Functional Outcomes of Tillaux and Triplane Fractures with 2 to 5 Millimeters of Intra-Articular Gap

Role of the CT Scan in Preoperative Planning for Tillaux-Chaput Fractures in Adults

BACKGROUND

Tillaux-Chaput fractures (TCFs) occur in the anterolateral rim of the distal tibia. TCFs are often overlooked on radiographic review, increasing the risk of chronic pain, instability, and ankle osteoarthritis. This study evaluated the effect of the computed tomography (CT) scan on preoperative planning for TCFs in adults.

METHODS

A retrospective review of ankle fractures evaluated from 2013 to 2023 at a university hospital was conducted. The inclusion criteria were patients ≥18 years of age who underwent radiographic and CT evaluation and had a TCF that was confirmed by CT. The exclusion criteria included pilon and distal tibial fractures and prior ankle surgery. Three orthopaedic surgeons assessed radiographs, classified TCFs using the Rammelt classification, formulated a treatment plan (conservative versus surgical), and, if a surgical treatment was indicated, determined the patient positioning, fixation type, and approach for the TCF. After evaluating CT images, changes in treatment strategy were recorded. Forward stepwise regression was utilized to analyze variables associated with modifications in preoperative planning.

RESULTS

A total of 481 fractures had ankle radiographs and CT scans; of these, 83 (17.3%) had a TCF. After the CT evaluation, the Rammelt classification and the surgical decision changed by 69.1% and 12.5%, respectively. Changes in patient positioning, the type of fixation, and the surgical approach for a TCF (when surgery was indicated) occurred in 32.1%, 43.8%, and 35.3% of all cases, respectively. Multivariable analysis showed that the detection of a TCF on CT predicted changes in the surgical decision and fixation type, while changes in the TCF classification predicted modifications in the fixation type and surgical approach. Posterior malleolar fractures were the unique predictor of changes in the patient positioning.

CONCLUSIONS

CT evaluation modified the surgical decision, type of fixation, and surgical approach for a TCF in 12.5%, 43.8%, and 35.3% of cases, respectively. Moreover, the detection of a TCF and a change in the classification after CT evaluation were predictors of a change in treatment strategy. These findings underscore the importance of the CT scan in the preoperative planning for TCFs in adults. Therefore, we strongly recommend conducting a CT scan when a TCF is suspected in adult patients.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Concomitant Factors Associated With Tillaux-Chaput Fractures in Adults: A Case-Control Study

BACKGROUND

Tillaux-Chaput fractures (TCFs) consist of fractures of the anterolateral distal tibia. They rarely occur in isolation in adults. When TCFs are missed, there is a risk of chronic pain, instability, and ankle osteoarthritis. This study aimed to identify which factors are related to the presence of TCFs in ankle injuries.

METHODS

A retrospective review of 1134 ankle fractures evaluated between 2013 and 2023 at a level 1 trauma center was performed. Inclusion criteria were patients aged ≥18 years, ankle radiographs and computed tomographic (CT) scan evaluation, and the presence of a TCF confirmed by CT scan. Exclusion criteria were prior ankle surgery, pilon, or distal tibial fractures. A musculoskeletal radiologist and a foot and ankle-trained orthopaedic surgeon classified the TCFs into type 1, an extraarticular avulsion; type 2, a fracture involving the incisura fibularis; and type 3, a fracture with impaction of the anterolateral tibial plafond. A matching control group of ankle fractures without TCF was created with a 1:2 ratio. The following variables were collected: sex, age (<50 vs >50 years), ankle dislocation or subluxation, Weber classification, Maisonneuve fracture, type of medial and posterior malleolar fracture, Lauge-Hansen classification, malleoli involved, and osteochondral lesion of the talus. Multivariate logistic regression was performed to detect which variables had an association with the TCF and their subtypes. P value <.05 was considered significant.

