Introduction
Nonphyseal fractures of the tibia and fibula are among the most common injuries involving the lower extremities in children and adolescents. ∗
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They are second only to fractures of the femur as a cause for hospital admissions for pediatric trauma. Most can be treated nonoperatively with satisfactory long-term results and minimal complications. However, certain tibial fractures pose unique problems that must be carefully evaluated and treated to avoid complications.Pathology
Relevant Anatomy
The shafts of the tibia and fibula are composed of a proximal metaphysis, central diaphysis, and distal metaphysis. The blood supply to the tibia is from (1) a nutrient artery, which is a branch of the posterior tibial artery that enters at the junction of the distal and middle thirds of the tibia and is responsible for the endosteal or medullary blood supply; (2) periosteal vessels, which are segmented and enter from muscular attachments; and (3) epiphyseal vessels. The inner two thirds of the cortex is supplied by the endosteal vessels, and the outer third is supplied by the periosteal vessels. Proximally, the epiphyseal and periosteal vessels are branches of the medial and lateral inferior geniculate arteries from the popliteal artery. The collateral circulation is rich proximally, especially on the medial aspect. Tibia fractures distal to the nutrient artery may deprive the distal fragment of its medullary blood supply, and, in such cases, the distal end of the tibia must rely on its periosteal and metaphyseal blood supply for healing. This supply is limited because of a lack of muscle attachment, and a slower rate of healing generally results. Periosteal and soft tissue stripping of the distal fracture from the injury or surgical intervention further slows the healing process.
The blood supply to the fibula is from the peroneal artery, which gives off a nutrient artery that enters the diaphysis just proximal to its midpoint. The rest of the artery supplies multiple segmental musculoperiosteal vessels that pass circumferentially around the fibula and supply both the fibula and the adjacent muscles.
From a surgical perspective, it must be remembered that the popliteal artery descends between the posterior aspects of the medial and lateral femoral condyles. It passes between the medial and lateral heads of the gastrocnemius muscle and along the distal border of the popliteus muscle before dividing into the anterior and posterior tibial arteries. The anterior tibial artery passes anteriorly between the two heads of the tibialis posterior muscle and enters the anterior compartment of the leg by passing through the proximal aspect of the interosseous membrane at the flare of the proximal tibial and fibular metaphyses. Displaced fractures in this region may damage the anterior tibial artery. Fortunately, such injuries rarely occur. The foramen in the interosseous membrane is long and narrow; it affords some protection inasmuch as the anterior tibial artery is allowed to move both proximally and distally. Corrective varus or valgus osteotomies of the proximal portion of the tibia can also damage the anterior tibial artery. Subperiosteal dissection in the region below the tibial tubercle helps protect this vessel.
Fracture Patterns
Fracture patterns involving the tibial and fibular diaphyses include compression (torus), incomplete tension–compression (greenstick), and complete fractures. Plastic deformities can also occur but predominantly involve the fibula. Complete fractures are further classified according to the direction of the fracture (i.e., spiral, oblique, or transverse) and as comminuted or segmental. Approximately 37% of tibial fractures are comminuted. Tibial and fibular fractures may also be open or closed, depending on the integrity of the overlying skin and soft tissues.
Prevalence
Fractures of the tibial and fibular shafts are the most common long bone fractures of the lower extremity and represent approximately 15% of all pediatric fractures. They occur more frequently in boys than in girls. Parrini and colleagues reported on 1027 long bone fractures in children between 1 and 11 years of age, including 326 tibial fractures (32%): 157 were isolated fractures of the tibia and 169 fractures were of both the tibia and fibula. Cheng and Shen studied 3350 children with 3413 limb fractures and also found tibial shaft fractures to be the most common lower extremity fracture, with a relatively static prevalence of 9% to 12% throughout various pediatric age groups.
An epidemiologic study by Karrholm and associates in Sweden in 1981 showed an annual incidence of 190 tibial fractures per 10,000 boys between infancy and 18 years of age and 110 tibial fractures per 10,000 girls in the same age range. In boys, the incidence peaked between 3 and 4 years of age and again between 15 and 16 years of age. The first peak involved predominantly spiral or oblique fractures, and the second peak involved primarily transverse fractures. In girls, the incidence was relatively even up to 11 to 12 years of age, and the tendency was toward a declining incidence with advancing age.
Mechanisms of Injury
Fractures of the tibia and fibula may be the result of direct or indirect forces. Direct trauma frequently produces a transverse fracture or segmental fracture pattern, whereas indirect forces are typically rotational and produce an oblique or spiral fracture.
In a 1982 study by Karrholm and associates, motor vehicle accidents involving children as passengers, as bicycle riders, or as pedestrians were the most common mechanism of tibial fractures. The age range of children in motor vehicle accidents was 8 to 14 years. Of interest, injuries from winter sports activities had almost the same incidence as motor vehicle accidents in girls. Falls were the most common mechanism of injury in young children. In a 1988 study by Shannak of 142 tibial shaft fractures, motor vehicle accidents caused 63% of the fractures; falls, 18%; direct violence, 15%; and sports, only 4%. A 2007 study by Kute and associates evaluated the trauma database of a pediatric level I trauma center and found that, of 238 patients admitted after all-terrain vehicle (ATV) accidents, 63% of patients had fractures; of those, 14% occurred in the tibia and fibula.
Consequences of Injury
Despite the frequency of pediatric tibial and fibular fractures, the consequences for most children are minimal. These fractures heal readily with minimal complications. Children typically have a rapid return to normal activities, including sports, and minimal disability. However, in a small percentage of cases, especially those involving open fractures or severe soft tissue injury, residual disability may occur.
