Our patient is a 16-year-old male with no medical history who presented to our emergency department from another institution after being tackled in a junior varsity football game. He experienced a significant blunt trauma to the abdomen resulting in a brief loss of consciousness. He felt immediate pain in his left ankle on awakening; however, he was able to bear weight briefly until the pain became too severe. On examination, he had a generalized swelling over both the medial and lateral aspects of the left ankle compared with the right. Ecchymosis was also present on the medial side of the left ankle. He displayed tenderness to palpation over the anterolateral portion of the left ankle only. Radiographs in the anterior-posterior (Fig. 1), lateral, and oblique views revealed a Salter-Harris type IV fracture of the distal left tibia involving the posterior tibial metaphysis and the anterolateral aspect of the tibial epiphysis.
The epiphyseal fragment was displaced proximally, anteriorly, and laterally, with a 2.5 mm step-off at the articular surface seen on the lateral view. Due to high suspicion for a Tillaux fracture and inadequate evidence on plain radiographs, a computed tomography (CT) scan of the left ankle without intravenous contrast was taken. This study revealed an avulsion fracture of the anterolateral tibial epiphysis that is laterally and anteriorly displaced in addition to the non-displaced fracture of the posterior malleolus involving the metaphysis and extending into the tibial plafond with no significant step-off (Fig. 2and 3).
The decision was made to treat surgically based on the size of the articular step-off (2.5 mm) of the epiphyseal fragment. The tibialis anterior tendon and superficial peroneal tendons were marked out on the patient's skin. An anteromedial portal for ankle arthroscopy was made and the scope was inserted. A diagnostic scope confirmed the presence of a Tillaux fracture over the anterolateral aspect of the left ankle. Soft tissue was present in the fracture site so an anterolateral portal just lateral to the superficial peroneal nerve was made and a chondrotome was inserted to debride the soft tissues. A dental pick was used to hold the fracture and reduce it under direct arthroscopic visualization. K-wires held the reduction in place while radiographs were obtained to confirm the reduction radiographically. An additional K-wire was placed to be more parallel with the joint, after which the non-parallel K-wire was removed. The K-wires were removed and measured and two 4 mm cannulated screws were then inserted into the distal tibia and visualized arthroscopically and radiographically (Fig. 4, 5, 6and 7).
Final radiographs were taken and the procedure was deemed successful. The posterior malleolus fracture was also visualized on these radiographs, which was confirmed to be non-displaced. Thus, the decision was made to not use any hardware for fixation and to treat this fracture closed without fixation. The patient's left ankle was then placed in a shortleg plaster splint with instructions to remain non-weight-bearing and return to clinic in 2weeks.
At 2 weeks postoperatively, the patient was not having any significant pain and could freely move his toes in the splint. The splint was removed and replaced with another shortleg plaster splint with continued non-weight-bearing status. Ankle strengthening and range of motion exercises were allowed to take place starting at 4 weeks postoperatively, with the patient transitioned to a controlled ankle movement (CAM) walking boot and continued non-weight-bearing status. At 8 weeks postoperatively, the patient was allowed to start balancing on his left ankle for activities of daily living and weight-shifting only, with non-weight-bearing status while walking. By 12 weeks postoperatively, the patient had weaned himself out of his CAM boot and into an aircast splint though he remained non-weight-bearing. He was tolerating weight-shifting and balancing well. At this time, the decision was made to allow him to begin weight-bearing as tolerated. At 20 weeks postoperatively, he was tolerating weight-bearing while walking and had no complaints of pain. Normal strength of the ankle joint was noted with active range of motion of 30  of plantar flexion and 20  of dorsiflexion. At 1 year postoperatively, the patient had returned to participatein athletics without restrictions and reported no pain with activity. He has retained full strength of the ankle joint and had increased his range of motion to 45  of plantar flexion and 30  of dorsiflexion. Final radiographs (Fig. 8) of the ankle show the fracture healing with no loosening of hardware.