RESULTS

A total of 481 ankle fractures had radiographs and CT scans available for evaluation, of which 83 (17.3%) had a TCF. Of these, 44.6% were type 1, 44.6% type 2, and 9.6% type 3. The mean age was 52.2 years; 66.3% were women. Six patients (7.2%) had an isolated TCF. Fifty-eight (69.9%), 50 (60.2%), and 62 (74.7%) ankles had involvement of the lateral, medial, and posterior malleolus, respectively. Age ≥50 years (OR 2.73, 95% CI 1.45-5.14) and pronation external rotation injuries (OR 2.94, 95% CI 1.43-6.06) had a significant association with TCF. Moreover, ankle dislocation or subluxation (OR 3.16, 95% CI 1.11-8.96) and the absence of posterior malleolar fracture (OR 5.97, 95% CI 1.65-21.6) were significantly associated with TCF type 2 and 3.

CONCLUSION

In this study, age ≥50 years and pronation external rotation injuries were the unique independent risk factors for TCF. Furthermore, ankle dislocation or subluxation and the absence of posterior malleolar fractures increased the odds of having a more severe TCF. This study provides insights into the factors associated with TCF and its subtypes during adulthood.

Operative Treatment of Distal Tibial Fractures in Children Managed With Epiphyseal Screws: A Comparison of Outcomes When Screws Are Retained Versus Removed Following Fracture Union

BACKGROUND

Fractures of the distal tibial epiphysis in children are often accompanied by articular surface disruption. With increased displacement, internal fixation is frequently performed with an epiphyseal screw to close the fracture gap. Despite limited, high-level clinical evidence to support implant removal, epiphyseal screws are commonly removed after fracture healing due to potentially increased contact forces on the tibiotalar joint. The purpose of this study was to investigate and compare outcomes and complications in children that underwent surgical treatment of distal tibial epiphyseal fractures with placement of an epiphyseal screw(s) and had the implant(s) retained versus removed at a minimum of 2-year postoperative follow-up.

METHODS

Children younger than 18 years from two urban tertiary care centers who underwent operative management of distal tibia Salter-Harris III and IV fractures using epiphyseal screws (2013-2020) were divided into two cohorts: retained epiphyseal screws and implant removed. Demographics, intraoperative, postoperative, and radiographic data were collected. Patient-reported outcomes (PROs) using the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numeric Evaluation (SANE) questionnaires were collected at the final follow-up. Statistical analysis, including power analysis, was performed.

RESULTS

Fifty-two children were included (30 males, 22 females) with a mean age of 13.3 years at the time of injury (range, 7.7-16.4 years). Thirty-five children retained the implants; seventeen had implants removed. All completed the FAAM questionnaires at a mean follow-up of 4.4 ± 1.9 years, while 29 completed the SANE questionnaire at a mean follow-up of 4.4 ± 1.7 years. No statistically significant difference in patient demographics, surgical variables, or PROs was observed. Six children experienced complications from the initial surgery, including infections and complex regional pain syndrome, with no difference in complication rates between the cohorts ( P =0.08). Furthermore, no complication was observed as a result of implant removal.

CONCLUSIONS

Children with retained epiphyseal implants have similar functional outcomes as compared with those who had implants removed after distal tibial epiphyseal fracture fixation and union.

LEVEL OF EVIDENCE

Level III-Retrospective comparative study.

Metaphyseal Fracture Displacement is Predictive of Intra-articular Diastasis in Adolescent Triplane Ankle Fractures

BACKGROUND

Triplane fractures are rare enough that large homogeneous series to support management decisions are lacking. During initial evaluation, the addition of computed tomography (CT) to conventional X-rays (XR) does not always alter the patient's clinical course. Therefore, routine use of CT is controversial. This study aims to: (1) clarify quantitative relationships between articular displacement measured on XR versus CT and (2) identify whether metaphyseal displacement on the lateral XR predicts clinically relevant articular displacement on a CT scan.

METHODS

A 10-year retrospective review of consecutive triplane fractures was performed at a level 1 pediatric trauma center. Maximum articular and metaphyseal displacement were recorded from XR and CT. Quantitative relationships between XR and CT measurements were compared among imaging modalities and radiographically operative versus nonoperative fractures.

RESULTS

Eighty-seven patients met the inclusion criteria. XR underestimated articular displacement by 229% in the sagittal plane (1 mm on XR vs 3.3 mm on CT; P < 0.05) and 17% in the coronal plane (2.3 mm on XR vs 2.7 mm on CT; P < 0.05). XR underestimated articular step-off by 184% in the coronal plane and 177% in the sagittal plane ( P < 0.05). CT measurements more often differentiated patients who did or did not undergo surgery at our institution. Metaphyseal displacement was significantly higher in patients with traditionally operative articular displacement (≥2.5 mm on CT) versus those with articular displacement below traditionally operative thresholds (2.4 vs 0.9 mm, P = 0.001). Sixty patients had metaphyseal displacement >1 mm on the lateral XR, of whom 56 had surgical-magnitude articular displacement (≥2.5 mm) on CT (positive predictive value = 94%).

