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Adult Tillaux fracture in association with Volkmann and Maisonneuve fractures. Case report
Fractura de Tillaux en adultos en asociación con las fracturas de Volkmann y Maisonneuve. Reporte de caso
Henrique Mansur-Gonçalvesa,
Corresponding author
henrimansur@globo.com

Corresponding author. Hospital de Força Aérea de Brasília – HFAB; Área Militar do Aeroporto Internacional de Brasília, Brasília, DF Brazil. 71607-900 / Tel.:.+55-61-3364-7767 /+55-21-994241450.
, Thiago Coelho-Limab, Cesar Barbosa-Gonçalvesc, Isnar Moreira-de-Castro-Juniord, Max Ramose
a Master's Degree Student, Universidad Federal del Estado de Rio de Janeiro, Rio de Janeiro, RJ, Brazil
b Escuela de Medicina de Ribeirão Preto de la universidad de São Paulo, São Paulo, SP, Brazil
c Departamento de Cirugía de pie y Tobillo, Hospital Naval Marcílio Dias, Rio de Janeiro, RJ, Brazil
d Departamento de Cirugía de pie y Tobillo, Instituto Nacional de Traumatología y Ortopedia, Rio de Janeiro, RJ, Brazil
e Universidad Federal del Estado de Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tillaux fracture is an avulsion fracture of the anterolateral aspect of the tibial plafond owing to the pull of a taut anteroinferior tibiofibular ligament &#40;AITL&#41;&#46; In adults&#44; differ from children&#44; the ligament generally gives away before avulsion of its attachment to the anterolateral tibial plafond occurs&#44; leading to relative rarity of this avulsion pattern&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;4</span></a> The mechanism of this fracture is typically supination with external rotation&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In children&#44; the size of the fracture depends on the extent of the fusion medially&#44; because distal tibial epiphyseal closure has an asymmetric pattern&#46; Physeal closure starts from the center and then progresses toward the medial side&#46; Finally&#44; the lateral aspect of distal tibial fusion occurs&#46; The medial closure occurs at approximately 13 to 14 years of age&#44; with lateral closure beginning at 14&#46;5 to 16 years of age&#46; The interval &#40;&#8764;18 months&#41; during which the distal tibial physis completes its closure and gains maturity is referred to as &#8220;transition period&#8221;&#46; Adolescent Tillaux fracture occurs during transition period when the medial and central physis has finished closure&#44; but the lateral physis still open&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Volkmann fracture generally occurs in ankle fracture due to either mechanism of pronation or supination with external rotation&#46; External rotation forces make the talus rotate further laterally and the posteroinferior tibiofibular ligament &#40;PITFL&#41; stretch&#44; thus either the PITFL will rupture or an avulsion fracture from the posterolateral tibia occur&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Maisonneuve fracture is an injury caused by a pronation-external rotation force at the ankle that results in rupture along the syndesmosis with its diastasis&#44; lateral talar shift and spiral fracture of the proximal half of the fibula&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Tillaux fractures have rarely been reported in adults&#46; Of the six published case reports in patients over 18 years old&#44; only one had Tillaux fracture associated with Volkmann fracture&#44; and none of them had association with Maisonneuve fracture&#46;In the present report&#44; we describe the case of a Tillaux fracture in an adult&#44; associates with a Volkmann and a Maisonneuve fractures&#46; To the best of our knowledge&#44; no data are available regarding the association of all of these lesions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 74-year-old female presented to the emergency room after been hit by a car&#46; The patient was unable to bear weight on her left lower extremity&#46; On clinical examination&#44; swelling and significant tenderness was present over the proximal extremity of her leg until her ankle&#46; The neurovascular examination was normal&#46; Radiographs showed spiral fracture of the proximal half of the fibula &#40;Maisonneuve&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41; and posterior malleolus fracture &#40;Volkmann fragment&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46; The CT Scan revealed fracture of the anterolateral aspect of the tibial plafond &#40;Tillaux-Chaput&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The patient also had an ischiopubian branch&#44; without displacement&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical Technique</span><p id="par0030" class="elsevierStylePara elsevierViewall">Patient underwent surgery fourteen days following the initial injury&#46; With patient under spinal anesthesia&#44; tourniquet control and right lateral decubitus position&#44; a posterolateral incision was made&#46; The Volkmann fragment was reduced and fixed with a third tubular buttress plate&#46; Thus&#44; the decubitus was changed to dorsal position and the syndesmosis was stabilized using a single 3&#46;5<span class="elsevierStyleHsp" style=""></span>mm fully threaded cortical screw engaging three cortices&#46; Through an anterolateral approach&#44; the Tillaux fracture was reduced and fixed with two cannulated lag-screws &#40;<a class="elsevierStyleCrossRef" href="#fig0015">figure 3</a>&#41;&#46; The entire procedure was done under fluoroscopic guidance &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figures 4&#44; 5 &#38; 6</a>&#41;&#46; Postoperatively&#44; the patient was placed in a below-knee non-weight bearing plaster cast for 6 weeks&#46; Within twelve weeks&#44; clinical and radiographic assessments revealed the fracture to be well consolidated without any complications &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figures 7 &#38; 8</a>&#41;&#46; At that time&#44; full weight bearing was allowed&#46; After twelve months of surgery&#44; the patient returned with no symptoms or pain and complete range of motion of the ankle&#46; The AOFAS ankle and hindfoot scale score was 100&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Tillaux fracture has rarely been reported in