Anterolateral quadrant of epiphysis (similar to Tillaux)
Medial & posterior epiphysis with posterior metaphyseal spike
Tibial metaphysis
Epidemiology
Mean age 14.8 for boys & 12.8 for girls
48% associated with fibula fracture & 8.5% associated with ipsilateral tibia fracture
Anatomy & Pathology
Physis Closure
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
Classification
Described as 2, 3, or 4 part; subtype of 2 & 3 part which goes into medial malleous instead of joint
Some authors describe 2 & 3 part medial triplane fractures (usually lateral)
2 Part – Lateral & posterior epiphyseal fragment with posterior metaphyseal spike attached
3 Part – as described above
4 Part – anterolateral & anteromedial epiphyseal fragments. Posterior epiphyseal fragment with posterior metaphyseal spike attached
Intramalleolar variants
Type I – intramalleolar, intraarticular fracture at junction of tibial plafond & medial malleolus
Type II – intramalleolar, intraarticular fracture outside weight bearing zone of plafond
Type III – intramalleolar, extraarticular fracture
Investigations
Xray
Standard ankle films important for initial diagnosis
CT scan
Manditory
CT scan with transverse sections through epiphysis & metaphysis important for diagnosis of 2-4 part
Treatment
Undisplaced (<2mm)
Long leg cast with foot in IR if lateral & eversion if medial
CT scan immediately post reduction to confirm
F/U X-ray at 7 days
NWB cast x 3-4 weeks, change to BK walking cast for 3-4 more weeks
Displaced (>2mm)
Attempt CR(successful ~50% of time)
IR foot if lateral
abduction if medial
long leg cast ± percutaneous 4.0mm cannulated screws.
CT to confirm
Open reduction if fails
Anterolateral approach if lateral
antermedial approach if medial
use CT as guide
May need additional incisions
Arthroscopic techniques are described for 2 part
Medial Triplane
2 part- hockey stick anteromedial incision
Reduce & confirm with anteromedial arthrotomy & II
Two 4-mm cancellous screws medial to lateral or anterior to posterior or both
Lateral Triplane
2 part- hockey stick anterolateral incision
Two screws lateral to medial or anterior to posterior
Three or more parts
often require more extensive exposure
Can do transfibular approach through fibular fracture or osteotomy
Fix in stepwise fashion, usually S-H II/IV followed by III components
