What is Tillaux Fracture?
Pediatric fractures often involve what are called physeal plates in 12% of long bone fractures. The physeal plates are the weakest part of the bone because they are made of cartilage. A specific type of fracture, called a Tillaux fracture, occurs in about 2.9% of injuries to the area of young people’s bones that supports their growth. In this kind of fracture, the end part of the shin bone, or tibia, doesn’t grow evenly. This contributes to the classic Tillaux fracture pattern seen in teenagers.
This fracture is classified as a Salter-Harris type III fracture, which means it is a break that occurs within a joint. It involves the lower part of the shin bone and the part of the bone that forms the joint with the ankle bone. The fracture is named after a French doctor named Paul Jules Tillaux who was the first person to describe it in 1892.
Even though this fracture usually occurs on its own, it can be associated with a break in the lower part of the small bone in the leg, or fibula. It can also be related to a fracture in the shin bone.
Looking at the anatomy, there’s a triangular dip at the lower end of the shin bone where the smaller lower leg bone, or fibula, lies. Below this dip are what’s known as the anterior and posterior tibial tubercles. A ligament, called the interosseous ligament, attaches the shin bone to the fibula at this point and forms part of the ligament network of the ankle. Other components of this network include the anteroinferior tibiofibular and posteriorinferior tibiofibular ligaments.
What Causes Tillaux Fracture?
A Tillaux fracture is caused by a severe injury to the ankle. It typically happens when the foot is twisted outward while someone is moving or a sudden twist of the leg when the foot is stable. This motion leads to a strong pull on a ligament in the lower leg, causing part of the leg bone near the ankle (known as the Chaput tubercle) to be yanked off.
This kind of injury can often be mistaken for a simple sprain, so it’s crucial to have an x-ray or similar type of scan to verify the condition.
The process where the lower leg bone near the ankle stops growing takes place in a way that’s fairly predictable during the year and a half before someone reaches full physical maturity. The middle part of the bone stops growing first, followed by the front and back parts near the middle, and the outer part stops last. This particular pattern is why adolescents transitioning into adulthood often experience specific types of ankle fractures, including Tillaux and Triplane fractures.
Risk Factors and Frequency for Tillaux Fracture
The Tillaux fracture is a type of leg bone break that only happens in teenagers nearing the end of their growth spurt. This is because the fracture occurs in a specific part of the bone (the distal tibial physis) which is only susceptible to this kind of injury after it has begun to harden, a process that usually happens in the final year of a teenager’s growth spurt.
The Tillaux fracture is more common in girls and young people who do sports, because these groups tend to put more stress on their ankles. Girls often get this type of fracture at a younger age than boys because their bones may solidify earlier.
- The Tillaux fracture happens in a specific part of a bone that generally hardens as teenagers finish growing.
- This fracture is more common in girls and teenagers who play sports, due to the extra stress they put on their ankles.
- Girls may get this fracture at a younger age than boys because their growth typically finishes sooner.
Signs and Symptoms of Tillaux Fracture
When teenagers hurt their ankles, they often recall the event as a simple ankle twist that led to their ankle not supporting them anymore. This injury can be misidentified as a typical sprained ankle because it’s presents the same symptoms: pain and swelling on the outer front part of the ankle, similar to injuries to the anterior talofibular ligament (a ligament at the front of the ankle).
But, because teenagers’ bones are still growing and are in fact weaker than these ligaments, it’s necessary to take x-rays to rule out any bone injuries. Along with the typical symptoms, the presence of joint effusion can also be an indicator of this injury. Joint effusion is when there is an increase in fluid around the joint, usually due to bleeding from the fracture. This sign should alert the examiner to the seriousness of the injury and ensure thorough examination.
Testing for Tillaux Fracture
If your doctor suspects you have a Tillaux fracture, they will likely start by taking certain types of X-ray pictures of your ankle. These are known as anteroposterior, lateral, and Mortise views. The X-ray will show a typical pattern of damage towards the front side and outer edge of the ankle growth plate. The fracture will extend through the bone and into the ankle joint. This type of injury is called a Salter-Harris type III fracture of the outer lower part of the shinbone.
Your doctor may also use a CT scan to get a better look at the fracture and see how much the bone has moved out of place. A CT scan is more efficient than regular X-rays can see changes as small as 2 mm. This method is normally the preferred choice when dealing with Tillaux fractures.
Treatment Options for Tillaux Fracture
The best treatment for a Tillaux fracture depends largely on how significantly the bone is displaced or out of place. The main goal in any treatment scenario is to correctly reposition the bone, a process known as anatomic reduction.
If the bone displacement is less than 2 millimeters, you can usually treat the fracture without surgery. This process is referred to as non-operative management and involves closed reduction and immobilization in a cast. To achieve closed reduction, the foot is usually rotated inward, though sometimes bending and rotating the foot can also be effective. Once the bone is back in the correct position, a short leg cast is applied to help hold the bone in place. This cast is typically used for about four weeks, after which the person wears a walking boot for an additional two weeks to help improve ankle mobility.
If the bone displacement is more than 2 millimeters, and the fracture disrupts the smooth articulation of the distal tibia bone, surgery may be necessary.
One surgical option is called Closed Reduction and Percutaneous Pinning (CRPP). This procedure involves the same kind of bone repositioning used in non-operative management. However, the surgeon can also use a special wire inserted into the bone fragment to help guide the repositioning. The quality of the reduction is checked during surgery using imaging methods like fluoroscopy or arthrogram. If the repositioning is successful, the bone is then held in place with wires or screws.
Another surgery option is Open Reduction and Internal Fixation (ORIF). Through an incision on the outer side of the ankle, the surgeon directly visualizes the articular surface of the bone for optimal repositioning. Once the bone is repositioned, it’s secured using wires or screws. After the surgery, the person typically wears a cast or splint for about four weeks, followed by a walking boot for another two weeks to help restore ankle mobility.
Whether managed non-surgically or surgically, physical therapy for ankle mobility is vital in the recovery of a Tillaux fracture, regardless of the amount of displacement.
Finally, in some cases, a procedure called arthroscopically assisted reduction and fixation is used. This involves making small incisions and using a camera to help guide the repositioning and securing of the bone, but done with minimal intervention.
What else can Tillaux Fracture be?
When a patient has an injured ankle, two possible causes might be an ankle sprain, specifically the anterior talofibular ligament (ATFL), or something called a triplane fracture. A triplane fracture is especially common in younger children, who’ve not yet finished growing. This type of injury involves three separate fracture fragments and is a complex injury that extends across three planes or directions within the lower part of the tibia bone in the ankle.
Looking at X-rays from the front, the top part of the ankle bone appears to be fractured in a back-to-front direction and is similar to a certain type of injury known as a Salter-Harris type III. The central part of the bone appears to be fractured in a horizontal direction. Lastly, the back part of the bone, seen from the side, appears to have a fracture running front-to-back resembling a Salter-Harris type II injury. To fully determine the extent of the injury, detailed CT scans of the ankle are sometimes required.
It’s worth noting that triplane fractures tend to be more common in boys, while girls are more prone to another type of fracture known as a Tillaux fracture.
What to expect with Tillaux Fracture
The outlook for a complete recovery is great, and often, the normal level of activity for teenagers is enough to eliminate the need for physical therapy after they’ve healed.
Possible Complications When Diagnosed with Tillaux Fracture
After a traumatic event, some people may develop arthritis in the ankle, which can cause discomfort and restrict movement.
In addition to stiffness in the ankle, pain is another common symptom. Another potential but rare condition is premature growth arrest. This typically occurs in the case of Tillaux fractures, which usually happen when the growth plates in children are about to close.
