William Edwards Orthopaedic Foot & Ankle Centre Of Victoria

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Cite this article as follows: Helmig K C, Choi T J, Silva SR (January 26, 2022) Related to Tillaux and Bimalleolar Ankle Fractures in Pediatric Patients: A Case Report. 14(1): e21648. Doi:10.7759/.21648

William Edwards Orthopaedic Foot & Ankle Centre Of Victoria

Adolescents are at risk for a unique pattern of ankle fractures due to body obstruction. In particular, ankle gap fractures are unique to young patients because the distal end of the tibia is exposed. Intermittent ankle fractures are rare with a double ankle fracture pattern. This case is interesting because the previously presented combined fracture pattern and treatment methods have not been reported in the literature. A 15-year-old woman came to our hospital complaining of pain in her right ankle after falling while roller skating. On imaging, right tillux fractures, ipsilateral displaced medial malleolus fractures and minimal Weber C distal fibula fractures were observed. Tillaux fractures and medial malleolus fractures were treated with open reduction and internal fixation using partially threaded compression screws. The lateral malleolus was minimally mobile and did not require active repair. The patient recovered well without complications. Intermittent ankle injuries in adolescents have been reported in the literature. However, related injuries are rare and underrepresented in the current literature base. It is important to be aware of these related injuries, as missed injuries can cause pain and long-term disability.

Pdf) Measures Of Foot Pain, Foot Function, And General Foot Health

Ankle fractures in patients with skeletal immaturity have unique features in terms of fracture pattern and treatment, especially in patients with an asymmetrical open body transitioning to a mature closed state. Gap ankle fractures occur when the distal tibialis physics closes [1]. It takes an average of 18 months for the distal tibialis physics to completely close [1-3]. The distal tibial femoral occlusion starts medially, moves medially and ends laterally [1, 2]. Distal tibial fissure occlusion usually occurs between the ages of 12 to 15 years in women and 14 to 18 years in men [1, 4].

Tillaux fractures are a type of transitional fracture that commonly occurs in the later stages of distal tibial bone occlusion, in which only the lateral portion of the tibia remains open [1, 3]. Tillaux fractures are usually the result of dorsiflexion external rotation forces that rupture the anterior inferior tibial ligament (AITFL) [1, 2]. Bone impingement in AITFL results in a Salter-Harris III fracture of the anterolateral distal tibia [2, 3]. Although these fractures involve a growth plate, distal tibial physics are usually close to complete occlusion. Therefore, bodily arrest due to a Tillax fracture does not increase the risk of limb shortening or deformity [1].

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Bimalleolar ankle fractures are also common in pediatric patients and may not involve distal tibial and fibula physics [1]. The risk of body arrest after a double ankle fracture depends on the patient’s skeletal maturity, the mechanism of injury, and the initial and residual retraction movements of the fracture [1].

We present the case of a 15-year-old woman with Tillaux and bimalleolar ankle fractures, a rare injury that is frequently discussed in the literature. It is necessary to discuss this broken pattern with a step-by-step approach to abnormal injury and recovery.

Craig C. Greene, M.d., M.b.a. — Baton Rouge Orthopaedic Clinic

A healthy 15-year-old woman with an injury during roller skating is shown. Initial radiographs showed fractures of the right Tillaux joint and bimalleolar ankle (Figures 1a, 1b).

Original anteroposterior (a) and lateral (b) radiographs of the injured right ankle (R), showing medial malleolus and tilo fractures, and minor distal fibula fractures (fractures indicated by white arrows).

A closed reduction was attempted and she was placed in a short non-weight support splint. CT scans showed a Tillaux fracture and a displacement of more than 2 mm of the medial malleolus with minimal displacement of the Weber C distal fibula fracture (Figures 2a, 2b).

Preoperative three-dimensional (3D) CT scan (a) shows the continuous displacement of the medial malleolus and Tillaux fractures with minimal displacement of the distal fibula fracture (fractures are indicated by white arrows). Axial cut CT scan (b) shows a displaced Tillaux fracture fragment (indicated by white arrows) greater than 2 mm.

