Case Report Syed et al: Tillaux fracture in adult Tillaux Fracture In Adult: A Case Report Syed T, Storey P, Rocha R, Kocheta A, Singhai S Study performed at Rotherham District General Hospital, Rotherham, South Yorkshire, United Kingdom Abstract Case report We report a rare case of Tillaux fracture of the ankle in a 36-year-old man. He sustained the injury in a football tackle and presented to us with pain and swelling of the left ankle. After preliminary X- rays, a CT scan was done which showed a Tillaux type fracture which is a rare injury after epiphyseal fusion. The ankle was treated with open reduction and internal fixation with screws and plaster for 6 weeks. At 3 months the patient had no pain in the ankle and able to mobilize full weight bearing on that side. Keywords : Ankle fracture, Tillaux fracture, Anterolateral tibial avulsion Address of correspondence: How to cite this article: Dr. Towheed Syed, Syed T, Storey P, Rocha R, Kocheta A, Singhai S. Tillaux Fracture 4-4-3-18/401, Senior heights, Street In Adult: A Case Report. Ortho J MPC. 2020;26(2): 95-98 no.3, Lalamma gardens, Puppalguda, Available from: Manikonda, Hyderabad - 500089 https://ojmpc.com/index.php/ojmpc/article/view/126 Email – [email protected] Introduction aim to educate the clinicians about this rare injury in adults, which is worthy of discussion. Tillaux fracture is an uncommon, rare ankle injury, described as an avulsion fracture of Case report anterolateral part of distal tibia due to the stronger pull of the anterior tibiofibular A 36-year-old gentleman presented to the ligament, by an external rotation force to the emergency department immediately after foot causing a Salter Harris type III injury [1- trauma sustained in a football tackle. His body 3]. It is typically seen in adolescents who rotated internally when the foot was on have open epiphysis because the anterior ground, when he was hit by an opponent, tibiofibular ligament is stronger than the giving external rotational force injury to the epiphyseal bone, and so the strong pull of this ankle. He complained of excruciating pain and anterior tibiofibular ligament, predisposes to severe swelling on the anterolateral aspect of an epiphyseal bony injury rather than a distal tibia and ankle. He had superficial ligament rupture leading to an avulsion abrasions over the shin. No other injuries were physeal injury to anterolateral distal tibia identified. Distal neurovascular structures [2,3]. Occurrence of this rare tillaux fracture were normal. He had no significant previous in adults is further rare, because in adults i.e. medical history. after physeal fusion, ligament strength is less Plain radiographs of ankle showed a distal than bony strength and therefore a rupture of tibial avulsion fracture of the anterolateral the ligament is more likely than a bony aspect indicating a Tillaux-type injury. He was avulsion [4]. Only very few cases of this given analgesics and placed in a below knee Tillaux fracture in adults has been reported [4- plaster of paris back slab. He was admitted to 9]. In the present report, we describe such the ward and limb was elevated. A CT scan of rare case of a Tillaux fracture in an adult, with the ankle was performed to determine the extent of the fracture, to access the injury Orthopaedic Journal of M P Chapter. 2020. Vol. 26. Issue 2 95 Case Report Syed et al: Tillaux fracture in adult three dimensionally and to plan the surgery. It passed to ensure stable hold and anatomical confirmed an avulsion fracture of the distal reduction of the articular surface (fig 1). anterolateral tibial cortex with an intact Postoperatively, a back slab was applied and tibiofibular syndesmosis. This was deemed the patient’s limb was elevated whilst swelling consistent with an adult-type Tillaux injury. subsided. Check dressing was done on second postoperative day and oral antibiotics Since this was potentially unstable injury continued till five days. After suture removal requiring anatomical reduction and internal at 2 weeks a complete below knee cast was fixation, we planned to treat the patient applied. The post-operative regimen included surgically. Patient was operated in supine non-weight bearing mobilization for a period of position, under tourniquet under spinal 6 weeks in a below knee cast. Partial weight anesthesia via anterior approach to ankle. bearing was instituted for a further 2 weeks Intra operative findings confirmed an avulsion and physiotherapy to mobilize the ankle was fracture of the distal tibia with an intact begun. Full weight bearing began at eight tibiofibular ligament. The fragment was weeks along with proprioceptive rehabilitation. reduced and initially temporary fixed with k Radiographs at 6 weeks showed union of the wires, after confirming reduction under C arm. fragment. Normal foot and ankle function was Following this, 3 cannulated 4.5mm lag