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Triplane and Tillaux Fractures: Is a 2 mm Residual Gap Acceptable?

Crawford, Alvin H. MD

Journal of Pediatric Orthopaedics: June 2012 - Volume 32 - Issue - p S69–S73
doi: 10.1097/BPO.0b013e31824b25a1
Trauma Supplement
Free

Children’s ankle fractures are the second most common growth plate fractures in humans and one of the top 10 reasons for pediatric orthopaedic hospital admissions. Because triplane and Tillaux fractures occur during the period of distal tibial physeal closure, they are considered transitional injuries. The distal tibial physis closes in a unique, asymmetric pattern (middle, then medial, and finally lateral), and it is the portion of the physis that is open at the time of injury that is vulnerable to fracture in this age group. Triplane and Tillaux fractures occur after supination external rotation and compression stress with unpredictable multiplanar fracture patterns. The fracture may appear different on different x-ray projections, making computed tomography mandatory to determine the number of fragments. Because most of these fractures are intra-articular, anatomic or near-anatomic reduction of the joint surface is recommended to minimize future posttraumatic ankle arthritis. Because these fractures occur at the end of growth, they rarely result in growth arrest.

Cincinnati Children’s Hospital Medical Center, Division of Orthopaedic Surgery, Cincinnati, OH

The author declares no conflict of interest.

Reprints: Alvin H. Crawford, MD, Cincinnati Children’s Hospital Medical Center, Division of Orthopaedic Surgery, 3333 Burnet Avenue MLC 2017, Cincinnati, OH 45229. E-mail: alvin.crawford@cchmc.org.

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BACKGROUND

The juvenile Tillaux fracture is the second most common growth plate fracture1 and is usually a Salter-Harris III fracture, or rarely a Salter-Harris IV fracture, of the distal tibia. It occurs in the second decade as the child is nearing skeletal maturity. The mechanism of injury is supination external rotation with avulsion of the anterolateral distal tibial epiphysis. The distal fragment is displaced anterolaterally by the anterior inferior tibial-fibula ligament. Swelling is slight with local tenderness at the anterior joint line, in contrast to a sprain where the tenderness is below the joint line. Anatomic reduction of the epiphysis is mandatory (<2 mm displacement) and conventional wisdom would demand assessment by intraoperative arthrography or computed tomography (CT). Plain x-rays, including a mortise view to avoid obstruction by the fibula, show the fracture but often underestimate the true displacement.2 A CT scan was more sensitive than plain radiographs in detecting fractures with >2 mm displacement, but it can overestimate the true displacement. My treatment preference is a closed reduction under image intensifier with percutaneous pin-assisted reduction and cannulated screw fixation (Figs. 1A–D).

FIGURE 1

FIGURE 1

The triplane fracture occurs in the coronal, sagittal, and axial planes. The anterioposterior x-ray shows a Salter-Harris III fracture of the distal tibia, and the lateral view shows a Salter-Harris II fracture of the distal tibia (Figs. 2A, B). The average age at injury is 13 years in girls and 15 years in boys. The mechanism of injury is supination and external rotation. Plain x-rays are supplemented with CT scans to adequately identify the number of fracture fragments and the best strategy for fixation, especially when performed percutaneously. The number of fragments depends on which part of the physis is closed at the time of injury. Most centers recommend either open reduction with screw fixation or closed reduction with percutaneous cannulated screw fixation (my treatment of choice). A CT is used to determine the adequacy of reduction if one performs closed reduction before surgery. A residual step-off or a gap of >2 mm at the articular surface may increase the patient’s potential for developing osteoarthritis in the future.

FIGURE 2

FIGURE 2

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CLASSIFICATION

Six fracture patterns have been described with triplane fractures, but the 2-part and 3-part fractures are the most common.3–8 In its classic form, the fracture splits the joint surface and epiphysis in the sagittal plane, then traverses the growth plate in the axial plane, and ultimately exits the metaphysis in the coronal plane, hence the name “triplane.” Several authors have reported an “extrarticular” triplane variant, in which the epiphyseal portion of the fracture veers off into the medial malleolus, and never enters the ankle joint. This variant has profound surgical implications.