Associated Injuries
It is not uncommon for children who sustain tibial and fibular fractures to have associated injuries, especially children who are victims of high-energy trauma, such as from motor vehicle–related accidents. In the study by Karrholm and associates, 27 of 480 children (6%) with tibial and fibular fractures sustained associated injuries, of which the most common were head injuries, fractures of the femur, and injury to an upper extremity. Other body areas (i.e., face and neck, chest, and abdomen) may also be injured, depending on the severity of the trauma. Children with open tibial fractures have the highest incidence of associated injuries. ∗
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Classification
A classification of nonphyseal fractures of the tibia and fibula is presented in Table 16-1 . A modification of the classification of Dias, this classification divides the tibial and fibular shafts into their three major anatomic areas: proximal metaphysis, diaphyses, and distal metaphysis. Fractures of the tibial and fibular diaphyses are subdivided according to the location (proximal third, middle third, and distal third) and the combination of bones fractured. This classification is useful for determining treatment methods and understanding potential long-term results and possible complications.
| Fractures of the proximal tibial metaphysis |
| Fractures of the tibial and fibular shafts |
| Isolated fractures of the tibial shaft |
| Isolated fractures of the fibular shaft |
| Fractures of the distal tibial metaphysis |
Diagnosis
History
The typical symptom of a tibial or fibular fracture is pain. However, the severity of the pain varies with the magnitude of the injury, the mechanism, and the age of the child. Frequently, a history is unavailable because the injury was not observed and the child is unable to verbalize symptoms or the mechanism of injury. In these cases, child abuse or battered child syndrome must also be considered (see Chapter 18 ). In young children, an inability to walk may be the only sign or symptom. If the child is able to speak, it is important to ascertain the mechanism of injury, if possible.
Physical Examination
Because pain is the major symptom in a tibial or fibular shaft fracture, it is important to have the child point to the most painful area. Palpation in this area may reproduce or increase the child’s discomfort. Deformity is not a common finding in young children because many tibial fractures are nondisplaced. Swelling or edema of the lower part of the leg also varies according to the mechanism of injury, the extent of soft tissue injury, and the presence of displacement. Usually, the soft tissue swelling is maximal at the fracture site. Stress examination may reveal instability or crepitation but invariably increases pain. A stress examination is usually unnecessary when a fracture is suspected. Injured extremities with a suspected tibial fracture are best splinted before radiographic evaluation, usually with a long leg posterior plaster splint. This relieves pain, prevents additional injury to the soft tissues, and allows for more accurate positioning of the extremity for radiographs.
Nerve damage in association with closed tibial and fibular fractures is very uncommon (see under the section Neurologic Injury). However, in all fractures, it is important to check dorsiflexion and plantar flexion of the foot and toes, as well as sensation, especially to touch. Nerve damage, if present, is most likely the result of a direct injury to the peroneal nerve at the proximal fibular metaphysis.
Arterial injuries associated with a closed tibial shaft fracture are also very uncommon (see under the section Vascular Injury). The peripheral pulses of the dorsalis pedis and posterior tibial arteries must be evaluated and recorded at the initial physical examination. Arterial injuries are most likely to be associated with a displaced proximal tibial metaphyseal fracture or an open fracture. Capillary circulation, sensation to the toes, pain on passive stretching, and pain out of proportion to the injury must be monitored carefully because compartment syndromes can occur in children after tibial fractures (see under the section Compartment Syndrome).
The soft tissues of the lower part of the leg must also be evaluated. It is important to assess the integrity of the skin at the fracture site. Fractures related to bicycle spoke injuries may ultimately result in full-thickness skin loss requiring delayed skin grafting. Any evidence of skin penetration at the fracture site is an indication that the fracture is open and contaminated (see under the section Open Tibial and Fibular Fractures).
Radiographic Evaluation
When a tibial or fibular shaft fracture is suspected, radiographs must be taken. After splinting of the injured extremity, anteroposterior (AP) and lateral radiographs are obtained. They must include the knee and ankle joints to rule out an associated epiphyseal fracture. Comparison radiographs of the opposite extremity may be indicated in complicated injuries, but this situation is unusual. Occasionally, incomplete fractures, such as a torus fracture, may be difficult to visualize. A spiral fracture of the tibial shaft with an intact fibula may be visible on only one view. It is therefore imperative that orthogonal radiographs always be obtained. Oblique radiographs may be beneficial if the initial radiographic appearance is normal but a fracture is suspected.
Special Diagnostic Studies
Special diagnostic imaging studies of the tibia and fibula may include technetium bone scans, computed tomography (CT), and magnetic resonance imaging (MRI).
Technetium bone scans may be useful in identifying occult fractures, especially in infants. Park and colleagues found that bone scans could be used to differentiate occult fractures of the femur or tibia from early acute osteomyelitis in infants. Images obtained early (1 to 4 days after the onset of symptoms) demonstrated a subtle increase in uptake along the entire length of the injured bone when an occult fracture was present. The distribution of uptake was similar regardless of the fracture pattern. In early acute osteomyelitis, focal uptake was observed at the site of infection. Technetium bone scan can also be useful in toddler’s and stress fractures.
CT of the tibia can be used to assess torsional alignment after complex unilateral fractures. It can also be used in the assessment of pathologic fractures of the tibia to determine the presence, size, and intralesional contours of the lesion. MRI can be used to detect early stress fractures accurately. This procedure, although expensive, avoids the high doses of radiation incurred with bone scans and CT.
Management
Fractures of the Proximal Tibial Metaphysis
Proximal tibial metaphyseal fractures are relatively uncommon injuries that generally occur in children between 3 and 6 years of age (range, 1 to 12 years). ∗
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The male-to-female ratio of approximately 3:1 closely parallels the incidence of tibial fractures by gender in children. These fractures are typically the result of a direct injury to the lateral aspect of the extended knee. Most of these fractures have minimal or no displacement and appear benign radiographically; however, they may, in fact, be followed by a posttraumatic valgus deformity. Greenstick and complete fractures are most commonly associated with a valgus deformity. Such deformities are unusual after a torus fracture. In a greenstick fracture, the medial cortex (tension side) fractures while the lateral cortex (compression side) remains intact or hinges slightly. If the lateral cortex hinges, a valgus deformity occurs. However, displacement is not usually seen, and apposition remains normal. The fibula is typically intact but may occasionally sustain either a fracture or plastic deformation. Radiographically, the degree of angulation can be difficult to ascertain unless radiographs are obtained of both lower extremities symmetrically positioned on a long cassette and the true angulation is measured. Oblique views and, occasionally, fluoroscopy may be beneficial in defining the fracture and any angulation.There have been numerous reports of posttraumatic genu valgum after proximal tibial fractures. †
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Interestingly, similar valgus deformities may occur in association with other conditions affecting the proximal tibial metaphysis, such as acute and chronic osteomyelitis, harvesting of a bone graft, excision of an osteochondroma, and osteotomy.
