In adolescence, the distal tibial physis starts to close first at the anteromedial aspect of the medial malleolus, & the closure then extends posteriorly & laterally
last part of the physis to close is the anterolateral quadrant of the physis. This quadrant has the anterior tibiofibular ligament attached to it. If the foot externally rotates, this part of the epiphysis is pulled off, resulting in a juvenile Tillaux fracture.
Tillaux Fracture
juvenile Tillaux fracture is essentially a Salter-Harris III fracture of the distal tibial physis
Triplane Fracture
If the fracture line extends across the metaphysis, this creates a triplane fracture.
A triplane fracture essentially has the appearance of a SH III fracture on the AP & a SH II fracture on the lateral
Features
External Rotation injury
AITFL avulses anterolateral tibial epiphysis, corresponding to distal tibial physis which remains open
Can be Isolated or Associated with ipsilateral shaft fractures
Fibula usually prevents marked displacement
Investigations
Xray
Mortise view essential to aid diagnosis
CT Scan
very helpful
displacement
tillaux vs triplane
Treatment
Undisplaced
AKPOP: knee flexed 30° & foot IR
Confirm reduction with CT scan
Watch carefully
Displaced (>2mm)
Attempt closed reduction
IR of foot with direct pressure over anterolateral tibia or dorsiflex & IR pronated foot
stabilize with percutaneous pins or cannulated (4.0mm) screw ± washer
can cross physis, growth is not a concern
Confirm with CT scan
If Closed Reducations fails
first attempt to guide into position with 2 percutaneous smooth pins
ORIF if fails.
Anterolateral approach, with cannulated or cancellous screws.
