Tibia Shaft Fracture - Pediatric - Pediatrics

Introduction

Among the most frequently encountered pediatric fractures. Consists of
- traumatic tibial shaft +/- fibula fractures
  - most commonly due to pedestrian vs vehicle (50%)
- Toddler's fracture (see below)
Epidemiology
- 15% of all pediatric fractures
- 39% of tibia fractures occur in the diaphysis.
- 30% are associated with a fibula fracture.
  - usually undisplaced because of strong periosteum
Prognosis
- healing
  - 3 to 4 weeks for toddler's fracture
  - 6 to 8 weeks for other tibial fractures
Toddler's fracture
- characteristics
  - nondisplaced spiral or oblique fracture of tibial shaft only
    - fibula remains intact
  - also known as childhood accidental spiral tibial (CAST) fractures
- age group
  - children< 3 years (walking toddlers)
    - unlike child abuse injury, which occurs in children not yet walking
- mechanism
  - low energy trauma with rotational component
  - involves distal half of tibia
  - unlike non-accidental injury, which typically involves proximal half of tibia

Presentation

Symptoms
- pain
- bruising
- limping or refusal to bear weight
Physical exam
- warmth, swelling over fracture site
- tender over fracture site
- pain on ankle dorsiflexion
- always have high suspicion for compartment syndrome

Imaging

Radiographs
- views
  - AP and lateral views of the tibia and fibula are required
  - ipsilateral knee and ankle must be evaluated to rule out concomitant injury
- findings
  - Toddler's fracture are nondisplaced spiral tibial shaft fracture

Treatment Traumatic Tibia +/- Fibular fx

Nonoperative
- closed reduction and long leg casting
  - indications
    - almost all Toddler's fracture
    - most traumatic fractures
      - displaced with acceptable reduction
        
        50% apposition
        
        < 1 cm of shortening
        
        < 5-10 degrees of angulation in the sagittal and coronal planes
  - followup
    - follow up xrays in 2 weeks to evaluate for callus in order to confirm diagnosis in equivocal cases
    - serial radiographs are performed to monitor for developing deformity
Operative
- surgical treatment
  - indications (< 5% of tibia shaft fractures)
    - unacceptable reduction (see above)
    - marked soft tissue injury
    - open fractures
    - unstable fractures
    - compartment syndrome
    - neurovascular injury
    - multiple long bone fractures
    - >1cm shortening
    - unacceptable alignment following closed reduction (>10deg angulation)
  - techniques include
    - external fixation
    - plate fixation
    - percutaneous pinning
    - flexible IM nails

Techniques

Long Leg Casting
- immobilization is performed with a long leg cast with the knee flexed to provide rotational control and prevent weight bearing.
External fixation
- open fractures with extensive soft tissue injury is most common indication
- most common complication is malunion
- nonunion (~2%)
Plate fixation
Percutaneous pinning
- younger patients
Flexible or rigid intramedullary rods
- depending on the age of the patient and degree of soft tissue injury
- complications
  - nonunion (~10%)
  - malunion
  - infection

Complications

Compartment syndrome
- with both open and closed fractures
Leg-length discrepancy
Angular deformity
- varus for tibia only fractures
- valgus for tibia-fibula fractures
Associated physeal injury
- proximal or distal
Delayed union and nonunion
- usually only after external fixation

Questions (2)

(OBQ09.141) A 2-year and 11-month old child fell while playing with friends 2 hours ago and has avoided bearing weight on the right leg since that time. The child is afebrile and exam reveals tenderness along the distal tibial shaft with no significant swelling. Radiographs are shown in Figure A and B. What is the most appropriate treatment? Review Topic

QID: 2954

FIGURES:

A
B

1

MRI of the tibia

0%

(11/3106)

2

Aspiration of the tibia

0%

(4/3106)

3

Referral to child services

3%

(100/3106)

4

Long leg cast application

95%

(2961/3106)

5

Serum vitamin D, calcium, and phosphate levels

1%

(20/3106)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ07.60) A 23-month-old girl refuses to bear weight since falling on the playground yesterday. The child is afebrile and her WBC and erythrocyte sedimentation rate (ESR) are within normal limits. On physical exam the leg has no erythema, but does have mild tenderness along the distal tibial shaft. Plain radiographs are negative. What is the most appropriate management? Review Topic

QID: 721

1

vitamin D and calcium levels

5%

(41/810)

2

MRI of the pelvis

4%

(34/810)

3

long leg cast

88%