The incidence of a valgus deformity after a proximal tibial metaphyseal fracture varies greatly, ranging from 0% to 62%. Theories regarding the cause of valgus deformity have included injury to the lateral aspect of the proximal tibial physis, inadequate reduction, premature weight-bearing, hypertrophic callus formation, dynamic muscle action, soft tissue interposition (periosteum, pes anserinus, medial collateral ligament), tethering from an intact fibula, and asymmetric growth stimulation. However, valgus deformity has been reported after complete fractures of the proximal ends of the tibia and fibula.
Currently, most authors attribute valgus deformity to asymmetric growth of the proximal part of the tibia. ∗
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Houghton and Rooker, in experimental studies with immature rabbits, found that medial hemicircumferential division of the periosteum resulted in valgus overgrowth. They believed that if the medial periosteum is torn during a proximal tibial metaphyseal fracture, asymmetric overgrowth occurs and produces a valgus deformity. Spontaneous correction with growth has also been observed.Aronson and colleagues in 1990 reported on an experimental model with immature rabbits that confirmed asymmetric growth as the cause of posttraumatic valgus deformity. Twenty-two 8-week-old rabbits were divided into two equal groups. In one group, the periosteum on the medial aspect of the proximal tibial metaphysis was excised, and a partial osteotomy involving the medial half of the metaphysis was performed. In the other group, the same procedure was performed on the lateral side. Parallel K-wires were inserted above and below the partial osteotomy. A valgus deformity (mean of 12°) occurred in the first group, and a varus deformity (mean of 10°) developed in the second. In each animal, the K-wires remained parallel, thus indicating that the deformity occurred at the physis. Despite the asymmetric growth, the light microscopic appearance of the physes was normal. The deformities were therefore attributed to asymmetric physeal growth, which was not demonstrable histologically. Ogden reported that the normal circulation to the knee has a more extensive medial geniculate blood supply, especially in the proximal tibial region, than a lateral geniculate supply, which may be responsible for transient eccentric growth. Zionts and colleagues supported the concept of eccentric growth by demonstrating, in quantitative scintigraphic studies, proportionally greater uptake on the medial side than the lateral side and overall increased uptake on the injured as compared with the uninjured side. In 1995, Ogden and colleagues performed detailed measurements of the metaphyseal–diaphyseal–metaphyseal distances medially and laterally of the injured and noninjured tibias of 17 children with 19 proximal tibial metaphyseal fractures (2 children had bilateral fractures) monitored for a mean of 3.7 years (range, 2 to 7 years). The difference between the medial and lateral sides of the injured tibias was 7.4 mm, which was an indication of eccentric medial growth. Interestingly, the 3.3-mm difference noted between the injured and uninjured lateral sides was a reflection of overall growth stimulation on the injured side. These observations occurred with or without an intact fibula.
It is clear from these studies that a valgus deformity is not usually a complication of the initial reduction but, instead, is secondary to differential growth between the medial and lateral aspects of the proximal tibial epiphysis.
Evolution of Treatment
It is now accepted that a valgus deformity stabilizes and then improves with growth and development. The deformity usually develops within 5 months of injury, reaches its maximum within 18 to 24 months, stabilizes, and then begins to improve by a combination of longitudinal growth and physeal (proximal and distal) realignment. Unfortunately, no data indicate how much improvement can be anticipated. Ippolito and Pentimalli observed that deformities of 15° or less usually remodeled completely, especially in young children. More severe deformities did not completely remodel.
Zionts and MacEwen monitored seven children with posttraumatic tibia valga for a mean of 39 months after injury. These children ranged in age from 11 months to 6 years. It was found that the valgus deformity progressed most rapidly during the first year after injury and then continued at a slower rate for as long as 17 months; overgrowth of the tibia accompanied the valgus deformity. The mean overgrowth was 1 cm (range, 0.2 to 1.7 cm). Clinical correction with subsequent growth occurred in six of the seven patients. These authors recommended a conservative approach to management of both the acute fracture and the subsequent valgus deformity. If the valgus deformity fails to correct satisfactorily by early adolescence, a tibial osteotomy can be performed. They also recommended that the mechanical tibiofemoral angle, as described by Visser and Veldhuizen, be used to measure the alignment of the lower extremity rather than Drennan’s metaphyseal–diaphyseal angle. The latter measures only the alignment of the proximal end of the tibia. This angle is useful in the immediate postinjury stage but not in the follow-up period because considerable correction of the deformity is a result of distal realignment. The distal tibial epiphysis tends to reorient itself perpendicular to the pressure forces, thereby resulting in eccentric growth and an S -shaped appearance of the tibia radiographically.
In an experimental study in dogs, Karaharju and associates observed that the tibial physes changed their direction of growth after an osteotomy and residual valgus angulation. In the study by Ogden and colleagues, no true correction of the proximal tibia valga was observed, but eccentric growth was present distally and led to realignment of the ankle joint toward its normal parallel alignment with the floor and knee.
McCarthy and associates in 1998 made similar observations in their study of 15 children with posttraumatic genu valgum, of whom 10 were treated nonoperatively and 5 operatively. At approximately 4 years of follow-up, they found essentially no difference in the complementary physeal shaft and tibiofemoral angles and maximal valgus deformity of the two groups. They recommended nonoperative treatment and observation, especially for children 4 years or younger when injured.