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INDICATIONS FOR NONOPERATIVE TREATMENT

Sixty-five percent of triplane fractures present with >2 mm displacement.8 A gap of >2 mm on plain x-ray can lead to posttraumatic osteoarthritis and an attempt at reduction is indicated. A closed reduction can be performed in the emergency room with internal rotation of the foot, followed by anterior translation and ankle dorsiflexion. An assistant should stabilize the knee at 90 degrees during this forceful manipulation. After casting or splinting, the adequacy of reduction can be confirmed with a CT scan. A residual gap or step-off of <2 mm is acceptable. Because of the possibility of displacement in a cast when the swelling resolves, follow-up within 1 week is indicated. Some practitioners may feel comfortable with closed reduction and casting; and if so, this author would recommend a nonweight bearing above knee cast for the first 3 weeks.

Because Tillaux fractures are avulsion fractures of the anterior inferior tibial-fibula ligament, they may be less amenable to closed reduction than triplane fractures.9 Sustained plantar flexion, internal rotation followed by maximum ankle dorsiflexion have been successful at reducing Tillaux fractures, which were then held in position with a cast.10

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INDICATIONS FOR OPERATIVE TREATMENT

After closed reduction is performed and there is less anatomic reduction, a CT is requested. If there is a residual step-off of >2 to 3 mm in any plane, operative treatment is indicated. Although not optimal, these fractures can undergo successful open reduction even after 5 weeks of delayed presentation. Extrarticular triplane fractures do not require anatomic reduction because they do not violate the ankle joint. They may be treated like Salter II fractures of the distal tibia.

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OPERATIVE TECHNIQUES

Displacement of >2 mm in any plane is an indication for surgery for both Tillaux and triplane fractures.11 The current author’s approach to operative treatment is to perform a closed manipulation aided by percutaneous screw compression to stabilize the anatomically reduced triplane and Tillaux fractures.

General anesthesia is needed for complete relaxation. The patient should be prepared and draped for open reduction with a tourniquet in place. If the fracture is a Tillaux, it should be reduced with a joystick technique using a threaded guidepin from a 4.0- or 4.5-mm cannulated screw set. Fluoroscopic images must be taken at varied angles of ankle rotation so that the beam is exactly parallel to each fracture line to confirm an anatomic reduction. A cannulated partially threaded screw is placed over the guidewire to give compression fixation. Careful effort is made to maintain screw placement within the epiphysis. However, the medial and middle sections of the growth plate are closed and would not be unduly injured if the screw were to cross it.

For triplane fracture reduction, sustained traction is initiated in the foot in maximal plantar flexion and internal rotation. Reduction is achieved with maximal internal rotation of the foot, anterior translation, and then ankle dorsiflexion. If an anatomic reduction is achieved, a guidewire is passed from the anterolateral Tillaux epiphyseal portion of the triplane fracture to posteromedial as shown in Figures 3A–F.12 If there is a step-off in either plane, a Freer-Joker or threaded Steinmann pin may be used percutaneously to joystick the fragment into position. A cannulated threaded screw is driven across the fracture and an anatomic reduction with <2 mm displacement or step-off is confirmed on anterioposterior and lateral views and multiple degrees of rotation to confirm anatomic fixation of the joint surface. Anatomic reduction may also be confirmed arthroscopically or by performing an arthrogram (Fig. 4). If the closed reduction cannot be achieved easily, then open reduction is carried out. The current author has not performed an open surgical procedure on either a Tillaux or a triplane fracture presenting within 72 hours in 19 years.

FIGURE 3

FIGURE 3

FIGURE 4

FIGURE 4

A fibular fracture that is displaced, translated, or shortened >2 mm should be reduced first and stabilized with a small plate or with intramedullary fixation. With the triplane fracture, the powerful tibiofibular ligaments make the fibular fragment behave as a linked unit with the anterolateral fragment.13 Tibiofibular syndesmotic fixation is rarely required. A nonweight bearing below knee cast is applied.