CONCLUSIONS

Conventional radiographs underestimate the true articular displacement of triplane fractures. Surgical-magnitude articular step-off is rare, and the largest articular gap is usually visualized on the axial CT image. Metaphyseal displacement >1 mm, which is easily measured on a lateral XR, is strongly predictive of clinically relevant articular displacement on CT. This radiographic finding should prompt advanced imaging before proceeding with nonoperative management.

LEVEL OF EVIDENCE

Level III.

Computed Tomography Analysis of Distal Tibia Physeal Fracture Patterns: A Classification and Technique for Optimizing Screw Trajectory

BACKGROUND

Fractures involving the anterolateral distal tibia, often referred to as Tillaux or Triplane fractures, are often treated operatively to achieve an anatomic reduction of the ankle joint articular surface. Although axial images from computed tomography scans are commonly obtained to measure displacement, no studies have examined these fracture patterns in the axial plane. This information may be useful to guide screw trajectory with only fluoroscopic imaging intraoperatively.

METHODS

We queried an institutional radiology report database for all "Tillaux" or "triplane" fractures and manually reviewed to identify fractures with an anterolateral tibia fragment. The axial image immediately caudal to the physis or physeal scar was used for measurements. The angle between the incisura and the fracture line exiting the incisura was measured. The width of the fracture fragment and the anterior distal tibia was then measured perpendicular to the incisura, representing the width that would be seen on an intraoperative mortise. A cluster analysis was performed to identify fracture patterns.

RESULTS

The average age of patients included in the study was 16 ± 2 years. Sixty-nine patients met inclusion criteria 32 patients with Tillaux fractures (46.4%) and 37 patients with triplane fractures (53.6%) met study inclusion criteria for a total of 69 patients. The cluster analysis demonstrated 3 fracture patterns. For type 1 (n=16), the mean was 24.5 ± 6.5 degrees from the incisura and the mean distance from the tibiofibular joint was 21.1 ± 6.3%. For type 2 (n=20), the mean was 58.6 ± 7.2 degrees and the mean distance was 48.7 ± 8.9%. For type 3 (n=33), the mean was 88.6 ± 6.3 degrees and the mean distance was 49.1 ± 9.7%.

CONCLUSIONS

This is the first study to identify that pediatric distal tibia physeal fractures occur in 3 common patterns with consistent fragment sizes and fracture planes. This information can optimize screw start point and trajectory in the axial plane when referencing a mortise x-ray and C-arm beam.

LEVEL OF EVIDENCE

Diagnostic, Level III.

Conservative Management of Transitional Ankle Fractures in Adolescents: A Pilot Study to Determine Whether Type of Immobilization Affects Outcome

Intra-articular Tillaux and triplane ankle fractures are treated surgically when displaced. Minimally displaced fractures are treated with immobilization alone. Long leg casts (LLCs) are the most traditional method of immobilization because they can prevent weight bearing by flexing the knee and control ankle rotation. However, they also are heavy, decrease mobility, increase the area for contact dermatitis, and increase knee stiffness. Short leg casts (SLCs) may be adequate for these injuries. This study compared outcomes of adolescents with transitional ankle fractures treated in LLCs vs SLCs. All transitional ankle fractures treated with immobilization during 11 years at a multicenter children's health system were reviewed. Patients were grouped based on initial treatment with LLC vs SLC. Cases were analyzed for differences in demographics, length of treatment, weight-bearing status, outcomes, and complications. A total of 159 patients met inclusion criteria. Sixty-five were treated initially with LLCs and 94 were treated initially with SLCs, with no significant age difference between the groups. Computed tomography scans had been obtained for 55.4% of the patients with LLCs vs 29.8% of the patients with SLCs. Mean time in the initial cast was 24 days for both groups. Mean total time in any cast was 40 days for the LLC group vs 29 days for the SLC group. Mean time to weight bearing was 7 days shorter and return to full activity was 12 days shorter in the SLC group. There were no cases of fracture displacement, malunion, nonunion, or functional limitations. [Orthopedics. 2023;46(4):230-233.].