Tuten and associates in 1999 reevaluated the seven children of Zionts and MacEwen at a mean follow-up of 15.3 years (range, 10.4 to 19.9 years). Every patient had spontaneous improvement of the metaphyseal–diaphyseal and mechanical tibiofemoral angles. However, most of the correction was thought to have occurred in the proximal end of the tibia. The mechanical axis of the limb remained lateral to the center of the knee joint in every patient, and the mean deviation was 15 mm (range, 3 to 24 mm). The affected tibia was slightly longer. The affected knee score was excellent in five patients and fair in two. One patient required a tibial osteotomy because of knee pain secondary to malalignment. The authors concluded that posttraumatic tibia valga should be observed throughout growth and that operative intervention should be reserved for patients with symptoms from malalignment.
Current Algorithm
Most proximal tibial metaphyseal fractures can be treated nonoperatively with closed reduction techniques. Treatment consists of correction of any valgus angulation of greenstick fractures and immobilization in a long leg cast with the knee in extension for 4 to 6 weeks or until the fracture is well united. Slight overcorrection, if possible, may be desirable. Displaced fractures require reduction as well as correction of any residual valgus angulation. However, normal apposition is not always necessary. Currently, indications for operative management of these fractures are limited. An inability to correct a significant valgus deformity under general anesthesia rather than failure to close the medial fracture gap is probably the major indication. The latter is usually indicative of soft tissue entrapment, but this complication does not contribute to subsequent overgrowth.
After satisfactory fracture reduction and cast application, fracture alignment should be assessed radiographically at least weekly for the first 3 weeks after injury. Any loss of alignment should be corrected. During this initial period, the child must avoid weight-bearing to minimize compression forces and the possibility of valgus angulation at the fracture site in the cast.
Special Considerations for Multiple Traumatic Injuries
Children who are victims of multiple traumatic injuries may sustain an unrecognized proximal tibial metaphyseal fracture, especially if an ipsilateral femoral shaft fracture is present. Bohn and Durbin reported three males with proximal tibial metaphyseal fractures and ipsilateral femoral fractures in whom posttraumatic genu valgum and lower extremity overgrowth of 1.8 to 2.2 cm developed. In one, a 20° deformity resolved over a 5-year period. It is important that during the secondary survey the lower part of the legs be carefully evaluated for occult injuries and that radiographs be obtained in cases of suspected fractures. The presence of a proximal tibial metaphyseal fracture may necessitate a change in treatment plan for the other musculoskeletal injuries. If an associated femoral shaft fracture is present, stabilization by either internal or external fixation may be necessary so that adequate closed reduction of the proximal tibial metaphyseal fracture can be achieved and maintained.
Treatment Options
Nonoperative Management
The vast majority of angulated or displaced proximal tibial metaphyseal fractures are amenable to closed reduction and immobilization in a long leg plaster cast. Such management is almost always performed under general anesthesia to ensure adequate relaxation and pain relief. In some instances, the intact lateral cortex of a greenstick fracture must be fractured to achieve correct alignment. Once satisfactory alignment is obtained, the lower extremity must be immobilized in a long leg cast with the knee in extension. An AP radiograph of both lower extremities on a long cassette should document correction of the valgus deformity and symmetric alignment with the opposite uninvolved extremity. Slight overcorrection (5°, if possible) is desirable to counter any valgus overgrowth. A lateral radiograph of the fractured tibia should also be obtained.
After a satisfactory closed reduction, repeated radiographs are obtained weekly for the first 3 weeks to assess maintenance of alignment. These radiographs consist of a non–weight-bearing AP view of both lower extremities on a long cassette and a lateral view of the fractured extremity. Subtle changes in alignment may not be appreciated unless both extremities are included on the radiograph. Any loss of alignment should be corrected by cast wedging techniques or a repeated attempt at closed reduction. Repeated closed reduction may require general anesthesia, depending on the age of the child, the amount of correction necessary, and the degree of healing. Immobilization is continued until the fracture is well healed radiographically.
Surgical Management
Surgery is rarely indicated. Usually, the best alignment by closed reduction is accepted. Only if significant residual valgus deformity is present, with or without closure of the medial fracture gap (entrapped soft tissue), is open reduction considered. At surgery, after any entrapped soft tissue has been removed, the fracture can typically be reduced anatomically and the periosteum repaired. Internal fixation is not generally necessary, and fracture alignment is maintained by a long leg plaster cast with the knee in extension. The child is then monitored as described for nonoperative management.
Open proximal tibial metaphyseal fractures are rare but can occur in children who are victims of polytrauma. They are managed in the same manner as other open tibial shaft fractures (see under the section Open Tibial and Fibular Fractures). An external fixator may be necessary for stabilization, especially in children with segmental bone loss, instability, or other significant fractures or body area injuries. Epiphyseal pins may be necessary in these fractures to achieve adequate stability.
The final step in either management method is to advise the family that even though satisfactory or anatomic alignment of the fracture has been obtained, valgus deformity and tibial overgrowth are possible as a natural consequence of this fracture. Such counseling prepares the family for this complication, should it occur. The necessity of long-term follow-up must be emphasized.
Valgus Deformities
Treatment of valgus deformities after proximal tibial metaphyseal fractures is controversial. Conservative management with an orthosis has been suggested, but there is no evidence to substantiate the efficacy of this method. Surgical correction was initially believed to be necessary. Salter and Best reported that 10 of 13 patients with valgus deformity required tibial osteotomy for correction. Balthazar and Pappas pointed out that, even with osteotomies, the valgus deformity can recur. Such recurrence has been attributed to the same asymmetric overgrowth phenomenon that led to the valgus deformity initially. In their six patients who had osteotomies, the valgus deformity recurred, though to a lesser degree. Similar results were reported by DalMonte and colleagues, who observed recurrent valgus deformities in 7 of 16 patients (44%) after proximal tibial osteotomies. No significant difference was seen in the prevalence of recurrence in children younger than 5 years (60%) and those between 5 and 10 years of age (36%), except that the younger children experienced a greater recurrent deformity. These authors concluded that the osteotomy is essentially a second fracture and therefore has the same pathologic factors. Recurrent valgus deformity after corrective osteotomy has been observed by others.
