Working Diagnosis:
Tillaux Fracture

Treatment:
The patient was placed into a long leg cast and returned to the sports medicine clinic 4 weeks later where repeat radiographs demonstrated healing changes Case Photo #6 Case Photo #7 Case Photo #8 . She was transitioned into a walking boot which she wore for an additional 4 weeks. She was referred to physical therapy after her follow up at 8 weeks post-injury. She began returning to light sport activities around 11 weeks post-injury. She continued working with her athletic trainer for full return to all activities.

Outcome:
She was transitioned into a walking boot which she wore for an additional 4 weeks. She was referred to physical therapy after her follow up at 8 weeks post-injury. She began returning to light sport activities around 11 weeks post-injury. She continued working with her athletic trainer for full return to all activities.

Completed a return to play program under PT guidance and gradually acclimated back into sports without complaints.

Author's Comments:
A Tillaux fracture is a Salter Harris III fracture of the distal tibia sustained during youth (1). It typically occurs due to an inversion injury of the ankle leading to forceful strain of the anterior inferior tibiofibular ligament leading to avulsion at the anterolateral distal tibial epiphysis. The estimated incidence of Tillaux fractures is between 3-5% of all ankle fractures and it is seen more commonly in females (2). Tillaux fractures occur in youth most commonly between the ages of 12-14, as a child is nearing skeletal maturity. The injury pattern is uniquely related to the pattern of physeal closure. Physeal closure occurs first at the central aspect of the physis, proceeding anteromedial to posteromedial and finally physeal closure occurs at the lateral physis (3). The identification of a Tillaux fracture is of importance due to the intra articular of the fracture which can lead to complications of arthritis and malalignment. Treatment of a Tillaux fracture depends heavily on the degree of displacement. Fractures with less than 2 mm displacement can generally be treated with cast immobilization for a minimum of 3-4 weeks. The incidence of minimally displaced fractures has been reported at about 35% (2). Fractures with greater than 2 mm of displacement often require closed vs open reduction and associated percutaneous pinning or internal fixation.

Editor's Comments:
Juvenile tillaux fractures, also termed a transitional fracture, occur in young individuals with a physis that is transitioning from open to closed (3). As mentioned above, the physis of the distal tibia closes in a distinct pattern over the course of about 18 months. This type of fracture occurs when the central and posteromedial aspect of the physis are closed leading to a characteristic Salter-Harris III type fracture of the anterolateral distal tibia (3). Radiographic findings can be subtle in appearance, thus it is important for the physician to maintain a high level of suspicion in the setting of an ankle injury involving external rotation and an adolescent athlete. If symptoms of pain and swelling have not improved or do not align with the exam and or radiographs the physician should re-evaluate and consider repeating radiographs. The amount of displacement and joint congruity are key factors in determining treatment for the juvenile tillaux fracture. Further cross-sectional imaging such as a CT scan may be helpful in determining the amount of displacement and joint congruity (4). If the fracture is displaced less than 2 mm and there is appropriate ankle joint congruity, the fracture can typically be treated nonoperatively with cast immobilization and protected weightbearing initially. If there is displacement of the fracture exceeding 2 mm, the patient will often benefit from closed vs open reduction with internal fixation. Due to the timing of this fracture, often occurring in patient’s whose growth plates are essentially closed, growth arrest is not a common complication (4).

References:
1. Sharma B, Reddy IS, Meanock C. The adult Tillaux fracture: one not to miss. Case Reports. 2013;2013(jul18 1). doi:10.1136/bcr-2013-200105.
2. Koury SI, Stone CK, Harrell G, Charité DDL. Recognition and management of Tillaux fractures in adolescents. Pediatric Emergency Care. 1999;15(1):37-39. doi:10.1097/00006565-199902000-00011.
3. Shea KG. Frick SL. Ankle Fractures. Flynn JM, Skaggs DL, Waters PM ed. Rockwood and Wilkins’ Fractures in Children. 8th ed. Philadelphia: Lippincott Williams and Wilkins; 2015.
4. Sink EL. Flynn JM. Thoracolumbar Spine and Lower Extremity Fractures. Weinstein SL, Flynn JM. Lovell and Winter’s Pediatric Orthopedics. Philadelphia: Lippincott Williams and Wilkins; 2014.

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