Transitional Fractures: Tillaux and Triplane

Tillaux Fracture (Juvenile Tillaux)

Salter-Harris Type III

• Involves physis and epiphysis only.
• Anterolateral epiphyseal fragment.
• Occurs when only the lateral physis remains open.

Treatment: ORIF if more than 2mm articular step-off.

This represents the final stage of the transitional fracture spectrum.

Two-Part Triplane Fracture

Salter-Harris Type IV

• Lateral epiphyseal fragment (like Tillaux).
• PLUS posterolateral metaphyseal spike.
• Medial epiphysis attached to metaphysis (one fragment).

CT Appearance:

• Axial: Anterolateral epiphyseal fragment.
• Sagittal: Posterior metaphyseal fragment.
• Coronal: Single medial fragment (epiphysis + metaphysis together).

Surgical Approach:

• Often single lateral approach sufficient.
• Fix epiphysis, then metaphysis with separate screws.

The 2-part pattern is the most common triplane configuration.

Three-Part Triplane Fracture

Salter-Harris Type IV

• Anterolateral epiphyseal fragment.
• Medial epiphyseal fragment (SEPARATE from metaphysis).
• Posterolateral metaphyseal fragment.

CT Appearance:

• Axial: Two separate epiphyseal fragments.
• The medial epiphysis is a distinct fragment not attached to metaphysis.

Surgical Approach:

• May require BOTH lateral and medial approaches.
• More complex reduction.
• Fix medial epiphysis through medial approach if needed.

The 3-part pattern requires more complex surgical planning.

Non-Displaced or Minimally Displaced (Less than 2mm on CT)

Indications:

• Articular step-off less than 2mm on CT.
• Acceptable alignment on X-ray.

Treatment Protocol:

• Long leg cast or CAM boot for 4-6 weeks.
• Non-weight bearing initially, then progressive WB.
• Weekly X-rays for 2-3 weeks to ensure no displacement.

Tillaux ORIF (Greater than 2mm step-off)

Approach: Anterolateral (over the anterolateral tibial physis).

Technique:

1. Incision along anterolateral tibia.
2. Identify and protect superficial peroneal nerve branches.
3. Visualize the fracture and articular surface.
4. Reduce fragment anatomically.
5. Provisional K-wire fixation.
6. Definitive fixation with cannulated screw (4.0mm) within the epiphysis.
7. Confirm reduction with fluoroscopy.

Key Points:

• Single epiphyseal screw parallel to joint is usually sufficient.
• Avoid crossing the intact (medial) physis if possible.

Tillaux ORIF is a straightforward procedure with excellent outcomes.

Triplane ORIF

2-Part Triplane:

• Often reducible through lateral approach alone.
• Fix epiphyseal fragment with epiphyseal screw.
• Fix metaphyseal fragment with metaphyseal screw (can cross closed physis).

3-Part Triplane:

• May require medial approach for medial epiphyseal fragment.
• Sequence: Reduce and fix medial epiphysis first, then lateral, then metaphysis.

Implants:

• Cannulated screws (4.0-4.5mm).
• Epiphyseal screws should be parallel to the joint.
• Metaphyseal screws can cross the (closed) central physis.

Triplane fractures require careful pre-operative CT planning.

Patient Positioning

Position: Supine on radiolucent table. Padding: Bump under ipsilateral hip (slight internal rotation of leg). Draping: Free drape the lower extremity for manipulation. C-arm: From contralateral side for AP, mortise, and lateral views.

Anterolateral Approach

Indications: Tillaux and 2-part triplane.

Incision: Curved incision over anterolateral tibia, centered on the fracture.

Dissection:

1. Identify and protect superficial peroneal nerve branches.
2. Incise the ankle capsule/periosteum.
3. Expose the fracture and articular surface.
4. Irrigate joint to remove hematoma.

Dangers:

• Superficial peroneal nerve (crosses in the field).
• Anterior tibial artery (deeper, less at risk).

The anterolateral approach provides excellent visualization.

Reduction and Fixation

Reduction Maneuvers:

• Internal rotation of the foot reduces the Tillaux/lateral fragment.
• Direct manipulation with periosteal elevator or pointed reduction clamp.
• Visualize articular surface directly for anatomic reduction.

Provisional Fixation:

• 1.6mm K-wire across the fragment.
• Confirm reduction on fluoroscopy (AP, mortise, lateral).
• Check articular surface with direct visualization.

Definitive Fixation:

• Cannulated screw (4.0mm) over the guidewire.
• Epiphyseal screw parallel to joint, within the epiphysis.
• Metaphyseal screw (if triplane) can be standard partially threaded screw.
• Aim for lag effect if possible.

Confirm anatomic reduction under direct vision and fluoroscopy.

Wound Closure

Layers:

1. Close capsule/periosteum with absorbable suture.
2. Subcutaneous layer with absorbable suture.
3. Skin with subcuticular or interrupted nylon.

Dressing:

• Sterile dressing.
• Below-knee backslab initially.

Post-op:

• Convert to short leg cast or boot at 2 weeks.
• Non-weight bearing for 4 weeks, then progressive.

Standard wound care with suture removal at 2 weeks.