The Journal of Emergency Medicine, Vol. 49, No. 1, pp. e31–e32, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.12.086
Visual Diagnosis in Emergency Medicine
YOUNG INJURY IN AN OLDER ANKLE Joseph F. Baker, MBCHB and Fintan Doyle, FRCS (TR&ORTH) Department of Orthopaedic Surgery, Connolly Memorial Hospital, Blanchardstown, Dublin, Ireland Reprint Address: Joseph Baker, MBCHB, Department of Orthopaedic Surgery, Connolly Memorial Hospital, Blanchardstown, Dublin, Ireland
fashion. A smaller number of ankle fractures are considered atypical and, due to their relative rarity, have a propensity to be diagnosed in a delayed fashion or missed entirely (2,3). We describe the presentation here of an atypical fracture pattern that should be considered when the clinical situation suggests a fracture but the initial radiographic findings are unclear.
INTRODUCTION A majority of ankle fractures fit a certain pattern and can be easily classified according to the Weber classification or by proposed mechanism of injury (1). Many of the fracture patterns are readily identified on plain radiographs and appropriate treatment instigated in a timely
Figure 1. Mortise and lateral view radiographs of the injured ankle—a solid white arrow locates the subtle abnormality on both views. On the mortise view, the lateral border of the distal tibia, and the medial line marking the tibiofibular clear space are each demarcated with a black line—this should continue to the level of the plafond but is abruptly interrupted. Although the lateral view is not perfect, a step in the articular surface can be appreciated (solid black arrow) and the fractured fragment is clearly anterior.
RECEIVED: 8 August 2014; FINAL SUBMISSION RECEIVED: 21 October 2014; ACCEPTED: 21 December 2014 e31
e32
J. F. Baker and F. Doyle
Figure 2. Axial and coronal computed tomography slices of the injured ankle clearly showing the presence of the anterolateral fragment avulsed from the distal tibia, best demonstrated on the axial cut (white arrow). This fragment has essentially been avulsed off the distal portion of the anterolateral tibia, as it is the insertion site of the anteroinferior tibiofibular ligament, a component of the syndesmotic complex. The fractured fragment is externally rotated with respect to the tibia, consistent with the patient’s reported mechanism of injury.
CASE REPORT A 57-year-old woman with a previous history of hypertension and hypothyroidism presented to the Emergency Department after a simple twisting injury to her left ankle while stepping down off a bottom step. According to the patient’s description, the mechanism appeared most consistent with a supination-external rotation type injury. She was unable to bear weight after the injury and denied any previous problems with the ankle. On initial clinical examination, the patient was markedly tender around the lateral malleolar region with mild-to-moderate swelling. Plain radiographs were obtained (Figure 1). Due to a suspicion about the appearance of the tibiofibular clear space and abnormal appearance on the lateral projection, a computed tomography (CT) scan was performed to confirm the diagnosis (Figure 2). DISCUSSION The patient was diagnosed with a Tillaux fracture. This is an avulsion fracture of the anterolateral aspect of the distal tibia that typically results from an external rotation force on the foot with respect to the long axis of the tibia (4). These fractures normally occur in the pediatric population, especially in adolescents, when the physis is incompletely closed. In these individuals the fracture is normally a Salter-Harris III type. In the adult population
they are very unusual and the subject of a handful of case reports (5,6). Patients with this fracture will present with pain, swelling, and an inability to bear weight. The features are similar to significant ligamentous injuries and more common fractures, yet the radiographic findings may be subtle on plain radiographs. An oblique radiograph in addition to anteroposterior and lateral views may be helpful (7). In this case, the abnormal appearance of the tibiofibular clear space prompted further imaging. CT is more definitive than radiography and aids surgical planning. Early identification of this injury is essential, as anatomic restoration of the articular surface is desirable to ensure optimal outcome. REFERENCES 1. Thomsen NO, Overgaard S, Olsen LH, et al. Observer variation in the radiographic classification of ankle fractures. J Bone Joint Surg Br 1991;73:676–8. 2. Jibri Z, Mukherjee K, Kamath S, et al. Frequently missed findings in acute ankle injury. Semin Musculoskelet Radiol 2013;17:416–28. 3. Er E, Kara PH, Oyar O, et al. Overlooked extremity fractures in the emergency department. Ulus Travma Acil Cerrahi Derg 2013;19:25–8. 4. Cassas KJ, Jamison JP. Juvenile tillaux fracture in an adolescent basketball player. Phys Sportsmed 2005;33:30–3. 5. Oak NR, Sabb BJ, Kadakia AR, et al. Isolated adult Tillaux fracture: a report of two cases. J Foot Ankle Surg 2014;53:489–92. 6. Marti CB, Kolker DM, Gautier E. Isolated adult Tillaux fracture: a case report. Am J Orthop (Belle Mead NJ) 2005;34:337–9. 7. Duchesneau S, Fallat LM. The Tillaux fracture. J Foot Ankle Surg 1996;35:127–33:discussion 189.
