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Juvenile Tillaux Fracture in an Adolescent Basketball Player

Kyle J. Cassas, MD; John P. Jamison, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 2 - FEBRUARY 2022

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In Brief: Forced external rotation of the foot may cause a syndesmosis or high ankle sprain in an adult, but in a teenage patient, a juvenile Tillaux fracture may occur if the tibial physis has not yet closed. Diagnosis is made with plain radiographs, but CT may be necessary to determine the true articular displacement. Closed reduction with casting for 6 weeks is usually sufficient for most nondisplaced or minimally displaced fractures. Patients with more than 2 mm of displacement, as in this case of a 16-year-old basketball player, should be referred to an orthopedic surgeon. Complications include residual angular deformity and premature osteoarthritis. Most patients are able to return to full activity at 3 months postinjury.

Primary care physicians see many teenage patients who have traumatic ankle injuries. A vertical fracture of the distal lateral tibia, known as a juvenile Tillaux fracture, is relatively uncommon, but clinicians should maintain a high index of suspicion in young patients whose physes have not fully closed. Determining the position of the avulsed fragment is key to optimal treatment. Adequate anatomic alignment is essential to prevent the potential complications that are associated with this fracture.

Case Report

History. A 16-year-old athlete sought care 3 days after injuring her ankle while playing basketball. The patient reported anterior and lateral ankle pain and swelling. She was unable to bear weight immediately after the injury, and she was using crutches when she came to our office. She did not recall a popping sensation when the injury occurred, and she did not have numbness or paresthesias of the foot and ankle. Her medical and surgical histories were unremarkable, and she had no prior ankle trauma or other injuries. The patient did not have any history of menstrual or eating disorders.

Physical exam. In this well-nourished and well-developed adolescent, mild swelling of the anterior and lateral ankle were present without ecchymosis or deformity. A small ankle effusion was apparent. Active dorsiflexion and plantar flexion were limited because of pain. Tenderness was noted over the anterior joint line, lateral malleolus, anterior talofibular ligament, calcaneofibular ligament, syndesmotic region, and deltoid ligament.

The squeeze test (compression of the lower leg at the midcalf with pain referred to the syndesmosis) was positive, a Thompson's test was negative, and the patient had normal sensation and pulses. Strength, anterior drawer, and talar tilt testing were not performed because of pain.

Diagnostic imaging. Non-weight-bearing radiographs (anteroposterior [AP], lateral, and mortise views) revealed an avulsed fragment of the distal lateral portion of the tibia and a possible Salter-Harris type 1 fracture of the distal fibula (figure 1). Radiographs of the contralateral ankle were normal. Computed tomography (CT) showed a complex rotational Salter-Harris type 4 distal tibia fracture (displaced 9 mm anteriorly and laterally) and a nondisplaced Salter-Harris type 2 distal fibula fracture not apparent on plain radiographs (figure 2).

Diagnosis, treatment, and outcome. The final diagnosis was a juvenile Tillaux fracture with a nondisplaced Salter-Harris type 2 fracture of the distal fibula. A referral was made to orthopedic surgery for further evaluation. The patient underwent open reduction and internal fixation without complications, and the leg was placed in a fracture boot with non-weight-bearing status for 4 weeks. Serial radiographs revealed excellent alignment and healing (figure 3). After completing a physical therapy program, she was allowed to return to full activity at 12 weeks postinjury.

Discussion

Paul Jules Tillaux first described the avulsion fracture of the distal tibial physis in 1892.1 This injury is relatively uncommon,1 but it should be included in the differential diagnosis of adolescent patients (usually age 12 to 14) who have acute ankle injuries. A Tillaux fracture can only occur during the 18-month period when the distal tibial physis has begun to fuse centrally.1-5 Closure of the distal tibial physis occurs first in the central portion and then from the medial aspect toward the fibula. During a forced external rotation of the foot (on a partially closed physis), the lateral fragment of the distal tibial physis is avulsed by the anterior inferior tibiofibular ligament (figure 4).5 Most juvenile Tillaux fractures are classified as Salter-Harris type 3 or 4 injuries.3 Associated fibular fractures are rare, but it is important to palpate the entire length of the fibula during the exam to rule out associated injuries.

Examination reveals swelling of the anterior and lateral ankle, limited range of motion, and tenderness over the lateral tibia and syndesmosis, simulating a high ankle or syndesmosis sprain.6 Plain radiographs (AP, lateral, and mortise views) with comparison views of the uninjured side are usually adequate for diagnosis; however, some patients will require CT scanning to further evaluate the amount of articular surface displacement.3,7 Nondisplaced or minimally displaced juvenile Tillaux fractures can be managed conservatively with casting (initial long leg non-weight-bearing cast for 3 weeks, followed by a short leg walking cast for another 3 weeks); however, those with displacement greater than 2 mm should have orthopedic consultation and surgery to restore the congruity of the joint surface.1,2,5,7,8

Complications include residual angular deformity and premature osteoarthritis.1,2,5 Subsequent growth arrest is uncommon because of the partially fused tibial epiphysis. Short-term disabilities may include recovery from surgery and the initial non-weight-bearing period with the resulting deconditioning. The athlete will also need to demonstrate full range of motion, normal strength, and good proprioception before returning to sports. With proper treatment and rehabilitation, most athletes are able to return to full activity approximately 3 months postinjury.

References

  1. Koury SI, Stone CK, Harrell G, et al: Recognition and management of Tillaux fractures in adolescents. Pediatr Emerg Care 1999;15(1):37-39
  2. Simon WH, Floros R, Schoenhaus H, et al: Juvenile fracture of tillaux: a distal tibial epiphyseal fracture. J Am Podiatr Med Assoc 1989;79(6):295-299
  3. Canale ST: Tibial and fibula fractures, in Canale ST, Campbell WC: Campbell's Operative Orthopaedics, ed 10. St Louis, Mosby, 2003, pp 1537-1539
  4. Overly F, Steele DW: Common pediatric fractures and dislocations. Clin Ped Emerg Med 2002;3(2):106-117
  5. England SP, Sundberg S: Management of common pediatric fractures. Pediatr Clin North Am 1996;43(5):991-1012
  6. Steinlauf SD, Stricker SJ, Hulen CA: Juvenile Tillaux fracture simulating syndesmosis separation: a case report. Foot Ankle Int 1998;19(5):332-335
  7. Horn BD, Crisci K, Krug M, et al: Radiologic evaluation of juvenile tillaux fractures of the distal tibia. J Pediatr Orthop 2001;21(2):162-164
  8. Chambers HG: Ankle and foot disorders in skeletally immature athletes. Orthop Clin North Am 2003;34(3):445-459


Dr Cassas is assistant professor of family medicine at the University of Texas Southwestern Medical Center at Dallas and associate director of the Methodist Hospitals of Dallas Sports Medicine Fellowship. Dr Cassas holds a certificate of added qualifications in sports medicine. Dr Jamison is an orthopedic surgeon at Southwest Orthopedics and Sports Medicine in Dallas and on the clinical faculty of the Methodist Hospitals of Dallas Sports Medicine Fellowship. Address correspondence to Kyle J. Cassas, MD, Methodist Hospitals of Dallas, Family Practice and Sports Medicine Center, 3500 W Wheatland Rd, Dallas, TX 75237; e-mail to [email protected].

Disclosure information: Drs Cassas and Jamison disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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