The Incidence and Treatment Outcome of Atypical Triplane Fractures in Adolescents

Background

Atypical triplane fractures (ATFs) defined as a triplane fracture that did not involve the weight-bearing articulating surface or as an extra-articular triplane fracture. ATFs are scarcely reported and the incidence may be underestimated. Moreover, there is no consensus on treatment. This study aimed to evaluate ATFs incidence, fracture pattern, and treatment outcome, and propose treatment recommendations.

Methods

Twenty-five ATFs of 46 triplane fractures were retrospectively reviewed between 2011 and 2017. ATFs were classified according to the modified ATF classification. Treatment methods were analyzed. Radiologic outcomes were measured based on fracture displacement. Clinical outcomes included the American Orthopedic Foot and Ankle Society score, visual analogue scale, ankle range of motion, and complications at final follow-up period.

Results

A total of 11 type IV, 11 type III, and three type II ATFs were identified. All type II ATFs (intra-articular fracture) were treated with operative treatment. Nine patients were treated with operative treatment and 18 patients were treated with non-operative treatment in type III or IV ATFs (extra-articular fracture). Good radiologic and clinical outcomes were observed in all patients. The residual displacement after initial trial of closed reduction was between 4 and 5 mm in ten cases of type III or IV ATFs; however, no complications were observed, and all cases had good clinical results after non-operative treatment.

Conclusions

ATFs may be under-recognized. Operative treatment and non-operative treatment showed good outcome. Non-operative closed reduction and cast immobilization can be recommended for extra-articular ATF with displacement < 4 mm.

Level of Evidence

Level IV, case series.

Transitional ankle fracture management using a new joystick technique

PURPOSE

To investigate the feasibility and short-term clinical efficacy of the arthrography-assisted joystick technique for the treatment of adolescent transitional ankle fracture.

METHODS

A retrospective analysis was performed in 10 adolescent transitional ankle fracture patients treated with the arthrography-assisted joystick technology. There were 7 male patients and 3 female patients with a mean age of 12.80 ± 1.81 years (range: 10-16 years). All cases were closed fractures, and the operation was performed after the failure of manual reduction [X-ray or computed tomography (CT) showed that the fracture gap was > 2 mm]. After the operation, X-ray or CT examination was performed to assess reduction of the fracture. Ankle function and fracture healing were evaluated by assessing the imaging indexes and evaluating the American Orthopedic Foot and Ankle Society (AOFAS) ankle score system.

RESULTS

All patients were followed up for an average period of 12.00 ± 3.40 months (range: 8-20 months). The operation time was 40.50 ± 16.90 min (range: 25-80 min), the number of intraoperative fluoroscopy sessions was 18.70 ± 5.91 (range: 10-30 sessions), and the intraoperative blood loss was 5.90 ± 3.38 ml (range: 2-10 ml). X-ray examination showed that all cases achieved bone healing. The fracture healing time was 11.00 ± 2.45 weeks (range: 8-16 weeks). Four cases showed early closure of the epiphysis. The AOFAS scoring system evaluation results of these 10 pediatric cases were excellent.

CONCLUSION

The arthrography-assisted joystick technique for the treatment of adolescent transitional ankle fracture offers advantages, such as minimal trauma, simple operation, ideal reduction effect, and the recent curative effect is satisfactory.

All-epiphyseal versus trans-epiphyseal screw fixation for tillaux fractures: Does it matter?

BACKGROUND

Tillaux fractures occur primarily in adolescents due to the pattern of physeal closure and are classified as Salter-Harris type III physeal fractures. Operative management with screw fixation is recommended for more than 2 mm of displacement or more than 1 mm of translation. However, the efficacy and complications of trans-physeal vs all-physeal screw fixation have not been investigated extensively.

AIM

To compare the clinical and functional outcomes of trans-physeal (oblique) and all-epiphyseal (parallel) screw fixation in management of Tillaux fractures among pediatric patients.

