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The tillaux fracture: a case report
The Journal of Emergency Medicine, Vol. 16, No. 4, pp. 603– 606, 1998 Copyright © 1998 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/98 $19.00 1 .00
PII S0736-4679(98)00048-1
Clinical Communications
THE TILLAUX FRACTURE: A CASE REPORT Michael Anthony Kennedy,
DO, FACEP,
Andrew E. Sama,
MD, FACEP,
and Scott Padavan,
MD
Department of Emergency Medicine, North Shore University Hospital/NYU School of Medicine, Manhasset, New York Reprint Address: M. A. Kennedy, DO, FACEP, Department of Emergency Medicine, North Shore University Hospital/NYU School of Medicine, 300 Community Drive, Manhasset, NY 11030
e Abstract—In this report, we review the Salter-Harris classification of pediatric fractures, including its histologic basis in the biomechanics of bone growth, and present a case of ankle injury. The case describes a unique subtype of pediatric growth plate injury, the Tillaux fracture, whose treatment is then discussed. © 1998 Elsevier Science Inc.
Figure 2, bone growth occurs as the cartilage of the growth plate is actively replaced by bone matrix of the diaphysis. The plate itself may be further subdivided into five zones, which are shown. The bony epiphysis contains a so-called secondary ossification center, which is responsible for radial growth, and plays an obvious role in joint articulation. As can also be appreciated from Figure 2, the epiphysis is proximal to the more delicate and active resting and proliferative zones, and therefore its fractures have a greater propensity to disrupt these layers. For all these reasons, fractures involving the epiphysis may be considered in a separate, broader category from the more common Salter-Harris types I and II, which have a low complication rate and an almost uniformly favorable prognosis. Nonetheless, the prognosis for a type 3 fracture is still generally good.
e Keywords—Tillaux fracture; fracture, pediatric; pediatrics; ankle injury; growth plate injury
INTRODUCTION The Salter–Harris classification is a time-honored system used to describe injury involving an active epiphyseal growth plate or physis. Its utility lies in its ability to prognosticate and guide treatment. It also facilitates accurate communication between the emergency physician and the orthopedic surgeon. It is derived exclusively from radiographic information. Because the cartilaginous growth plate itself is lucent on plain films and the precise nature and degree of its injury cannot truly be seen, it is inferred from the surrounding bone damage. Five fracture-types are described (Figure 1), and the emergency physician’s skill in correctly identifying these is paramount in obtaining appropriate orthopedic consultation and preventing growth complications (Table 1). Few physicians may recall the precise process of bone growth and the histological characteristics of the epiphyseal plate that underlie it. As may be appreciated in
CASE REPORT A 14-year-old male presented to the Emergency Department 2 h after falling off a bicycle. A focused examination of the extremities revealed an abrasion over the anterior aspect of the right ankle, diffuse swelling, and no palpable bony deformity. Pulses and capillary refill were normal. Despite hesitancy to move the ankle, a full range of motion was demonstrated although the patient refused to bear weight. Following elevation and application of ice, ankle and foot x-ray studies were ordered. Toradol, 30 mg i.m., was administered for pain.
Clinical Communications (Pediatric) is coordinated by Roger Barkin,
RECEIVED: 5 June 1995; FINAL SUBMISSION ACCEPTED: 25 November 1997.
RECEIVED:
10 November 1997; 603
MD,
of HealthONE, Denver, Colorado
604
M. A. Kennedy et al.
Figure 1. Salter-Harris Classification. Reprinted with permission from American Family Physicians, Oct 1992; 4C(4):1180 – 4.
AP ankle films revealed an irregular lucency of the distal tibia’s lateral aspect (Figure 3). This lucency was also seen on the lateral projection and is a rare finding. It was initially, and properly, described as a Salter–Harris type III fracture—the fracture extending from the articular surface across the epiphysis and along its lateral margin. The location of the fracture, the patient’s age, and a careful review of the precise mechanism of injury were each consistent with the more exact diagnosis of Tillaux fracture—a subtype of Salter–Harris III. The patient was admitted to the orthopedic service and underwent open reduction and internal fixation the next day. He was discharged from the hospital 2 days after admission. In this case the patient suffered no permanent disability and recovered fully.
