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  4. Indications
  5. Treatment

Authors of section


Daniel Green, Philip Henman, Mamoun Kremli

Executive Editor

James Hunter

General Editor

Fergal Monsell

Open all credits

Open reduction; screw fixation

1. General considerations


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 …

Open reduction and screw fixation of a Tillaux fracture

… or crossing the physis into the metaphysis.

If the fragment is sufficiently large, two screws can be used.

Open reduction and screw fixation of a Tillaux fracture

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
Drill, cannulated, partially threaded screw, guide wire, dental hook, and reduction forceps

3. Patient preparation and approach

Patient positioning

Place the patient in a supine position on a radiolucent table.

Pediatric patient placed supine on a radiolucent table


These fractures are typically treated with an anterolateral approach to remove any block to reduction and stabilize the fracture.

Anterolateral approach to the pediatric distal tibia

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.

Open reduction of a Tillaux fracture

5. Fixation

Insert a lag screw in the chosen direction in a standard manner.

Screw fixation of a Tillaux fracture

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.

Pediatric patient walking with crutches and a short leg cast for immobilization of the ankle

8. Aftercare

General considerations

Protected weight-bearing for 3–4 weeks is recommended.

Touch weight-bearing with immobilization of the ankle

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.


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.


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.

Range-of-motion exercises of the ankle

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

Lateral, mortise, and AP x-rays of a Tillaux fracture of the pediatric distal tibia

CT image of the same case

CT image of the same case

Postoperative mortise and lateral x-rays of the same case with screw fixation

Screw fixation of a Tillaux fracture