METHODS

This was an ethics board approved retrospective review of pediatric patients who presented to our tertiary children’s care facility with Tillaux fractures. We included patients who had surgical fixation of a Tillaux fracture over a 10 year period. Data analysis included demographics, mode of injury, management protocols, and functional outcomes. The patients were divided into group 1 (oblique fixation) and group 2 (parallel fixation). Baseline patient characteristics and functional outcomes were compared between groups. Statistical tests to evaluate differences included Fisher’s Exact or Chi-squared and independent samples t or Mann Whitney tests for categorical and continuous variables, respectively.

RESULTS

A total of 42 patients (28 females and 14 males) were included. There were no significant differences in body mass index, sex, age, or time to surgery between the groups [IK2]. Sports injuries accounted for 61.9% of the cases, particularly non-contact (57.1%) and skating (28.6%) injuries. Computed Tomography (CT) scan was ordered for 28 patients (66.7%), leading to diagnosis confirmation in 17 patients and change in management plan in 11 patients. [GRC3] Groups 1 and 2 consisted of 17 and 25 patients, respectively. For mid to long-term functional outcomes, there were 14 and 10 patients in groups 1 and 2, respectively. Statistical analysis revealed no significant differences in the functional outcomes, pain scores, or satisfaction between groups. No infections, non-unions, physeal arrest, or post-operative ankle deformities were reported. Two (4.8%) patients had difficulty returning to sports post-surgery due to pain. One was a dancer, and the other patient had pain while running, which led to hardware removal. Both patients had parallel fixation. Hardware removal for groups 1 and 2 were 4 (23.5%) and 5 (20.0%) patients, respectively. The reasons for removal was pain in 2 patients, and parental preference in the remaining.

CONCLUSION

This is the largest reported series of pediatric patients with Tillaux fractures comparing functional outcomes of different methods of screw fixation orientation to the physis, which showed no difference regarding functional outcomes.

Visualization of complicated fractures by 3D-printed models for teaching and surgery: hands-on transitional fractures of the ankle

Aims

Understanding the orientation of fracture lines and mechanisms is the essential key to sufficient surgical therapy, but there is still a lack of visualization and teaching methods in traumatology and fracture theory. 3D-printed models offer easy approach to those fractures. This paper explains the use of the teaching possibility with 3-dimensional models of transitional fractures of the ankle.

Methods and results

For generating 3D printable models, already obtained CT data were used and segmented into its different tissues, especially parts concerning the fracture. After the segmentation process, the models were produced with FFF (fused filament fabrication) printing technology. The fracture models then were used for hands-on teaching courses in AO course (Arbeitsgemeinschaft für Osteosynthesefragen) of pediatric traumatology in 2020 in Frankfurt. In the course fracture anatomy with typical fracture lines, approaches, and screw placement could be shown, discussed and practiced.

Conclusion

The study shows the use of 3D-printed teaching models and helps to understand complicated fractures, in this case, transitional fractures of the ankle. The teaching method can be adapted to numerous other use cases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01879-1.

Are you sure that ankle is just sprained? A review of common ankle conditions, diagnoses and treatment

PURPOSE OF REVIEW

Acute ankle sprains frequently occur in active children and adolescents but may be the initial clinical presentation of other less common disorders affecting the lower extremities. There are many conditions that may cause one or multiple episodes of ankle injury that are misdiagnosed as an acute ankle sprain. This manuscript highlights diagnoses that should be considered when evaluating and managing a child or adolescent who presents initially and/or repeatedly with an acute ankle sprain.

RECENT FINDINGS

In recent years, various studies have continued to note the prevalence of misdiagnosed ankle sprains, especially amongst the paediatric population. If ankle radiographs demonstrate no abnormalities during an initial clinical examination, often the patient is diagnosed with an acute ankle sprain. However, this can be a misdiagnosis, especially when the patient has had recurrent episodes of ankle injury and ancillary studies are not performed.

SUMMARY

There are many diagnoses that can go unnoticed in the initial evaluation of a paediatric or adolescent ankle sprain. It is important for physicians to be aware of these other conditions to ensure proper treatment plans. This manuscript will analyse five conditions that may be misdiagnosed as an ankle sprain, including juvenile idiopathic arthritis, osteochondritis dissecans of the talus, hereditary sensory motor neuropathy (Charcot-Marie Tooth disease), tarsal coalition and transitional ankle fractures.

