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Review Question - QID 218688

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QID 218688 (Type "218688" in App Search)
A 7-year-old male falls while climbing a tree unsupervised at the park and presents with an injury to his left leg shown in Figures A and B. Which of the following represents the initial treatment that should be provided by the Orthopaedic provider after evaluation in the emergency room to maximize healing response and the child's overall recovery?
  • A
  • B

Closed reduction and flexible intramedullary nailing

14%

82/581

Closed reduction and long leg casting with non-weightbearing for 4-6 weeks

45%

262/581

Closed reduction and long leg casting with allowance for early weightbearing at 1 week

33%

190/581

Closed reduction and short leg casting with non-weightbearing for 4-6 weeks

3%

17/581

Closed reduction and short leg casting with allowance for early weightbearing at 1 week

4%

22/581

  • A
  • B

Select Answer to see Preferred Response

Tibial shaft fractures in children should initially be treated with long leg casting and can be allowed to bear weight as soon as one week after casting with no detriment to fracture healing in length-stable patterns.

Pediatric tibial shaft fractures represent the third most common long bone fracture in children, with > 39% occurring in the mid-diaphysis. They may or may not be associated with fibula fractures, which affect the possible direction of displacement and should be taken into consideration during cast application after reduction. Complete tibial shaft fractures with intact fibulae tend to displace into varus, while those with ipsilateral fibula fractures typically fall into valgus and recurvatum. Acceptable reduction parameters include < 50% translation (i.e. > 50% cortical overlap), < 1cm of shortening, and < 5 degrees of angulation in the coronal and/or sagittal plane. Adequately reduced fractures in casts with appropriate molds allow for weightbearing as early as one week after injury, which may positively affect healing rates and maximize the child's overall recovery.

Jenkins, et al. retrospectively reviewed 148 children with tibia fractures who were all treated with long leg casts and told to start weight-bearing 1 week after the time of injury. They found that the majority of children did not start to ambulate until 15 days from injury. For each additional day that a patient delayed weight bearing, their healing time increased by 0.3 days even after adjusting for age and sex. The authors therefore concluded that early weight bearing in this patient population is not only safe but may potentially be beneficial to the recovery of the child.

McCollough, et al. review functional fracture-bracing of long-bone fractures of the lower extremity in children. Fifty-six tibial fractures treated by fracture bracing healed in an average of 13.2 weeks with no complications. The authors concluded that fracture bracing gave more freedom to the child and was eminently satisfactory to the parents.

Silva, et al. published a comparison of two approaches for the closed treatment of low-energy tibial fractures in children, with 40 treated in a long-leg cast flexed to 60 degrees to prevent weightbearing and 41 treated in long-leg casts flexed to 10 degrees to allow for weightbearing. The authors concluded that though many orthopaedic surgeons treat tibial shaft fractures in children with a period of non-weight-bearing after application of a long leg cast, low-energy tibial shaft fractures can be successfully managed by immobilizing the knee in 10 degrees of flexion and encouraging early weight bearing, without affecting the time to union or increasing the risk of angulation and shortening at the fracture site.

Figures A and B are an AP and lateral radiograph of a left tibia demonstrating diaphyseal fractures of the tibia and fibula that are length stable.

Incorrect Answers:
Answer 1: Most tibia fractures in children should initially be treated non-operatively. Exceptions include open fractures, length-unstable patterns, a floating knee and/or multiple long bone fractures (i.e., a poly-trauma).
Answer 2: Though many orthopaedic surgeons may choose to limit weightbearing for fear of displacement, early weightbearing may better maximize healing response and the child's overall recovery.
Answers 4-5: The patient should be placed in a long leg cast with a lesser degree of flexion (~10 degrees) if allowing for weightbearing; a short leg cast would not be acceptable for immobilization of a tibial shaft fracture.

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