Tillaux

The distal tibial epiphysis ossifies between 6 and 24 months of age. The medial malleolus appears at 7-8 years and is complete at 10 years. It usually ossifies as a downward extension of the distal tibial ossific nucleus but may develop as a separate centre of ossification and thus be mistaken for a fracture line. The distal tibial physis closes first centrally, then medially and finally anterolaterally (Fig. 15.1), with the entire process lasting about 18 months. This sequence of closure of the distal tibial physis is important in the pattern of transitional fractures (triplane and juvenile Tillaux). Completion of distal tibial physeal closure is at around 14 years in girls and 16 years in boys. 

The first part of the name refers to the position of the foot at the moment of the injury. The second part indicates the direction of the abnormal force applied to the ankle. A further four types of fracture - juvenile Tillaux, triplane, axial compression and miscellaneous physeal injuries - were added later to complete the classification. Whilst this classification is useful in understanding the deforming forces of the fracture, and hence the type of manoeuvre needed to achieve a satisfactory closed reduction, the Salter-Harris classification is easier to commit to memory and provides a better predictor of outcome in terms of complications (Spiegel et al. 1978). 

Computerised tomography (CT) is particularly valuable in the assessment of transitional (triplane, juvenile Tillaux) and intraarticular fractures wdiere the magnitude of displacement - both fracture gap and intraarticular or physeal step - is critical in determining whether or not operative intervention is required. CT is also extremely useful in helping the surgeon to plan the surgical approach in these situations. 

Fig. 15.5a-e. Juvenile Tillaux fracture a AP and (b) lateral views, c CT axial view. d,e After reduction and internal fixation... 

Type I tibial fractures Juvenile Tillaux fractures... 

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