summary Pediatric Tibial Shaft Fractures are the third most common long bone fracture in children. Diagnosis can be confirmed with plain radiographs of the tibia. Treatment may be nonoperative or operative depending on the fracture morphology, age of the patient, and associated injuries. Epidemiology Incidence 15% of all pediatric fractures Demographics boys > girls average age of occurrence - 8 years Anatomic location 39% of tibia fractures occur in the mid-diaphysis Etiology Pathophysiology mechanism of injury adolescents login to view 2 more bullets toddlers login to view 2 more bullets Associated conditions orthopedic manifestations 30% are associated with a fibula fracture second most common fractured bone following nonaccidental trauma Anatomy Osteology tibia triangular shaped bone with apex anteriorly that broadens distally the anteromedial border is subcutaneous tibial flare distally leads to primarily cancellous bone and a thin cortical shell Muscles the anterior and lateral compartment musculature produce valgus deforming forces when both the tibia and fibula are fractured Blood supply posterior tibial a. provides nutrient and periosteal vessels the anterior tibial artery is vulnerable to injury as it passes through the interosseous membrane Biomechanics the fibula bears 6-17% of the weight-bearing load Classification Classification based on fracture location (proximal, midshaft, distal) and pattern Pediatric tibial shaft fracture patterns Incomplete Greenstick fracture of the tibia and/or fibula Complete Complete fracture of the tibia with or without ipsilateral fibula fracture or plastic deformation Tibial spiral fracture (Toddler's Fracture) Nondisplaced spiral or fracture of the tibia with intact fibula in a child under 2.5 years of age Presentation Symptoms pain bruising limping or refusal to bear weight Physical exam inspection warmth, swelling over fracture site palpation tender over fracture site motion pain on ankle dorsiflexion neurovascular always have high suspicion for compartment syndrome Imaging Radiographs recommended views AP and lateral views of the tibia and fibula are required ipsilateral knee and ankle must be evaluated to rule out concomitant injury optional views contralateral films of the uninjured leg findings radiographs may appear normal in toddler's fractures CT indications concern for physeal or intra-articular extension, pathologic lesion distal third tibia fractures may propagate to physis or articular surface MRI indications suspicion for pathologic or stress fracture rule out an occult fracture Bone scan indications rule out an occult fracture Treatment Nonoperative long leg casting indications login to view 2 more bullets followup login to view 1 more bullet closed reduction and long leg casting indications login to view 5 more bullets mold cast to decrease likelihood of fracture displacement login to view 2 more bullets followup login to view 3 more bullets Operative external fixation indications login to view 1 more bullet flexible intramedullary nails indications login to view 2 more bullets percutaneous pinning indications login to view 2 more bullets rigid intramedullary nailing indications login to view 1 more bullet plate fixation indications login to view 3 more bullets Techniques Closed reduction and long leg casting conscious sedation or general anesthesia approach extend cast to the groin with the knee flexed to 30 degrees and appropriate molding +/- bivalve depending on swelling specific complications compartment syndrome loss of reduction login to view 1 more bullet External fixation soft tissue if open fracture debride and irrigate prior to placing pins instrumentation 2 half-pins above and below fracture in the tibia specific complications pin tract infection refracture nonunion (~2%) malunion Flexible intramedullary rods bone work drill holes are made in the proximal or distal tibial metaphysis instrumentation flexible rods are introduced into the proximal or distal tibial metaphysis and passed across the fracture site immobilization typically a short period of immobilization and non-weight bearing given flexibility of nails specific complications nonunion (~10%) malunion infection outcomes shorter immobilization compared to casting (3 months) Complications Compartment syndrome incidence less common than adult tibial shaft fractures risk factors open and closed fractures treatment emergent fasciotomies login to view 3 more bullets Leg-length discrepancy risk factors children <10 comminution may lead to overgrowth iatrogenic pin placement may lead to growth arrest or recurvatum from tibial tubercle arrest Angular deformity risk factors complex deformity valgus and apex posterior deformity physeal extension treatment corrective osteotomy login to view 3 more bullets Associated physeal injury risk factors open and closed fractures distal fractures treatment reduction and follow-up Delayed union and nonunion incidence 25% in open tibia fractures risk factors increasing age increasing severity of wound treatment determined by type of nonunion login to view 2 more bullets Prognosis Healing 3 to 4 weeks for toddler's fracture 6 to 8 weeks for other tibial fractures