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CONTROVERSIAL ISSUES

Outcomes of transitional fractures are generally excellent, but nonanatomic reduction can lead to radiographic and clinical signs of arthritis during the teen and young adult years. The radiologic evaluation of this injury is controversial. The majority of the cases undergo surgical intervention. Although plain x-rays usually identify the type of transitional fracture, CT is mandated by most centers preoperatively to determine the number and position of fragments/parts. This may be especially important in cases of closed reduction and percutaneous fixation, in which the fragments are not directly visualized. Some centers perform postoperative CT scans to assess reduction. CT will accurately measure residual displacement of the fragments, and magnetic resonance imaging (MRI) was found to provide anatomic detail and information superior to plain film radiographs.14 The issue of whether or not CT/MRI alters treatment or prognosis when compared with plain x-ray has not been fully investigated. In a cadaveric study, distal tibial epiphyseal screws placed in the subarticular bone caused an increase in joint contact pressure, which was relieved with screw removal.14 It is unknown whether bone remodeling around the screw in a living patient would also return these forces to normal. Parents should be informed if there are social or cultural issues regarding retained implants, then the screw should be removed within 1 year. Cannulated screw removal from the distal tibial epiphysis after more than 1 year postoperatively is often complicated by screw breakage and screw head stripping.

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COMPLICATIONS

Most studies report minimal symptoms in patients 5 years after triplane fractures, but these patients are only in their teens.15 Even though growth problems are relatively rare after these distal tibial physeal injuries, the parents should be made aware of this possibility. Patients with >2 mm of residual displacement or step-off may present with arthritic x-ray changes between 6 and 9 years after injury but are often asymptomatic. Chondral compressive trauma is possibly the most frequent source of arthritic symptoms and is unrecognized at the time of injury. A residual gap of >2 mm at the articular weight bearing surface after reduction has not been consistent with good long-term results.15 Anatomic reduction is necessary in the sagittal plane as well as the coronal plane; that is, sagittal plane step-off is to be avoided. Follow-up of all growth plate injuries in children under 12 years of age should be mandatory.

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SUMMARY OF THE 3 MOST IMPORTANT POINTS

  • Most patients with triplane and Tillaux fractures have excellent short and medium-term outcomes if they heal in an anatomic position. CT/MRI scans are superior to plain x-ray in determining triplane and Tillaux fracture parts and position of fracture displacement after closed reduction.
  • I strongly recommend percutaneous indirect reduction using a Steinmann (guide) pin and threaded screw under general anesthesia with closure of the fracture gap to <2 mm on all x-ray views.
  • A gap of <2 mm is acceptable.
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ACKNOWLEDGMENT

The authors thank Emily Eismann for her assistance with the development of this article.

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REFERENCES

1. Galano GJ, Vitale MA, Kessler MW, et al. The most frequent traumatic orthopaedic injuries from a national pediatric inpatient population. J Pediatr Orthop. 2005;25:39–44
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7. Pesl T, Havranek P. Rare injuries to the distal tibiofibular joint in children. Eur J Pediatr Surg. 2006;16:255–259
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9. Stefanich RJ, Lozman J. The juvenile fracture of Tillaux. Clin Orthop Relat Res. 1986;210:219–227
10. Manderson EL, Ollivierre CO. Closed anatomic reduction of a juvenile tillaux fracture by dorsiflexion of the ankle. A case report. Clin Orthop Relat Res. 1992;276:262–266
11. Ertl JP, Barrack RL, Alexander AH, et al. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg Am. 1988;70:967–976
12. Schlesinger I, Wedge JH. Percutaneous reduction and fixation of displaced juvenile Tillaux fractures: a new surgical technique. J Pediatr Orthop. 1993;13:389–391
13. Thordarson DB, Motamed S, Hedman T, et al. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg Am. 1997;79:1809–1815
14. Charlton M, Costello R, Mooney JF III, et al. Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia. J Pediatr Orthop. 2005;25:635–640
15. Rapariz JM, Ocete G, González-Herranz P, et al. Distal tibial triplane fractures: long-term follow-up. J Pediatr Orthop. 1996;16:113–118
Keywords:

Tillaux; triplane; growth plate; articular fracture; displacement; children

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