adults&#46; Literature review only presented six others reports with eight cases&#46; This lesion is known to occur in adolescents and is defined as an avulsion fracture of the anterolateral distal tibial epiphysis&#46; Occurs during transition period&#44; between 12-14 years in girls and 15-18 in boys&#44; when the medial and central physis has finished closure but the lateral physis is still open&#44; making it weaker&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> The mechanism of this injury is external rotation of ankle that leads to an avulsion fracture owing to the pull of the anteroinferior tibiofibular ligament&#46; Volkmann fracture corresponds to an avulsion-fracture of the posteroinferior tibiofibular ligament from its tibial attachment&#46; Simultaneous Tillaux and Volkmann fractures in the adult patient is extremely rare&#44; with only two cases previously reported&#46; Tillaux fracture has rarely been associated with medial malleolus fracture or deltoid injury<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> and the syndesmosis should be carefully evaluated&#46; The presented case shows a unique association&#58; Tillaux and Volkmann fractures associated with a high fibula fracture or Maisonneuve fracture&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The possible mechanism of injury in this case presented was pronation-external rotation&#44; according Lauge-Hansen classification&#44; characterized by&#44; progressively&#44; deltoid ligament rupture or fracture of the medial malleolus&#59; disruption of the anterior syndesmosis and rupture of the interosseous ligament and membrane&#59; spiral fracture of the fibula in its proximal half&#59; and either a rupture of the posterior syndesmosis or a fracture of the posterior tibia&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Tillaux fracture associated with Volkmann fracture are also caused by supination-external rotation&#46; However&#44; in that mechanism the fibula fracture occurs at the level of syndesmosis and in case reported there was a Maisonneuve avulsion-fracture&#44; instead&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnosis is challenging in cases like this&#46; Tillaux and Volkmann fractures can be missed in direct radiographics with anteroposterior and lateral X-ray views of the ankle&#46; Furthermore&#44; Maisonneuve fracture can be neglected if the leg X-ray is not done&#46; Oblique ankle X-ray views can help in the diagnosis and additional CT evaluation is recommended if these lesions are suspected&#44; once it assists the diagnosis and the surgical treatment&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Maisonneuve fracture treatment is surgical&#44; with anatomic reduction and syndesmosis stabilization&#46; Isolated Tillaux and Volkmann fractures can be treated non surgically if there is no dislocation&#46; When displacement is<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mm&#44; reduction and fragment fixation is advised in order to prevent further degenerative arthritis and instability&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the presented case&#44; there were a unique association of lesions&#44; thus the syndesmosis was disrupted at two points&#44; with sequent ankle instability&#44; requiring fixation&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Tillaux fracture is an unusual injury in adults&#44; and it&#769;s association with Volkmann fracture and Maisonneuve fracture is even rarer&#46; These lesions can be neglected once a careful physical exam is not performed&#44; besides complimentary image exams&#46; They are a serious injuries because can promote a marked ankle instability&#46; Therefore&#44; the surgical treatment is indispensable&#44; beyond open reduction and internal fixation of the posterior malleolus&#44; the Tillaux fragment and the syndesmosis&#44; avoiding the early osteoarthritis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">Research had been performed with self funding resources by the authors&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">Authors does not declare any conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tillaux fracture is known to occur in adolescents once it happens during transition period when the medial and central physis has finished closure&#44; but the lateral physis is still opened&#46; The trauma mechanism is typically external rotation ankle injury resulting in an avulsion fracture of the anterolateral tibial plafond&#46; This fracture has rarely been reported in adults&#44; especially associated with others injuries&#46; We report a case of Tillaux fracture in an adult&#44; associated with a Volkmann fracture and a Maisonneuve fracture&#44; that were surgery treated with open reduction and internal fixation and had an excellent outcome&#46; Recognize and appropriately treat each one of these injuries is the key to prevent further degenerative arthritis and instability&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evidence Level&#58; IV</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se sabe que la fractura de Tillaux ocurre en adolescentes una vez que ocurre durante el per&#237;odo de transici&#243;n cuando la fisis medial y central ha finalizado el cierre&#44; pero la fisis lateral todav&#237;a est&#225; abierta&#46; El mecanismo de traumatismo es t&#237;picamente una lesi&#243;n de tobillo de rotaci&#243;n externa que resulta en una fractura por avulsi&#243;n del plaf&#243;n tibial anterolateral&#46; Esta fractura rara vez se ha informado en adultos&#44; especialmente asociada con otras lesiones&#46; Divulgamos un caso de fractura de Tillaux en un adulto&#44; asociado con una fractura de Volkmann y una fractura de Maisonneuve&#44; que se trataron mediante cirug&#237;a con reducci&#243;n abierta y fijaci&#243;n interna y tuvieron un resultado excelente&#46; Reconocer y tratar apropiadamente cada una de estas lesiones es la clave para prevenir artritis e inestabilidad degenerativas&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nivel de Evidencia&#58; IV</p></span>"
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Article information
ISSN: 01208845
Original language: English
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