DISCUSSION In 1964, Kleiger and Mankin described an isolated fracture of the lateral, distal tibial epiphysis referred to today as the Tillaux fracture. This fracture occurs when the foot is externally rotated and an epiphyseal fragment is avulsed by the anterior tibiofibular ligament (1). The distal tibial epiphysis begins to undergo fusion and ceases its longitudinal growth at about age 12 for girls and 13 for boys. Moreover, the medial portion of the physis closes first, and fusion then progresses posterolaterally with the anterolateral portion fusing last (2). This asymmetric closure of the growth plate results from the local mechanical stresses to which it is subject: relatively greater weight is borne by the medial portion.
The Tillaux Fracture
605
Table 1. Fracture Types, Treatment, and Prognosis Fracture Type Type I Type II Type III Type IV Type V
Prognosis Fracture through the growth plate Fracture through the growth plate and metaphysis Fracture through the growth plate and epiphysis Fracture through the growth plate, epiphysis and metaphysis (Fig. 1) Crush or compression injury of growth plate
Fracture Type Type I & II Type III Type IV Type V
Excellent Very good Generally good Fair Poor
Treatment Closed immobilization Closed immobilization with occasional internal fixation—Tillaux Fracture Open reduction and internal fixation Treatment of growth arrest
It also accounts for the lateral portion’s predisposition to be damaged with this mechanism. The diagnosis of a Tillaux fracture is made by radiographs, the use of tomography, or a computed tomography scan (3). The Tillaux is unique among Salter–Harris
Figure 2. Histological bone growth.
Figure 3. X-ray of Tillaux fracture lateral tibial lucency (arrow).
type III fractures in that its treatment is usually operative. Only if the epiphyseal fracture is nondisplaced and very small fragments are visualized can conservative treatment involving immobilization alone be considered (6). Any joint surface displacement greater than 2 mm should be viewed as an absolute indication for operative treatment (7). The repositioned epiphyseal fragment should be secured with epiphyseal or epimetaphyseal screws (8).
606
M. A. Kennedy et al.
The prognosis is good if adequate anatomical reduction is achieved. The most serious complications reported are pain and stiffness secondary to articular incongruity with an inadequately closed reduction.
CONCLUSION In dealing with pediatric lower extremity fractures involving the tibia, emergency physicians should look for
the Tillaux fracture. Components of proper diagnosis include an understanding of its age distribution, the growth properties of the tibial physis, and a working knowledge of the Salter–Harris fracture classification system. When plain films are inadequate, and mechanism of injury or age suggest its likelihood, a computed tomography scan should be considered. Treatment of the Tillaux fracture is generally operative, and thus, timely orthopedic consultation or follow-up is recommended.
REFERENCES 1. Rockwood Jr CA, Wilkins KE, King RE. Fractures in children, 3rd Ed., JB Lippincott: Philadelphia; 1991:1341– 4. 2. Leitch JM, Lundy PJ, Paterson DC. Three-dimensional imaging of a juvenile Tillaux fracture. J Pediatr Orthop. 1989;9:602–3. 3. MacNealy GA, Rogers LI, Hernandez R, Pozmanski A. Injuries of the distal tibial epiphysis. AJR. 1982;138:683–9. 4. Hoeffel JC, Lascombes P, Punceset T. Biplane fracture of Tillaux. Europ J Radiol. 1989;9:250 –3. 5. Brown JH, Deluca SA. Growth plate injuries—Salter-Harris classification. Am Fam Phys. 1992;4(4):1180 – 4.
6. Kleiger B, Mankin HJ. Fractures of the lateral portion of the distal tibia epiphysis. J Bone Jt Surg Am Vol. 1964;46:25–31. 7. Laer L. Classification, diagnosis and treatment of transitional fractures of the distal part of the tibia. J Bone Jt Surg Am Vol. 1985;67:687. 8. Krueger FM, Siebert CH. Sports-related two plane fractures of the distal tibia. Arch Orthop Trauma Surg. 1991;11D:316 –7. 9. Kennedy MA. Changes in the mechanical and electrical environment and the effect on bone. Orthopedics. 1987;10:789 –91.
