Open reduction; screw fixation
1. General considerations
Introduction
The Tillaux fracture is a transitional fracture of the anterolateral distal tibial epiphysis. This typically occurs in older children. The amount of remaining growth is therefore negligible, and crossing the physis with screws is permitted.
Displaced articular fractures require an open approach, with anatomical reduction to restore the articular surface and align the physis.
A CT scan is recommended for diagnosis and preoperative planning.
Screws can either be placed within the epiphysis …
… or crossing the physis into the metaphysis.
If the fragment is sufficiently large, two screws can be used.
Treatment goals
Anatomical restoration of these fractures reduces the risks of malunion and subsequent osteoarthritis.
2. Instruments and implants
Appropriately sized cannulated or noncannulated lag screws (2.7, 3.5, or 4.0 mm) can be used.
The following equipment is used:
- Cannulated screw set with guide wire
- Drill
- Image intensifier
- Reduction forceps
- Dental pick or hook
3. Patient preparation and approach
Patient positioning
Place the patient in a supine position on a radiolucent table.
Approach
These fractures are typically treated with an anterolateral approach to remove any block to reduction and stabilize the fracture.
4. Reduction
Remove blood clots, loose fragments, soft callus, and entrapped periosteum.
Reduce the fracture with gentle manipulation, a dental pick, or reduction forceps.
If needed, temporarily stabilize the fracture with K-wire(s).
Visually check for anatomical reduction of the articular surface.
5. Fixation
Insert a lag screw in the chosen direction in a standard manner.
6. Final assessment
Recheck the fracture alignment and implant position clinically and with an image intensifier before anesthesia is reversed.
Confirm stability of the fixation by moving the ankle through a range of dorsi/plantar flexion.
7. Immobilization
A molded below-knee cast or fixed ankle boot is recommended for a period of 2–6 weeks as the strength of fixation may not provide sufficient stability for unrestricted weight bearing.
8. Aftercare
General considerations
Protected weight-bearing for 3–4 weeks is recommended.
Pain control
Patients tend to be more comfortable if the limb is splinted.
Routine pain medication is prescribed for 3–5 days after surgery.
Neurovascular examination
The patient should be examined frequently to exclude neurovascular compromise or evolving compartment syndrome.
Discharge care
Discharge follows local practice and is usually possible within 48 hours.
Follow-up
The first clinical and radiological follow-up is usually undertaken 5–7 days after surgery to check the wound and confirm that reduction has been maintained.
Cast removal
A cast or boot can be removed 2–6 weeks after injury.
Mobilization
After cast removal, graduated weight-bearing is usually possible.
Patients are encouraged to start range-of-motion exercises. Physiotherapy supervision may be required in some cases but is not mandatory.
Sports and activities that involve running and jumping are not recommended until full recovery of local symptoms.
Implant removal
Implant removal is not mandatory and requires a risk-benefit discussion with patient and carers.
9. Case
AP, mortise, and lateral x-rays of a Tillaux fracture
CT image of the same case
Postoperative mortise and lateral x-rays of the same case with screw fixation