screws regained by three months. and 2 headless compression screws were Fig 1 . Pre-operative AP (a) and lateral (b) x rays and 3-D reconstruction CT scan views (c and d) of the patient with tillaux type fracture fixed with CCS as shown in intra photograph (e to g) and post-operative AP (h) and lateral (i) views. a b c d h I e f g Discussion Jules Tillaux in 1892 who described this avulsion injury and its mechanism of injury Ankle syndesmosis is formed by distal tibia following his experiments on cadavers. He and fibula and is stabilised with four ligaments described it as an external rotation of ankle - the anterior and posterior tibiofibular that leads to an avulsion fracture of the ligaments, transverse tibiofibular ligament and anterolateral aspect of the tibial plafond owing interosseous membrane [1]. to the pull of a taut antero-inferior tibiofibular ligament [11]. Chaput later described similar Sir Astley Cooper, was first to recognize the counterpart injury to the posterolateral tibia Tillaux fracture in 1822, as an avulsion injury (avulsion of posterior tibio-fibular ligament), to antero-lateral distal tibial epiphysis [10]. later called Tillaux-Chaput injury. Tillaux fracture is an eponym given by Paul Orthopaedic Journal of M P Chapter. 2020. Vol. 26. Issue 2 96 Case Report Syed et al: Tillaux fracture in adult Distal tibial epiphysis appears at age 6-10 ankle especially in the anterior part of the months and it unites with the diaphysis at ankle, after a low energy trauma, whereas in about age 18 years [1]. Kleiger and Mankin adults it is usually a high energy trauma and showed that fusion in the distal tibial epiphysis may be associates with other fractures [4-9]. occurs first in the middle third of the epiphysis, followed by, the medial side, and Antero-posterior, lateral and oblique plain finally in the lateral portion [12]. Tillaux radiographs of the ankle are helpful in fracture occurs after the medial part of the diagnosing this fracture. But un-displaced physis has fused but before the lateral part fracture or cursory examination of the closes, hence this injury is commoner in radiographs can miss the injury, necessitating adolescents. computed tomography as a useful adjunct to confirm the diagnosis, clearly define the In adolescents, the lateral physis is open and extent of the fracture, rule out any associated anterior tibiofibular ligament is stronger than injuries involving the tibial pilon and to plan the epiphyseal bone (growth plate). When a management [13,14]. strong external rotational force acts on ankle, it causes a pull force on this strong taut Acute management includes elevation, ice anterior tibiofibular ligament which rather than fomentation and rest. Un-displaced fractures causing pure ligament rupture, predisposes to can be managed non-operatively by below an avulsion epiphyseal bony injury leading to knee non-weight bearing cast immobilisation an avulsion physeal injury to anterolateral for six weeks. Since these are intra-articular distal tibia. Further since the lateral physis fractures and usually displaced due to avulsion growth plate is avulsed away with fracture line pull by the ligament, these injuries need involving the joint, this Tillaux fracture is closed or open reduction with internal fixation typically a Salter Harris type III physeal injury to restore ankle joint congruity aiming [2-4]. In adults this type of injury is very rare congruous reduction, rigid fixation, and early because physeal fusion has already been mobilization for better functional outcome and obtained and the ligament strength is less to prevent complications like nonunion, than the bony strength and ligament will malunion, arthritis, deformity and avascular usually give way and rupture before avulsion necrosis of the fracture fragment [6,7]. of its attachment to the anterolateral tibial plafond, leading to relative rarity of this This open reduction can be done by anterior or avulsion fracture injury pattern in adults. the anterolateral approach [6]. As per Kumar et al anterolateral approach provides the best In adult type of tillaux fracture, the avulsed access to the fracture [9], but we used fracture fragment is triangular as compared to anterior approach for fixation and reduction, the juvenile one, where the fragment is because we suppose the approach should quadrangular. Adult pattern of Tillaux depend on the extend of the fracture line. fractures are classified into Type A and Type Since we have done CT scan, which showed B. Type A is avulsion fracture of the antero- the exact extend of the fracture line, we used lateral aspect of the distal tibial plafond and the anterior approach for fixation. Careful use Type B is a fracture pattern extending into the of wires as “joysticks” to achieve accurate medial aspect resulting in antero medial reduction and fixation, with 1 or 2 inter- pattern [6,7].