PII S0736-4679(98)00048-1
Clinical Communications
THE TILLAUX FRACTURE: A CASE REPORT Michael Anthony Kennedy,
DO, FACEP,
Andrew E. Sama,
MD, FACEP,
and Scott Padavan,
MD
Department of Emergency Medicine, North Shore University Hospital/NYU School of Medicine, Manhasset, New York Reprint Address: M. A. Kennedy, DO, FACEP, Department of Emergency Medicine, North Shore University Hospital/NYU School of Medicine, 300 Community Drive, Manhasset, NY 11030
e Abstract—In this report, we review the Salter-Harris classification of pediatric fractures, including its histologic basis in the biomechanics of bone growth, and present a case of ankle injury. The case describes a unique subtype of pediatric growth plate injury, the Tillaux fracture, whose treatment is then discussed. © 1998 Elsevier Science Inc.
Figure 2, bone growth occurs as the cartilage of the growth plate is actively replaced by bone matrix of the diaphysis. The plate itself may be further subdivided into five zones, which are shown. The bony epiphysis contains a so-called secondary ossification center, which is responsible for radial growth, and plays an obvious role in joint articulation. As can also be appreciated from Figure 2, the epiphysis is proximal to the more delicate and active resting and proliferative zones, and therefore its fractures have a greater propensity to disrupt these layers. For all these reasons, fractures involving the epiphysis may be considered in a separate, broader category from the more common Salter-Harris types I and II, which have a low complication rate and an almost uniformly favorable prognosis. Nonetheless, the prognosis for a type 3 fracture is still generally good.
e Keywords—Tillaux fracture; fracture, pediatric; pediatrics; ankle injury; growth plate injury
INTRODUCTION The Salter–Harris classification is a time-honored system used to describe injury involving an active epiphyseal growth plate or physis. Its utility lies in its ability to prognosticate and guide treatment. It also facilitates accurate communication between the emergency physician and the orthopedic surgeon. It is derived exclusively from radiographic information. Because the cartilaginous growth plate itself is lucent on plain films and the precise nature and degree of its injury cannot truly be seen, it is inferred from the surrounding bone damage. Five fracture-types are described (Figure 1), and the emergency physician’s skill in correctly identifying these is paramount in obtaining appropriate orthopedic consultation and preventing growth complications (Table 1). Few physicians may recall the precise process of bone growth and the histological characteristics of the epiphyseal plate that underlie it. As may be appreciated in
CASE REPORT A 14-year-old male presented to the Emergency Department 2 h after falling off a bicycle. A focused examination of the extremities revealed an abrasion over the anterior aspect of the right ankle, diffuse swelling, and no palpable bony deformity. Pulses and capillary refill were normal. Despite hesitancy to move the ankle, a full range of motion was demonstrated although the patient refused to bear weight. Following elevation and application of ice, ankle and foot x-ray studies were ordered. Toradol, 30 mg i.m., was administered for pain.
Clinical Communications (Pediatric) is coordinated by Roger Barkin,
RECEIVED: 5 June 1995; FINAL SUBMISSION ACCEPTED: 25 November 1997.
RECEIVED:
10 November 1997; 603
MD,
of HealthONE, Denver, Colorado
604
M. A. Kennedy et al.
Figure 1. Salter-Harris Classification. Reprinted with permission from American Family Physicians, Oct 1992; 4C(4):1180 – 4.
AP ankle films revealed an irregular lucency of the distal tibia’s lateral aspect (Figure 3). This lucency was also seen on the lateral projection and is a rare finding. It was initially, and properly, described as a Salter–Harris type III fracture—the fracture extending from the articular surface across the epiphysis and along its lateral margin. The location of the fracture, the patient’s age, and a careful review of the precise mechanism of injury were each consistent with the more exact diagnosis of Tillaux fracture—a subtype of Salter–Harris III. The patient was admitted to the orthopedic service and underwent open reduction and internal fixation the next day. He was discharged from the hospital 2 days after admission. In this case the patient suffered no permanent disability and recovered fully.