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Surgical intervention was recommended due to Tillaux’s residual displacement and medial malleolus fracture. The patient was transferred to the operating room for planned open reduction and internal fixation of the medial malleolus and Tillaux fractures. A stepwise approach was used, starting with the medial malleolus. An incision was made just in front of the medial malleolus and the articular surface was precisely contoured to ensure a good reduction. The reduction was fixed with a two-point bone clamp, and the medial malleolus was fixed with two 4.0 mm screws. A separate anterolateral incision was then made to treat the Tillaux fracture. Fractures were identified, reduced and secured with dental picks. A partially threaded 4.0-mm screw was placed across the fracture with good compression visible at the fracture site. The size of the shattered pieces allowed space for only one screw. Intraoperative fluoroscopy was used to confirm good reduction of medial malleolus and Tillaux fractures, proper screw placement, and non-displacement of fibula fractures (Figures 3a-3c).

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Anterior-posterior (a), mortise view (b) and lateral (c) fluoroscopy images during surgery show reduction of medial malleolus and Tillaux fracture fragments with proper placement of the compression screw.

A short leg splint was applied and the patient was discharged without pressure on the surgical limb. The patient was weight-bearing and in a walking cast for 2 weeks without weight bearing for a total of 4 weeks. Six weeks after her surgery, she switched to an ankle brace that could withstand her weight bearing and started doing her ankle range of motion exercises daily. Three months after her surgery, the patient had a complete pain-free range of motion, pain-free at weight-bearing, and returned to all activities without restriction. On radiographs, the distal fibula, medial malleolus, and Tillaux fractures healed well (Figures 4a, 4b).

No further orthopedic follow-up was required as the patient was doing well clinically and her fracture had healed radiographically at 3 months. In the chart review, the patient was referred to our system’s pediatrician, who specifically stated that there was no ankle pain, swelling, or restriction for 18 months after surgery.

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The injuries shown are unusual. However, the principles of fracture treatment remain the same. The primary goal of the treatment of pediatric ankle fractures is to reconstruct concordance, body anatomy, and lower extremity alignment [1]. Fractures (greater than 2 mm) require a closed reduction attempt. However, repeated attempts may further damage the exposed body already damaged by the injury [1, 4]. If occlusive reduction is successful, splint or cast immobilization is performed and the patient is closely followed in hospital [1]. In particular, in the case of Tillaux fracture, post-reduction CT scan is indicated to evaluate post-reduction motion because residual motion greater than 2 mm is an indication for surgical intervention [1, 4]. Adhering to the principles of treatment when approaching rare lesions, as in the case presented, allows a systematic and gradual approach to fractures.

A review of the literature resulted in four articles on Tillaux fractures along with other ankle injuries in adolescents and adults [5-8]. Yuan et al. Six Tillaux fractures with ipsilateral medial malleolus fractures were presented [5]. One patient underwent open reduction and internal K-wire repair of a medial ankle fracture, and five were treated with closed reduction and K-wire fixation [5]. All Tillaux fractures were reduced open and internally fixed with a K-wire [5]. Five patients had ipsilateral distal fibula fractures, of which three were treated with plate and screw fixation [5]. One patient in the Yuan series underwent open reduction and internal fixation of the medial malleolus and Tillaux fractures, but not the ipsilateral distal fibula fractures [5]. One patient in the Yuan series was treated in the same way as in our case, but the setup used in Yuan’s study is different from our case [5]. Partial thread screws and K-wire fixation are both options for managing medial malleolus and tilo fractures. Partially threaded screws aid in compression at the fracture site, while smooth K-wires are useful for small fracture fragments that are at risk of penetration due to screw placement.

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Numerous case reports detail Tillaux and Volkmann fractures (scapular fractures of the posterior inferior tibial ligament) in adolescents and adults [6-8]. This fracture pattern differs from the pattern presented in our case, but appears to be a Tillaux fracture combined with an additional ankle injury. The proposed injury mechanism in Tillaux and Volkmann joint fractures is external rotational force [6]. Tillaux fractures are usually associated with external rotational forces. In our case, depending on the broken pattern, it is more likely that there is a rotational force other than the pronunciation. A short oblique Weber C distal fibula fracture with a transverse medial malleolus fracture presents an external pronation rotational force at the ankle. The abnormal compound fractures seen in our case may also be due to the patient’s roller skating and the abnormal force applied to the ankle at the time of the injury. The mechanism of injury can be an important consideration when evaluating patients and imaging.

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