Updated: 6/13/2021

Tibial Shaft Fractures - Pediatric

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  • 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
          • most commonly due to pedestrian vs vehicle (50%)
          • direct blow
        • toddlers
          • low energy twisting or falls
          • torsional forces result in a spiral or oblique fracture pattern or a "toddler's fracture"
    • 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
          • almost all Toddler's fracture
          • Greenstick fractures
        • followup
          • follow up x-rays in 2 weeks to evaluate for callus in order to confirm the diagnosis in equivocal cases
      • closed reduction and long leg casting
        • indications
          • most traumatic fractures
            • displaced with acceptable reduction
              • 50% translation
              • < 1 cm of shortening
              • < 5-10 degrees of angulation in the sagittal and coronal planes
        • mold cast to decrease likelihood of fracture displacement
          • complete fractures with intact fibula tend to fall into varus
          • complete fractures with fracture fibula tend to fall into valgus and recurvatum
        • followup
          • serial radiographs are performed to monitor for developing deformity
          • serial followup if physeal extension to monitor for growth disturbance
    • Operative
      • external fixation
        • indications
          • open or closed fractures with extensive soft tissue injury, length unstable fractures, or poly-trauma patients
      • flexible intramedullary nails
        • indications
          • open or closed fractures in skeletally immature patients
          • multiple long bone fractures or floating knee
      • percutaneous pinning
        • indications
          • noncomminuted, unstable oblique fractures
          • may be used with casting
      • rigid intramedullary nailing
        • indications
          • open or closed tibial shaft fractures in patients at or near skeletal maturity
      • plate fixation
        • indications
          • open or closed fractures with physeal or articular extension
          • length unstable fractures
          • nonunions or malunions
  • 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
          • may be corrected with opening or closing cast wedging
    • 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
          • indications
            • similar to adults
            • 3 As: analgesia, anxiety, agitation
    • 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
          • indication
            • rotational malunion
            • symptomatic and at risk of joint degeneration
    • 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
          • hypertrophic: bone grafting and rigid fixation
          • oligotrophic or atrophic: bone grafting and fixation, +/- resection
  • Prognosis
    • Healing
      • 3 to 4 weeks for toddler's fracture
      • 6 to 8 weeks for other tibial fractures

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(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?

QID: 2954
FIGURES:
1

MRI of the tibia

0%

(15/4173)

2

Aspiration of the tibia

0%

(5/4173)

3

Referral to child services

4%

(151/4173)

4

Long leg cast application

95%

(3959/4173)

5

Serum vitamin D, calcium, and phosphate levels

1%

(30/4173)

L 1 C

Select Answer to see Preferred Response

(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?

QID: 721
1

vitamin D and calcium levels

6%

(79/1420)

2

MRI of the pelvis

5%

(67/1420)

3

long leg cast

88%

(1243/1420)

4

chromosomal analysis

1%

(9/1420)

5

aspiration of the knee

1%

(16/1420)

L 1 C

Select Answer to see Preferred Response

(SBQ04PE.60) A 3-year-old male presents with inability to bear weight on his right leg for the past 3 days. They deny any known injury at that time. Examination reveals full motion of the right hip, knee, and ankle. He has tenderness to palpation over the anterior tibia with minimal swelling. No erythema is appreciated. His temperature is 99.6°F. He has no leukocytosis and CRP and ESR are normal. Radiographs of the right leg are seen in Figure A. What is the most likely diagnosis?l

QID: 2245
FIGURES:
1

Subperiosteal abscess

8%

(110/1389)

2

Nondisplaced oblique or spiral fracture of the tibia with an intact fibula

68%

(945/1389)

3

Osteomyelitis

5%

(70/1389)

4

Non-ossifying fibroma

5%

(72/1389)

5

Non-accidental trauma

13%

(186/1389)

L 3 D

Select Answer to see Preferred Response

Evidence (7)
VIDEOS & PODCASTS (1)
CASES (5)
EXPERT COMMENTS (6)
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