Short Stature

Paediatric ankle - triplane and Tillaux fracture

Radiographic assessment of juvenile ankle fractures including Tillaux and triplane patterns.

10 questions 2 source pages

Images appear with the first question taken from each source page — tap a question to open it.

Q1Describe the triplane fracture on AP and lateral X-ray.▸

Distal tibia fracture involving the epiphysis
AP view = SH III, lateral view = SH II
Distal fragment displaced medial and posterior
Triplane: fracture courses through the coronal, transverse and sagittal planes
Intra-articular fracture; MOI: ER (external rotation)

Q2What is the acute management of a triplane fracture?▸

Systemically rule out other injuries
Locally look for wound, compartment syndrome, and document distal NV status
RICE, slab, analgesics
Displacement is >2mm

Q3What is the definitive management of a displaced triplane fracture?▸

Aim: anatomical reduction and stable fixation; CT -> CR +/- OR
Fix with screws - interfragmental compression with screws parallel to the physis
CR technique: 2-part - lateral (IR), medial (abduction)
AL approach: reduce with dorsiflexion + IR +/- pronation or Weber reduction forceps; 4.0 cannulated screw (transmetaphyseal and transepiphyseal)
OT for 3-4 part (sequence: posterior fragment -> fibula -> AL fragment)
Advise removal of transepiphyseal screws (JPO 2005 Charlton: increased peak intra-articular contact pressures)

Q4What are the growth and physeal facts of the distal tibia?▸

Distal tibia physis closes at 16 years; distal fibula closes 1 year after
Contributes 40% of tibia growth and 20% of lower limb growth
All ligaments attach distal to the physis
Distal tibial physis fuses age 11-13 in boys; transitional fracture ~18 months
Medial os subtibiale 20%, lateral os subfibulare 1%
First site of closure = Kump's bump (central -> anteromedial -> posteromedial -> anterolateral)

Q5Describe the parts and types of triplane fractures.▸

Coronal: crosses the epiphysis; axial: splits the physis; sagittal: exits in the metaphysis
Can be 2, 3 or 4 parts
2 parts (named after the coronal fragment): lateral triplane = supination-external rotation (most common); medial triplane = adduction
3 parts: separate Tillaux fragment (SH 3 on AP)
4 part: Tillaux + AM fragment

Q6Describe the Tillaux fracture on the mortise view.▸

Q7What is the mechanism and typical age of a Tillaux fracture?▸

Q8How is a Tillaux fracture investigated?▸

Q9How is a Tillaux fracture managed according to displacement?▸

<2mm: conservative with a long leg cast for rotational control
Cast position: foot IR + direct anterior pressure + knee 30 degrees flexion; 4/52 long leg cast then 2/52 short leg cast
Post-cast CT to confirm no displacement
>2mm: CR +/- OR via AL approach and stable fixation with a percutaneous screw
Screw can be transphyseal as the patient approaches skeletal maturity

Q10How is a Tillaux fracture distinguished from a triplane injury?▸

Tillaux fracture = SH 3
A transitional fracture
Lack of a fracture component in the coronal plane distinguishes it from a triplane injury

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