Zionts and MacEwen and Tuten and associates recommend that most valgus deformities be observed until early adolescence. If spontaneous improvement fails to provide sufficient clinical correction or if the malalignment is causing pain, a proximal tibial varus shortening osteotomy and fibular diaphyseal osteotomy may be necessary. Zionts and MacEwen also suggested medial epiphysiodesis as another method for simultaneous correction of both the angular deformity and any remaining lower extremity length inequality. Medial epiphysiodesis has also been recommended by Robert and associates. Although tibial overgrowth is not usually excessive, it may be important for both the valgus and the overgrowth to be corrected simultaneously if surgery is performed.
Follow-up Care and Rehabilitation
Once fracture healing is complete, the long leg cast can be removed. Initially, the child is allowed full weight-bearing, and knee range-of-motion exercises are encouraged. Failure to achieve satisfactory knee motion within 2 weeks of cast removal is an indication for supervised physical therapy, but such therapy is rarely necessary. Radiographic follow-up at 3-month intervals is usually performed during the first year and should consist of a standing AP view of both lower extremities on a long cassette for assessment of alignment. Orthogonal radiographs or scanograms may be necessary if significant tibial overgrowth has occurred. It is important that all children be monitored for at least 2 years after a fracture. Longer follow-up is necessary if a valgus deformity or significant lower extremity length inequality occurs.
Results
It appears that in approximately 50% of children who sustain proximal tibial metaphyseal fractures, a clinically apparent valgus deformity, tibial overgrowth, or both will develop. Zionts and MacEwen showed that the maximal deformity induced by overgrowth is present by approximately 18 months after the injury. Improvement begins thereafter, and maximal improvement has usually been achieved by 4 years after the injury. Minor residual deformities may continue to correct with subsequent growth and physeal alignment. Significant deformities persisting after 12 years of age may require surgical correction.
Authors’ Preferred Method of Treatment
In the initial management of an acute fracture, any angular or valgus deformity may be corrected, or even slightly overcorrected, by nonoperative closed reduction techniques under general anesthesia. The parents must be warned of possible valgus deformity and tibial overgrowth. To evaluate alignment after closed reduction, adequate radiographs must be obtained. Alignment of the lower extremities should be assessed on an AP view of both lower extremities symmetrically positioned on a long cassette. With this method, the true alignment of the tibia can be measured directly and compared with the opposite side. If correction of a valgus deformity cannot be achieved by closing the medial fracture gap or fracturing the lateral cortex, open reduction is indicated. Failure to close the medial fracture site is typically indicative of soft tissue interposition from the periosteum, pes anserinus, medial collateral ligament, or a combination thereof. After satisfactory reduction is achieved, a long leg cast is applied with the knee in extension. Only by having the knee in extension is it possible to radiographically assess alignment of the tibia. The child is reevaluated radiographically at weekly intervals for the first 3 weeks after the injury. Any change in position of the alignment in the cast is an indication for cast wedging or repeated closed reduction.
Treatment of valgus deformities is not usually considered for 2 to 3 years after injury, depending on the age of the patient and the degree of valgus. The authors do not believe that the use of orthoses or night splints corrects or alters the growth abnormality. Families are advised that approximately 50% correction of any valgus deformity will occur during the first 3 to 4 years after injury ( Fig. 16-1 ). Only after this time is it possible to determine whether further treatment is necessary. If the maximal valgus deformity exceeds 20°, the residual deformity may be too severe to accept, and an osteotomy may be necessary. Valgus deformities are not generally clinically significant until they are 5% to 10% greater than on the normal side.
If a corrective osteotomy is performed, it is usually a closing wedge proximal tibial and oblique diaphyseal fibular osteotomy. It is important that a fasciotomy of the anterior compartment be performed to minimize the risk of compartment syndrome. The deformity should be slightly overcorrected at the time of surgery because of the tendency for recurrence. Internal fixation with staples or crossed Steinmann pins can be used. Compression plates can also be considered, but they require a second, more extensive operative procedure for removal. The authors recommend stabilization after the osteotomy to maintain alignment and prefer percutaneous crossed Steinmann pins or a simple external fixation system consisting of a single threaded Steinmann pin placed above and below the osteotomy and secured with an external fixation clamp. This simple technique maintains apposition and prevents rotation and angulation. The leg is then immobilized in a long leg cast with the knee in extension. The child is closely monitored radiographically to assess alignment and healing. Once the osteotomy site has healed (usually in 6 weeks), the Steinmann pins are removed, typically in an outpatient clinic.
Temporary stapling of the medial aspect of the proximal tibial epiphysis is also an attractive treatment option because it allows correction with growth and does not provide the same magnitude of stimulation as a corrective osteotomy, which can contribute to recurrence. The authors have no experience with this procedure for this condition.
After satisfactory healing, the child is allowed full weight-bearing, and knee range-of-motion exercises are encouraged. If satisfactory motion of the knee has not been obtained after 2 weeks, supervised physical therapy is instituted. The child should be monitored for at least 2 years to observe for recurrent valgus deformity, tibial overgrowth, or both. Standing radiographs are obtained at 3- to 6-month intervals, and scanograms are obtained annually.
Fractures of the Tibial and Fibular Shafts
Fractures involving both the tibial and the fibular diaphyses are more common than isolated fractures of the tibia. In Shannak’s 1988 review of 117 children with tibial shaft fractures, 85 (73%) had an associated fracture of the fibula. The mean age at fracture was 8 years (range, 1 to 15 years). Boys were involved three times more frequently than girls. The middle or lower third of the tibial shaft was involved in 104 fractures (90%). Oblique (35%) and comminuted (32%) were the most common fracture patterns. Only four fractures (3%) were open. Parrini and colleagues also found that tibial and fibular fractures were more common than isolated tibial shaft fractures in children between 1 and 11 years of age. Similar findings were reported by Yang and Letts in 1997. Typically, fractures of both the tibia and the fibula require greater energy than an isolated tibial shaft fracture does. They generally result from direct injury rather than from rotation, as occurs in the latter. This mechanism accounts for the increased incidence of oblique, transverse, and comminuted fracture patterns.
