Tillaux fracture


Tillaux fracture

Description, Causes and Risk Factors:

Tillaux fracture is a fracture of the growth plate of lower end of the tibia. It is seen exclusively in adolescents between the age of 12 to 14 years. 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.

Tillaux 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).

It is caused by a force that tends to rotate the foot outwards. This force makes the anterior tibio-fiblar ligament taut. As the force continues to act the taut ligament pulls apart a bone fragment resulting in the fracture. This fragment is located on the outer un-ossified part of the tibia, which is weaker than the inner ossified part hence fractures more easily.

Tillaux 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. 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 the image below.

Tillaux fracture is common in adolescents 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 and Symptoms:

    Severe pain over the anterior aspect of the ankle.

  • Inability to bear weight.

  • Limp.

  • Swelling over the anterior aspect of the distal leg and ankle.

  • Presence of bruising or ecchymosis.

  • External rotation deformity of the foot possible in severe injuries.

  • Possible tenderness over the region of the medial malleolus or the deltoid ligament if there is failure of the medial column.

Diagnosis:

Diagnosis may include:

    Plain radiographs of the distal leg and ankle in 3 planes are recommended, including anteroposterior (AP), lateral, and oblique views.

  • Frequently, diagnosing this injury is difficult on AP and lateral views alone, especially when the fragment is only minimally displaced.

  • An oblique view is most helpful for excluding triplane fractures.

  • A mortise view can help to demonstrate widening of the syndesmosis.

  • Note any soft-tissue swelling seen on radiographs.

  • Radiographs of the entire tibia and fibula are recommended to exclude high fibular fractures.

  • Computed tomography (CT) scanning with 3-dimensional reconstruction is far more accurate than are plain radiographs in estimating degree of joint displacement and fracture separation.Tomography was used in the past but now has largely been replaced by CT scanning.

  • Fluoroscopy performed while internally rotating the foot also is helpful in the assessment of reduction.

Treatment:

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 non-weight-bearing, below-knee cast is sufficient. 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. 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.

Displaced fractures are treated by surgery. During surgery the fracture is exposed through a skin incision, the fragments are the aligned accurately and fixed in that position with 1 or 2 screws. As the fracture is in part of the tibia bone forming the ankle joint hence it may take more than the normal time to unite. This is because the fracture is exposed to the synovial fluid of the ankle joint.

NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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