments, transverse tibiofibular ligament, and interosseous membrane. The anterior tibiofibular ligament originates on the anterolateral surface of the tibia and runs obliquely and inferiorly to the distal fibula. The posterior tibiofibular ligament originates on the posterolateral tubercle of the tibia and inserts on the posterior fibula. It is stronger and thicker than its anterior counterpart. Because of this difference, torsional forces in adults usually cause an avulsion fracture of the posterior tibial tubercle, leaving the posterior ligament intact while the weaker anterior tibiofibular ligament usually ruptures (Tillaux lesion). In children, ligaments usually are stronger than the physis, thereby causing an avulsion injury of the distal anterolateral tibial epiphysis (Tillaux fracture) rather than the rupture of the ligament itself. CONTRAINDICATIONSSection 5 of 12
Late presentation is a relative contraindication for forcible manipulation or open reduction to attempt anatomic fixation, because this may lead to further epiphyseal damage. WORKUPSection 6 of 12
Imaging Studies
See also the following related Medscape topic: Diagnostic Procedures
TREATMENTSection 7 of 12
Medical TherapyAcute 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 non–weight-bearing, below-knee cast is sufficient.8 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 and Ollivierre believe that anatomic reduction is achieved and better maintained by maximum dorsiflexion of the ankle during the internal rotation maneuver.9 The extremity is immobilized for 6-8 weeks in an above-knee cast with the knee flexed to about 30-45° to avoid weight bearing. Surgical TherapyIf the fragments are displaced more than 2 mm and an acceptable reduction cannot be achieved, surgery is necessary.10 If the injury presents late, it is better to accept malunion than to cause damage to the epiphysis by forcible manipulation or open surgery. Preoperative detailsPrior 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. Intraoperative detailsThe 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, taking great care 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. Postoperative details
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, while 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. Follow-upRoutine follow-up after union of the fractured fragment frequently is unnecessary. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Ankle Fracture. COMPLICATIONSSection 8 of 12
Complications due to the original injury include the following:
Damage to the physis due to forceful manipulation may lead to the above complications as well. Complications due to surgery include the following:
OUTCOME AND PROGNOSISSection 9 of 12
Several series have shown good long-term results with low incidence of arthrosis (defined as reduction of joint space) either following cast treatment for undisplaced fractures or following operative intervention. Because this fracture occurs in adolescents with a relatively mature growth plate, minimal potential exists for deformity due to growth plate damage. FUTURE AND CONTROVERSIESSection 10 of 12
Arthroscopically assisted reduction and fixation of the adult Tillaux fracture has shown good results and is a promising procedure.11, 12, 13 MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Apr 3, 2008 | |||||||