Evolution of Treatment
The major problems with fractures of the tibial and fibular shafts are shortening, angulation, and malrotation. Valgus deformities are common because of the action of the long flexor muscles of the lower leg. However, these problems are not usually severe, and almost all fractures are amenable to nonoperative or closed methods of treatment. In the study by Shannak, the 117 pediatric tibial shaft fractures were followed for a mean of 3.9 years (range, 3 to 10 years); it was determined that satisfactory results can almost always be expected with conservative treatment and that surgery is usually not indicated or justified. Shortening of 5 mm or less is compensated for by growth acceleration, and mild varus angulations undergo spontaneous correction. Unfortunately, valgus malalignment and rotational deformities persist and must be corrected. However, in certain situations, surgical management with either internal or external fixation may be advantageous. These select indications are presented in Table 16-2 .
| Open fractures |
| Type III and some type II |
| Segmental bone loss |
| Unstable closed fractures |
| Segmental |
| Neurovascular injuries |
| Multiple traumatic injuries |
| Severe body area injuries |
| Head injuries with spasticity or combativeness |
| Ipsilateral femoral fractures |
| Multiple fractures |
| Soft tissue abnormalities |
| Burns |
| Skin loss |
| Compartment syndromes (fasciotomies) |
Current Algorithm
Nearly all closed tibial and fibular shaft fractures in children can be managed by nonoperative techniques. Nondisplaced fractures are immobilized in a long leg cast with the knee flexed 20° to 60°. Depending on the fracture pattern, the child is not allowed to bear weight for 3 to 4 weeks or until early radiographic healing is evident. A long leg cast with the knee extended may then be applied; full weight-bearing is allowed until complete healing has occurred. In distal third fractures, a patellar tendon-bearing (PTB) cast or short leg cast may, instead, be applied.
Displaced closed fractures require closed reduction, and strict attention must be paid to maintenance of tibial length and correct angulation and rotation alignment. This procedure can usually be accomplished with manipulation and application of a long leg cast with the knee flexed 20° to 60°. If the tibial fracture is oblique or comminuted, maintenance of length may be difficult, and surgical treatment may need to be considered. After application of the long leg cast, the patient must be monitored closely, usually weekly for 2 to 3 weeks, so that maintenance of fracture alignment can be assessed. Minor alterations in angulation can be corrected by cast wedging techniques. When the fracture is stable both clinically and radiographically, usually 4 to 6 weeks after the injury, a long leg weight-bearing cast with the knee in extension or possibly a PTB or short leg cast, depending on the fracture type and location, may be applied for an additional 2 to 3 weeks until the fracture is well healed.
Unstable closed fractures (oblique or comminuted) in a child who is a victim of polytrauma may benefit from the more aggressive operative methods of management, particularly external fixation or the newer flexible intramedullary rods.
Special Considerations for Multiple Traumatic Injuries
Children who have multiple traumatic injuries and additional long bone fractures or significant injuries to other body areas may benefit from having their fractures stabilized surgically (see Table 16-2 ). Surgical stabilization enhances their overall care by improving both stability and mobility. The child is more easily cared for, and other diagnostic studies such as CT and MRI are facilitated because the child can be transported and properly positioned in the gantry. The most common method of surgical stabilization of pediatric tibial and fibular fractures is external fixation. A variety of half-pin cantilever systems and small-pin transfixation rings have been used for external fixation of tibial fractures in children. The former is the preferred method because of the ease and speed of application and the decreased risk of neurovascular injury; in addition, this system does not block surgical exposure to any associated wounds. The Taylor spatial frame can also be considered as another method of external fixation. Wires, pins, and screws are occasionally used as surgical adjuncts. Compression plates and screws are not generally recommended because of the extensive dissection necessary for application, the increased risk of infection, and the need for a second extensive procedure for hardware removal. Flexible intramedullary rods, which avoid injuries to the proximal and distal tibial epiphyses, are becoming a popular newer alternative.
Treatment Options
Closed fractures of the tibial and fibular diaphyses in children are usually uncomplicated, and their healing is typically rapid compared with similar fractures in adults. Current treatment methods consist of nonoperative and surgical management.
Nonoperative Management
Most closed fractures of the tibial and fibular shafts can be managed by closed reduction and immobilization in a long leg cast. Displaced fractures usually require reduction under general anesthesia, whereas nondisplaced fractures can frequently be managed with a cast after sedation. This first cast usually has the knee flexed 20° to 60° to discourage weight-bearing. Once satisfactory alignment has been achieved, the fracture is assessed radiographically at weekly intervals for the first 3 weeks. Minor changes in alignment can be corrected with cast wedging techniques. Significant loss of alignment may require repeated closed reduction under general anesthesia. After 1 to 4 weeks, depending on the type of fracture and degree of radiographic healing, a weight-bearing long leg cast with the knee in extension may be applied. The cast is worn until fracture healing is complete. In patients with fractures in the lower third of the tibia and fibula, a PTB cast or possibly a short leg cast may be used instead. A functional brace, as described by Sarmiento and Latta, can also be considered for older adolescents. Sarmiento’s group applied the functional brace approximately 2 weeks after the injury and initial treatment with a long leg plaster cast. They reported minimal problems with shortening, angulation, malrotation, and delayed union or nonunion.
The major problem when both the tibial and the fibular shafts are fractured is shortening. Angulation can also develop inasmuch as the long flexor muscles tend to produce a valgus rather than a varus deformity at the fracture. Recurvatum may also occur, especially in children with considerable soft tissue swelling at the time of initial reduction and cast application. Wedging of the cast by opening or closing techniques may be required to correct the angulation. Often, it is best to wait 1 to 2 weeks for the soft tissue swelling to resolve and for the fracture to develop some stability. If considerable swelling is observed initially, it may be better to apply a posterior splint and then perform the definitive manipulative reduction 4 to 7 days later when the swelling has subsided, the risk of compartment syndrome has passed, and a more appropriate, well-fitting cast can be applied.
