Working Diagnosis:
Tillaux Fracture of the Distal Tibia

Treatment:
The patient was placed in a tall walking boot and made non-weight-bearing on the left lower extremity. She was seen by orthopedic surgery the following day, who recommended operative management with open reduction and internal fixation. She was placed in a splint and instructed to elevate the leg when able until surgery three days later.

Outcome:
Two weeks post operatively, she was seen in clinic and transitioned from her splint to a walking boot. At her subsequent visits, her non-weight-bearing precautions were removed, she progressed to normal footwear, fitted for lace-up ankle brace, and referred to physical therapy. Repeat X-rays consistently showed routine healing. Five months after surgery, she returned to running and cheering.

Author's Comments:
Pediatric fractures most commonly occur at the physeal plate. The anterior-lateral portion of the plate closes last. Closure is dictated by estrogen, which is why these injuries commonly occur at a younger age in girls than boys.

Tillaux fractures typically occur as a result of supination and external rotation of the foot. This causes avulsion of the anterolateral tibia where the anterior-inferior tibiofibular ligament attaches.

These injuries are commonly diagnosed by radiographs, but CT scans are helpful in determining the degree of displacement. The degree of displacement often determines if the injury will require operative management (more than 2 mm).

Editor's Comments:
A Tillaux fracture is a “transitional” Salter-Harris fracture, that occurs as the physis is closing. In athletes a bit older, the same mechanism may lead to a high ankle sprain (anterior-inferior tibiofibular ligament sprain). A Tillaux fracture occurs in athletes around 12-15 years of age due to forced dorsiflexion and external rotation. Since these injuries occur in those whose distal tibial physis is nearly closed, growth arrest is not the major concern. Ankle joint congruity is. Non-operative vs. operative management is determined by fracture alignment, which is best assessed by CT.

References:
Habusta, S., Ponnarasu, S., Mabrouk, A., & Griffin, Edward. (n.d.). Tillaux Fracture. https://www.ncbi.nlm.nih.gov/books/NBK482332/

Ahn, L. (n.d.). Tillaux fractures. Orthobullets. https://www.orthobullets.com/pediatrics/4028/tillaux-fractures

Millan-Billi, A. (2022). Tillaux fracture in adults �" Case report and review of literature. Journal of Clinical Orthopaedics and Trauma, 27. https://doi.org/101809

Crawford, A. (2012). Triplane and Tillaux Fractures Is a 2 mm Residual Gap Acceptable? Journal of Pediatric Orthopedics, 32. https://doi.org/10.1097/BPO.0b013e31824b25a1

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