Analysis of Clinical Outcomes in Pediatric Distal Tibia Triplanar Fractures Treated Surgically and Conservatively

Purpose

We aimed to analyze the clinical and functional outcomes of patients who underwent surgery or received conservative treatment to look into the impact of treatment methods on clinical outcomes.

Methods

A retrospective study was performed on 25 patients with a minimum one-year follow-up. Patients were divided into two groups based on joint and physis displacement measured on preop CT images. Patients with a displacement of > 2 mm underwent surgery, while those with a displacement of < 2 mm received conservative treatment. The clinical results were assessed using the Ankle-Hindfoot Scale developed by the American Orthopedic Foot and Ankle Society (AOFAS) and the Modified Weber Protocol (MWP).

Results

The sample consisted of 14 patients who underwent surgery and 11 patients who received conservative treatment. The surgical group had a mean follow-up of 36.79±14.43 months, while the conservative group had a mean follow-up of 31.82±13.55 months. The surgical and conservative groups had a postop 1st-year AOFAS score of 96.64±3.54 and 93.64 ± 4.69, respectively. The difference was statistically insignificant (p > 0.05), but the surgical group had higher scores numerically. The surgical and conservative groups had a postop 6th-month AOFAS score of 84.64±1.64 and 80.82±2.85, respectively. The difference was statistically significant (p < 0.05).

Conclusion

The results of both surgical treatment and conservative treatment are satisfactory. Especially, surgical treatment should not be avoided in patients requiring surgery with a displacement of more than 2 mm and surgeons may consider surgery for better clinical outcomes and earlier rehabilitation in the treatment of triplane fractures.

Comparison of K-wire versus screw fixation after open reduction of transitional (Tillaux and triplane) distal tibia fractures

Our study aimed to compare the clinical and radiographic outcomes of transitional distal tibia fractures treated with K-wire fixation versus screw fixation after open reduction. A retrospective study was performed on all displaced transitional distal tibia fractures that underwent operative fixation. Following open reduction, surgical fixation was performed using either percutaneously inserted 2.0 mm K-wires, or 4.0 mm partially-threaded cannulated cancellous screws. Clinical and radiographic outcomes between the two groups were assessed using the modified Weber score. Other outcome measures assessed were surgical time, casting duration, follow-up duration and duration before return-to-sports. We recruited 49 patients with transitional distal tibia fractures requiring open reduction and surgical fixation. There were 18 patients in the K-wiring group (KWG), and 31 patients in the screw fixation group (SFG). All patients in both groups had excellent clinical and radiographic outcome based on the modified Weber's scoring, full radiological healing, and no residual displacement upon final follow up. The KWG had significantly shorter surgical time (41.0 min versus 75.1 min, P < 0.0001) and shorter follow-up duration needed before discharge (5.4 months versus 8.7 months, P = 0.024). However, they required a longer post-operative casting duration (7.3 weeks versus 5.3 weeks, P = 0.006). No significant difference was found for the duration before return to sports between both groups. Complications were few in this study group. Superficial pin site infection was noted in one patient in the KWG, and valgus deformity of the ankle was noted in one patient in the SFG. In our study, surgical treatment of transitional distal tibia fractures demonstrated equally excellent outcomes when treated by open reduction with either K-wire or cannulated screw fixation. Level of evidence: III.

Fixation of anterolateral distal tibial fractures: the anterior malleolus

OBJECTIVE

The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura.

INDICATIONS

Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura.

CONTRAINDICATIONS

Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities.

SURGICAL TECHNIQUE

Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3).

POSTOPERATIVE MANAGEMENT

Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance.

RESULTS

Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.

Clinical Outcomes of Triplane Fractures Based on Imaging Modality Utilization and Management: A Systematic Review and Meta-analysis

BACKGROUND

Because of the complex nature and relatively rare prevalence of triplane fractures, ideal imaging and optimal treatment remain controversial. The purpose of this investigation was to systematically review and compare clinical outcomes in skeletally immature patients with triplane fractures on the basis of imaging modalities [radiography alone vs. radiography+computed tomography (CT)] and fracture management (operative vs. nonoperative).

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using a PRISMA checklist. All the literature related to skeletally immature patients with triplane fractures published from January 1988 to March 2020 were identified. Inclusion criteria consisted of skeletally immature patients with triplane fractures with reported imaging modality performed during diagnosis, fracture management, and postoperative outcomes on the basis of functional scores and the incidence of any complications.