For unstable fractures of the tibial and fibular diaphyses, especially those that are displaced, comminuted, and with appreciable shortening, other methods of closed management have been proposed. A long leg cast with the knee flexed and the foot in mild plantar flexion can be effective. After 3 weeks, the cast is changed, and the foot is brought to the neutral position. Shannak recommended skeletal traction with a Steinmann pin through the os calcis of the heel. After 10 to 14 days, sufficient healing has usually occurred to allow application of a long leg cast with the knee in extension. These methods are rarely used today. Most authors prefer surgical stabilization with some type of external or internal fixation.
Surgical Management
Acceptable parameters for alignment for nonoperative management include up to 5° of varus or valgus angulation, less than 5° of sagittal angulation, and 1.0 cm or less of shortening. Translation of the entire shaft is acceptable in a child 8 years of age or younger, and up to 50% translation is acceptable in older children and adolescents. The principles of surgical management of pediatric fractures are distinctly different from those used in skeletally mature adults. When surgical management is indicated for a pediatric fracture, the general principles of Spiegal and Mast must be considered. These principles are applicable both in polytrauma patients and in those with specific tibial fractures. The principles applicable to tibial shaft fractures include (1) satisfactory, possibly anatomic, alignment should be achieved, with particular attention to rotation and angular orientation; (2) internal fixation devices, if used, should be easy to remove; (3) rigid fixation to maintain fracture alignment rather than to allow for immediate mobilization of the lower leg is usually the goal; therefore a supplemental plaster cast may be required; and (4) external fixators, when used, should be removed as soon as any soft tissue wounds have healed or the fracture is stable and will not become displaced. Cast immobilization is continued until complete healing has occurred. The choice of surgical treatment of pediatric fractures should be guided by analyzing the extent of soft tissue injury, the location of the fracture, the fracture pattern, and the extent of other associated injuries.
External Fixation
External skeletal fixation has been the most common surgical treatment for pediatric tibial and fibular fractures, particularly those that are very comminuted and unstable or associated with severe overlying soft tissue injury ∗
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(see Table 16-2 ). Techniques include pins above and below the fractures that are incorporated into a plaster cast ( Fig. 16-2 ) or a variety of commercial half-pin and ring fixator systems. External fixation is usually maintained until adequate callus formation has been achieved and the fracture is stable. At that time, the fixator is removed and replaced by a long leg cast with the knee in extension. Tolo reported that the use of external fixators increased the healing time and was associated with a significant prevalence (50%) of superficial pin tract infections and a high rate of refracture. Three of 13 tibial fractures (23%) refractured 5 to 10 months after injury. Whether the refractures were caused by stress shielding, premature frame removal, or relative ischemia from the local trauma was unknown. All three refractures healed with immobilization in long leg casts. In 2007 Myers and colleagues in a study of 31 consecutive high-energy tibial fractures, reported a significant incidence of complications with external fixation. These included malunion, delayed union, wound infection, osteomyelitis, and lower extremity length discrepancy. There were no refractures.
The advantages of external fixation of pediatric tibial shaft fractures include rigid immobilization, direct surveillance of the lower part of the leg and any associated wounds, facilitation of wound dressing and management, patient mobilization for other diagnostic studies and management of other body area injuries, and possible application under local anesthesia in severely injured children. The use of the Taylor spatial frame has recently been shown to be a newer method of external fixation, particularly in unstable fractures in older children and adolescents.
Internal Fixation
Closed or open reduction with internal fixation of pediatric tibial and fibular diaphyseal fractures is not commonly indicated, but their frequency is increasing. Operative techniques include limited internal fixation with K-wires, Steinmann pins, and cortical lag screws; compression plates and screws ( Fig. 16-3 ); and flexible intramedullary rods.
Compression plates and screws require extensive dissection and periosteal stripping, which can increase the risk of infection or delayed union or nonunion because of further disruption of the blood supply to the bone. Nevertheless, they are an acceptable technique in closed, comminuted fractures when satisfactory alignment by nonoperative techniques cannot be achieved. Newer percutaneous techniques for plate application have been described, and this modification will likely decrease the rate of these complications. Reamed intramedullary nails can be considered for older adolescents approaching skeletal maturity.
Flexible intramedullary rods are gaining popularity in pediatric fractures, including tibial shaft fractures. In 1985, Ligier and colleagues from France reported on the results of using two flexible intramedullary rods in 19 pediatric tibial fractures. Such treatment produced elastic stability at the fracture site, which enhanced the formation of bridging external callus by eliminating shear forces and allowing compression forces across the fracture site. One rod was inserted through the medial and the other through the lateral proximal tibial metaphysis, distal to the physis and posterior to the apophysis of the tibial tubercle, and then passed distally across the fracture site to terminate proximal to the distal tibial physis. They reported that no cast immobilization was necessary, and all fractures healed within 3 months. The major indications for intramedullary fixation were predominantly for unstable fractures that failed nonoperative management. In 1988, Verstreken and associates from Belgium also used the technique of elastic stable rodding in children. They recommended its use for tibial fractures with contralateral lower limb injuries in children 6 years and older, especially those who had sustained multiple injuries from trauma. In 2001, Qidwai reported on 84 tibial fractures, including 30 open fractures treated with a similar technique of intramedullary K-wires (2.5 to 3.5 mm in diameter). The mean age at fracture was 10.2 years (range, 4 to 15 years), and 54 had an associated fibular fracture. The fractures healed at a mean of 9.5 weeks (range, 8 to 14 weeks), and the implants were removed at a mean of 5.6 months postoperatively. The mean follow-up was 18 months (range, 13 to 16 months). No delayed unions, nonunions, or lower extremity length discrepancies greater than 1.0 cm were observed. No postoperative infections occurred in the 54 closed fractures. However, in the 30 open fractures, five postoperative infections (four superficial and one deep) were reported. The author concluded that the technique was simple and produced good clinical, radiographic, and functional results. In another study, O’Brien and colleagues followed 16 unstable tibial fractures treated by flexible nailing (three of which were open), and all healed uneventfully. In a comparison study of 31 consecutive tibial fractures, including 16 patients managed with flexible intramedullary nails and 15 patients managed with external fixation, Kubiak and colleagues demonstrated improved functional results with the former. This included eight open fractures in the intramedullary nailing group and five open fractures in the external fixator group. Gicquel and colleagues noted that insufficient bending of the medial nail may lead to valgus malunion when both the tibia and fibula are fractured. Other authors have recently reported satisfactory results with low complication rates using flexible intramedullary nails. Other options include percutaneous pin fixation.
