Tillaux Fracture

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The term Tillaux fracture is an eponym describing a fracture of the anterolateral tibial epiphysis that is commonly seen in adolescents. ^[1] 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.

Commonly, the two unique fracture patterns of the distal tibia in adolescents are the triplane fracture and the juvenile Tillaux fracture. They are also called transition fractures, because in both injury patterns, the germinal layer of the partially closed growth plate is violated. The aim of treatment with these fractures is the prevention of early osteoarthritis of the ankle by accurate and stable reduction of the intra-articular fracture fragments to maintain total joint congruity.

Sir 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. ^[2]

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). ^[3]

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 fix these fractures internally, which yields a high proportion of good results.

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Ankle Fracture.

Stability of the ankle is due to a combination of its bony architecture, joint capsule, and ligaments. The syndesmosis is stabilized by the following four ligaments:

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 avulsion injury of the distal anterolateral tibial epiphysis (Tillaux fracture) rather than rupture of the ligament itself.

The 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 et al 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 anteromedial epiphysis, then in the posteromedial epiphysis, and finally in the lateral portion of the epiphysis, with the entire process taking about 12-18 months. ^[4]

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 the vertical fracture line. Therefore, the physeal injury is a Salter-Harris type III of the lateral part of the distal tibial epiphysis. ^[2] The fibula, which is pliable, usually does not fracture. The anterior and the posterior tibiofibular ligaments remain intact.

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. ^{[5, 6]}

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 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).

Fractures 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, though the majority of ankle injuries generally occur in males. ^{[7, 8]} Increased participation in sporting activities for adolescents, particularly those involving pivoting forces, has contributed to increasing incidence since the latter part of the 20th century.

Several series have shown good long-term results with a low incidence of arthrosis (defined as reduction of joint space) after either cast treatment for undisplaced fractures or operative intervention. ^[9]

Because this fracture occurs in adolescents with a relatively mature growth plate, minimal potential exists for deformity resulting from growth-plate damage.

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Satishchandra Kale, MD, MBBS, MBA, MCh(Orth), FRCS(Edin), FRCS(Tr&Orth) Diploma in Sports and Exercise Medicine(UK)

Satishchandra Kale, MD, MBBS, MBA, MCh(Orth), FRCS(Edin), FRCS(Tr&Orth) is a member of the following medical societies: Bombay Orthopedic Society, British Orthopaedic Association, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

Tillaux Fracture

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