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Updated: Sep 18 2023

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
          • early weight bearing as soon as 1 week after cast placement is not only safe but may be beneficial to the child's recovery without negatively impacting healing rates 
    • 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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