DISCUSSION In 1964, Kleiger and Mankin described an isolated fracture of the lateral, distal tibial epiphysis referred to today as the Tillaux fracture. This fracture occurs when the foot is externally rotated and an epiphyseal fragment is avulsed by the anterior tibiofibular ligament (1). The distal tibial epiphysis begins to undergo fusion and ceases its longitudinal growth at about age 12 for girls and 13 for boys. Moreover, the medial portion of the physis closes first, and fusion then progresses posterolaterally with the anterolateral portion fusing last (2). This asymmetric closure of the growth plate results from the local mechanical stresses to which it is subject: relatively greater weight is borne by the medial portion.
The Tillaux Fracture
605
Table 1. Fracture Types, Treatment, and Prognosis Fracture Type Type I Type II Type III Type IV Type V
Prognosis Fracture through the growth plate Fracture through the growth plate and metaphysis Fracture through the growth plate and epiphysis Fracture through the growth plate, epiphysis and metaphysis (Fig. 1) Crush or compression injury of growth plate
Fracture Type Type I & II Type III Type IV Type V
Excellent Very good Generally good Fair Poor
Treatment Closed immobilization Closed immobilization with occasional internal fixation—Tillaux Fracture Open reduction and internal fixation Treatment of growth arrest
It also accounts for the lateral portion’s predisposition to be damaged with this mechanism. The diagnosis of a Tillaux fracture is made by radiographs, the use of tomography, or a computed tomography scan (3). The Tillaux is unique among Salter–Harris
Figure 2. Histological bone growth.
Figure 3. X-ray of Tillaux fracture lateral tibial lucency (arrow).
type III fractures in that its treatment is usually operative. Only if the epiphyseal fracture is nondisplaced and very small fragments are visualized can conservative treatment involving immobilization alone be considered (6). Any joint surface displacement greater than 2 mm should be viewed as an absolute indication for operative treatment (7). The repositioned epiphyseal fragment should be secured with epiphyseal or epimetaphyseal screws (8).
606
M. A. Kennedy et al.
The prognosis is good if adequate anatomical reduction is achieved. The most serious complications reported are pain and stiffness secondary to articular incongruity with an inadequately closed reduction.
CONCLUSION In dealing with pediatric lower extremity fractures involving the tibia, emergency physicians should look for
the Tillaux fracture. Components of proper diagnosis include an understanding of its age distribution, the growth properties of the tibial physis, and a working knowledge of the Salter–Harris fracture classification system. When plain films are inadequate, and mechanism of injury or age suggest its likelihood, a computed tomography scan should be considered. Treatment of the Tillaux fracture is generally operative, and thus, timely orthopedic consultation or follow-up is recommended.
REFERENCES 1. Rockwood Jr CA, Wilkins KE, King RE. Fractures in children, 3rd Ed., JB Lippincott: Philadelphia; 1991:1341– 4. 2. Leitch JM, Lundy PJ, Paterson DC. Three-dimensional imaging of a juvenile Tillaux fracture. J Pediatr Orthop. 1989;9:602–3. 3. MacNealy GA, Rogers LI, Hernandez R, Pozmanski A. Injuries of the distal tibial epiphysis. AJR. 1982;138:683–9. 4. Hoeffel JC, Lascombes P, Punceset T. Biplane fracture of Tillaux. Europ J Radiol. 1989;9:250 –3. 5. Brown JH, Deluca SA. Growth plate injuries—Salter-Harris classification. Am Fam Phys. 1992;4(4):1180 – 4.
6. Kleiger B, Mankin HJ. Fractures of the lateral portion of the distal tibia epiphysis. J Bone Jt Surg Am Vol. 1964;46:25–31. 7. Laer L. Classification, diagnosis and treatment of transitional fractures of the distal part of the tibia. J Bone Jt Surg Am Vol. 1985;67:687. 8. Krueger FM, Siebert CH. Sports-related two plane fractures of the distal tibia. Arch Orthop Trauma Surg. 1991;11D:316 –7. 9. Kennedy MA. Changes in the mechanical and electrical environment and the effect on bone. Orthopedics. 1987;10:789 –91.