http://dx.doi.org/10.1016/j.jemermed.2014.12.086
Visual Diagnosis in Emergency Medicine
YOUNG INJURY IN AN OLDER ANKLE Joseph F. Baker, MBCHB and Fintan Doyle, FRCS (TR&ORTH) Department of Orthopaedic Surgery, Connolly Memorial Hospital, Blanchardstown, Dublin, Ireland Reprint Address: Joseph Baker, MBCHB, Department of Orthopaedic Surgery, Connolly Memorial Hospital, Blanchardstown, Dublin, Ireland
fashion. A smaller number of ankle fractures are considered atypical and, due to their relative rarity, have a propensity to be diagnosed in a delayed fashion or missed entirely (2,3). We describe the presentation here of an atypical fracture pattern that should be considered when the clinical situation suggests a fracture but the initial radiographic findings are unclear.
INTRODUCTION A majority of ankle fractures fit a certain pattern and can be easily classified according to the Weber classification or by proposed mechanism of injury (1). Many of the fracture patterns are readily identified on plain radiographs and appropriate treatment instigated in a timely
Figure 1. Mortise and lateral view radiographs of the injured ankle—a solid white arrow locates the subtle abnormality on both views. On the mortise view, the lateral border of the distal tibia, and the medial line marking the tibiofibular clear space are each demarcated with a black line—this should continue to the level of the plafond but is abruptly interrupted. Although the lateral view is not perfect, a step in the articular surface can be appreciated (solid black arrow) and the fractured fragment is clearly anterior.
RECEIVED: 8 August 2014; FINAL SUBMISSION RECEIVED: 21 October 2014; ACCEPTED: 21 December 2014 e31
e32
J. F. Baker and F. Doyle
Figure 2. Axial and coronal computed tomography slices of the injured ankle clearly showing the presence of the anterolateral fragment avulsed from the distal tibia, best demonstrated on the axial cut (white arrow). This fragment has essentially been avulsed off the distal portion of the anterolateral tibia, as it is the insertion site of the anteroinferior tibiofibular ligament, a component of the syndesmotic complex. The fractured fragment is externally rotated with respect to the tibia, consistent with the patient’s reported mechanism of injury.
CASE REPORT A 57-year-old woman with a previous history of hypertension and hypothyroidism presented to the Emergency Department after a simple twisting injury to her left ankle while stepping down off a bottom step. According to the patient’s description, the mechanism appeared most consistent with a supination-external rotation type injury. She was unable to bear weight after the injury and denied any previous problems with the ankle. On initial clinical examination, the patient was markedly tender around the lateral malleolar region with mild-to-moderate swelling. Plain radiographs were obtained (Figure 1). Due to a suspicion about the appearance of the tibiofibular clear space and abnormal appearance on the lateral projection, a computed tomography (CT) scan was performed to confirm the diagnosis (Figure 2). DISCUSSION The patient was diagnosed with a Tillaux fracture. This is an avulsion fracture of the anterolateral aspect of the distal tibia that typically results from an external rotation force on the foot with respect to the long axis of the tibia (4). These fractures normally occur in the pediatric population, especially in adolescents, when the physis is incompletely closed. In these individuals the fracture is normally a Salter-Harris III type. In the adult population
they are very unusual and the subject of a handful of case reports (5,6). Patients with this fracture will present with pain, swelling, and an inability to bear weight. The features are similar to significant ligamentous injuries and more common fractures, yet the radiographic findings may be subtle on plain radiographs. An oblique radiograph in addition to anteroposterior and lateral views may be helpful (7). In this case, the abnormal appearance of the tibiofibular clear space prompted further imaging. CT is more definitive than radiography and aids surgical planning. Early identification of this injury is essential, as anatomic restoration of the articular surface is desirable to ensure optimal outcome. REFERENCES 1. Thomsen NO, Overgaard S, Olsen LH, et al. Observer variation in the radiographic classification of ankle fractures. J Bone Joint Surg Br 1991;73:676–8. 2. Jibri Z, Mukherjee K, Kamath S, et al. Frequently missed findings in acute ankle injury. Semin Musculoskelet Radiol 2013;17:416–28. 3. Er E, Kara PH, Oyar O, et al. Overlooked extremity fractures in the emergency department. Ulus Travma Acil Cerrahi Derg 2013;19:25–8. 4. Cassas KJ, Jamison JP. Juvenile tillaux fracture in an adolescent basketball player. Phys Sportsmed 2005;33:30–3. 5. Oak NR, Sabb BJ, Kadakia AR, et al. Isolated adult Tillaux fracture: a report of two cases. J Foot Ankle Surg 2014;53:489–92. 6. Marti CB, Kolker DM, Gautier E. Isolated adult Tillaux fracture: a case report. Am J Orthop (Belle Mead NJ) 2005;34:337–9. 7. Duchesneau S, Fallat LM. The Tillaux fracture. J Foot Ankle Surg 1996;35:127–33:discussion 189.
