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https://upload.orthobullets.com/topic/4026/images/tibial shaft.jpg
https://upload.orthobullets.com/topic/4026/images/tibial.jpg
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
 

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