RESULTS

A total of 11 articles met inclusion criteria, comprising a total of 203 skeletally immature patients with 203 documented triplane fractures. Male individuals were significantly older at the time of injury (14.2±0.6 y) when compared with female individuals (12.6±0.9 y) (P=0.006). Fracture diagnosis and management were evaluated using radiography+CT in 63% (128/203) of patients, whereas 37% (75/203) underwent radiography only. No significant differences in good/excellent Modified Weber Protocol scores were reported in patients treated nonoperatively versus those undergoing operative treatment (P=0.78), whereas Modified Weber Protocol scores were significantly higher in patients using radiography alone (P=0.02). No significant difference in complication incidence was reported on the basis of management type (nonoperative, 16%; operative, 15%; P=0.47).

CONCLUSIONS

Patients undergoing operative management of triplane fractures achieved comparable functional outcomes scores without an increased incidence of complications when compared with patients undergoing nonoperative treatment. Further investigations analyzing outcomes at middle and long-term follow-up are necessary to determine the clinical utility of CT and various treatment modalities for the management of triplane fractures.

LEVEL OF EVIDENCE

Level IV-Systematic review.

[Fractures of the anterolateral tibial rim : The fourth malleolus]

The anterolateral tibial rim with the anterior tibial tubercle (Tubercule de Tillaux-Chaput) serves as an insertion site of the anterior inferior tibiofibular ligament (AITFL). It can also be termed the anterior malleolus or fourth malleolus. Fractures of the anterolateral tibial rim typically result from an external rotation or abduction mechanism of the talus within the ankle mortise. They are frequently overlooked in plain radiographs. Computed tomography (CT) is needed for an exact visualization of the fracture anatomy and treatment planning. A total of three main types can be differentiated: (1) extra-articular avulsion fracture of the AITFL, (2) fracture of the anterolateral distal tibia with involvement of the joint and tibial incisura and (3) impaction fracture of the anterolateral tibial plafond. Surgical fixation of displaced anterolateral distal tibial fractures aims at bone-to-bone stabilization of the anterior syndesmosis, restoration of the tibial incisura for the distal fibula and joint surface. Displaced extra-articular avulsion fractures (type 1) are fixed with a suture anchor or transosseal suture. Larger fragments involving the tibial incisura and plafond (type 2) are mostly fixed with screws. Impression fractures of the anterolateral tibial plafond (type 3) necessitate elevation with restoration of the joint surface, bone grafting of the impaction zone as needed and anterior buttress plating. Only a few studies have reported the treatment results of anterolateral tibial rim fractures in adults. Conservative treatment of dislocated fragments reportedly leads to non-union and malposition of the distal fibula with incongruence of the ankle mortise requiring revision. Impaction fractures (type 3) can lead to secondary avascular necrosis of the anterolateral tibial plafond.

Paediatric Ankle Fractures: Guidelines to Management

INTRODUCTION

Paediatric ankle fractures represents about 5% of all paediatric fractures. It is the most common physis to be injured in the lower limb accounting to approximately 15-20% of all physeal injuries. This article reviews the literature on this common injury which still has many controversial areas and gives guidelines to management based on the existing evidence along with clinical experience gained from a Level I trauma center.

CLASSIFICATION

The original Salter-Harris Classification with the additional types is a good system to guide on the management. The transitional fractures form a separate group with technically two broad types-biplane and triplane injuries. Though there are many sub-types in this group with some popular eponymous fractures, the treatment principles remain the same.

MANAGEMENT

A very low threshold for CT scan is recommended when there is a clinical suspicion of fracture with a negative radiograph or an intra-articular fracture in the radiograph especially in the adolescent age group. CT scan helps in accurate quantification of the intra-articular displacement and also helps to comprehend the fracture geometry better. All the intra-articular fractures with displacement > 2 mm need perfect anatomical reduction and stabilization. Assisted closed reduction and percutaneous fixation along with arthrogram to confirm articular congruity is acceptable as long as the reduction is perfect. Irrespective of the method of treatment, in children with more than 2 years of growth remaining it is important to counsel regarding the high incidence of pre-mature physeal closure and the need for regular follow-up.