We present a 46 year old male who fell off a ladder and sustained a bi-malleolar fracture along with Tillaux fracture left ankle.
A 49 year old male presented to the accident and emergency department after a fall from 10 feet height. He sustained abduction and external rotation injury of his left ankle. He had an open fracture of his ankle. The open wounds were washed with saline and betadine and started on intravenous antibiotics.
The plain radiographs of his ankle revealed a bimalleolar fracture of the ankle with a Tillaux fracture. He had been referred to the rthopaedic department. He underwent open reduction and internal fixation of the ankle fracture. The Tillaux fracture was fixed with one partially threaded cannulated screw. Follow-up at 6 months, he was pain free and mobilising full weight bearing. He has good range of movements in his ankle. The repeat radiographs revealed the fracture healed well and the metal work was in satisfactory position.
The distal tibia and fibula is stabilised with four ligaments. The anterior and posterior tibofibular ligaments, transverse tibiofibular ligament and interosseous membrane. Tillaux fracture is an eponym describing antero-lateral tibial epiphysis avulsed due to the strong tibio-fibular ligament. This happens usually in external rotation injuries. This is common in adolescents and rare in adults.
Paul Jules Tillaux described this avulsion fracture in 1892, following his experiments on cadavers. Chaput later described similar injury to the posterolateral tibia (Avulsion of posterior tibio-fibular ligament), later called Tillaux-Chaput injury.
The distal tibial epiphysis appears from age 6-10 months and, the entire lower end of the tibia is completely ossified by the age 14-15 years. It unites with the diaphysis at about age 18 years. Kleiger and Mankin showed that fusion in the distal tibial epiphysis occurs first in the middle third of the epiphysis, next in the medial side, and finally in the lateral portion.
Tillaux fracture occurs after the medial part of the physis has fused but before the lateral part closes. In children the ligaments are stronger than the growth plate; the anterolateral tibial epiphysis fragment is avulsed due to the strong anterior tibiofibular ligament in an external rotation injury of the foot in relation to the leg.
In adults, because the physis is completely closed and the bone is stronger than the ligaments it gives way instead of avulsing the tibial fragment from its attachment, resulting in a ligament injury known as a Tillaux lesion. However in rare cases the distal tibial tubercle is avulsed off the anterolateral aspect of the distal tibia resulting in Tillaux fracture.
The children present with painful ankle after a low energy trauma. They are unable to weight bear and tender especially in the anterior part of the ankle. In adults it is usually a high energy trauma and associates with other fractures.
Anteroposterior (AP), lateral, and oblique views plain radiographs of the ankle are helpful in diagnosing this fracture. If the avulsed fragment is undisplaced the oblique views are of particular help. The Computer tomography is more accurate in estimating the displacement of the fracture fragment.
Acute management includes elevation, ice packing and rest. Most of these fractures are undisplaced and are amenable for non-operative management. This includes below knee non-weight bearing cast immobilisation for six weeks. Surgical intervention is required if the fracture fragment is displaced more than 2mm, that involves open reduction and internal fixation, followed by immobilisation in the cast for six weeks.
The complications of these fractures include non-union, malunion, degenerative arthritis, varus deformity and avascular necrosis of the fracture fragment. The long-term studies reported good outcome with low incidence of arthrosis, either following cast treatment for undisplaced fractures or following operative intervention.
Tillaux fracture ankle in an adult
Based on the provided imaging (including preoperative and postoperative X-rays) and the patient's clinical history, the following observations are made:
1. Fracture lines are visible in both the medial and lateral malleoli of the left ankle, suggesting a bi-malleolar fracture.
2. A small avulsion fracture fragment is seen in the anterolateral aspect of the distal tibia, related to the attachment site of the anterior inferior tibiofibular ligament, consistent with a Tillaux fracture.
3. Postoperative images show internal fixation of both the distal tibia and distal fibula with plates and screws, demonstrating satisfactory alignment and reduction of the fracture.
4. Soft tissue swelling is present, indicating acute soft tissue injury following trauma.
These three findings are the primary radiological and clinical considerations.
Considering the patient's age (46 years), mechanism of injury (fall from height), radiographic findings, and surgical intervention, the most likely diagnosis is:
Treatment Strategy:
1. Surgical Treatment: As in this case, open reduction and internal fixation (ORIF) were performed using plates and screws to stabilize both malleoli and the Tillaux avulsion fragment.
2. Postoperative Immobilization and Management: Following internal fixation, a cast or brace is typically required for about 6 weeks to promote fracture healing and prevent reinjury.
3. Follow-up Evaluation and Rehabilitation: Periodic X-ray check-ups to monitor fracture healing progress, with rehabilitation plans adjusted accordingly.
Rehabilitation/Exercise Prescription (FITT-VP Principle):
1. Early Phase (0-2 weeks post-op):
2. Mid Phase (2-6 weeks post-op):
3. Late Phase (after 6 weeks post-op):
Note: If the patient has fragile bone quality or other comorbidities, strength training should be approached cautiously and monitored closely to ensure safety.
This report is based solely on the provided imaging and brief medical history for reference and does not replace an in-person diagnosis or professional medical advice. Patients should undergo regular follow-ups and receive further diagnosis, treatment, and rehabilitation guidance from professional orthopedic surgeons and rehabilitation therapists.
Tillaux fracture ankle in an adult