Follow-up Care and Rehabilitation
Most children with tibial and fibular fractures do not require physical therapy for rehabilitation. They usually regain full knee and ankle motion within the expected time and return to full activities much sooner than their parents and orthopaedic surgeons would like. An inability to regain full knee and ankle motion within 2 to 3 weeks after the cast is removed is a common indication for physical therapy. Normal activities, including sports, can be allowed once motion is regained, muscle strength returns to normal, and radiographs show solid union, usually 4 to 6 weeks after the last cast is removed. The child is then monitored at 3- to 6-month intervals for approximately 2 years to assess function, leg length, and resolution of any residual problems such as mild angulation.
Results
The results after nonoperative management of uncomplicated closed tibial and fibular shaft fractures are uniformly satisfactory. The fractures heal rapidly, depending on age, and minor discrepancies in length and angulation may correct spontaneously with subsequent growth.
Approximately 25% of children with tibial and fibular shaft fractures have minor tibial length inequalities and angulatory changes at initial healing. Significant rotational problems are fortunately uncommon. Because the amount of overgrowth of the tibia and fibula secondary to fracture stimulation is small, it is important to maintain adequate length during healing. In tibial fractures in boys older than 12 years and in girls older than 10 years, an attempt must be made to achieve full length. The amount of shortening that can be accepted after closed reduction of these fractures is 5 to 10 mm in girls 3 to 10 years of age and in boys 3 to 12 years of age. Older children and adolescents require alignment that is as close to anatomic as possible. Younger children may have overgrowth in both the tibia and femur, whereas older children and young adolescents may actually experience growth retardation. The type of fracture and the presence of residual angulation do not appear to affect the amount of overgrowth. The growth stimulation process is usually complete 2 years after injury. Reynolds demonstrated that, within 3 months of injury, the rate of growth was at its maximum and was 38% in excess of normal. The growth rate then decreased but remained significantly elevated for 2 years; it returned to normal in the tibia approximately 40 months after injury.
It is also important to correct any coexistent angular or rotational deformity. Angular deformities may improve with growth, but rotational malalignment does not. Varus deformities of up to 15° in young children can undergo spontaneous correction. However, valgus and posterior angulation tend to persist, as do rotational deformities, particularly medial or internal rotation. In uncomplicated fractures, function can be expected to return to normal.
Gordon and associates reviewed 51 tibial shaft fractures in 50 patients treated with flexible intramedullary nailing. The cohort included 25 closed fractures and 26 open fractures. Of the fractures, 21 were treated with closed nailing and 30 required open reduction. Only one patient (2%) developed an infection; the patient had a grade II open tibial fracture and developed osteomyelitis after fracture union. Fifty of the 51 fractures healed in acceptable alignment. A 13.6-year-old patient required an osteotomy 23 weeks postoperatively to correct a valgus-procurvatum deformity. Forty-four of the 50 fractures healed without appreciable limb-length discrepancy. Three patients had asymptomatic lengthening, and four had asymptomatic shortening. Five fractures had delayed healing (range, 31 to 55 weeks): three healed with repeated casting, and two went on to nonunion and required repeated surgical intervention to achieve healing. Of note, three of the five fractures that had delayed healing were closed injuries.
Authors’ Preferred Method of Treatment
Because closed tibial and fibular fractures in children usually heal rapidly and with satisfactory long-term results, the authors recommend closed reduction and immobilization in a long leg cast for the majority of cases. Only a small percentage of closed fractures require operative management with either external or internal fixation.
Most nondisplaced fractures are managed by a long leg cast applied with the knee in 20° to 60° of flexion. Weight-bearing is avoided for 2 to 3 weeks; a long leg cast is then applied with the knee in extension, and toe-touch weight-bearing is allowed. Once callus formation is visible, the cast may be changed to either a PTB or a short leg cast, depending on the fracture location and the degree of radiographic healing.
Displaced fractures of the tibia and fibula are reduced under general anesthesia. When displacement is present, extensive injury to the surrounding soft tissues has usually occurred. These children have an increased risk of compartment syndrome and are admitted to the hospital for observation after reduction and immobilization in either a posterior splint or a long leg cast, depending on the degree of soft tissue swelling. If a splint is used initially, the long leg cast should be applied 4 to 7 days later to allow resolution of the soft tissue swelling; the procedure is usually performed under general anesthesia. After immobilization, the patient is evaluated radiographically at weekly intervals for the first 3 weeks. If alignment is lost, the need for cast wedging or repeated closed reduction must be considered. In most cases, the displacement is minor and can be managed by cast wedging.
For an unstable fracture with unacceptable alignment after closed reduction, an external fixator may be necessary. The authors prefer half-pin systems. They are easy to apply, but care must be taken to avoid injury to the proximal and distal tibial physes. The use of fluoroscopy ensures safe application of these devices. These systems control length, angulation, and rotation. They are typically supplemented with a posterior splint for the first several weeks to immobilize both the knee and the ankle for comfort. Depending on the age and reliability of the child, partial weight-bearing may be allowed 2 to 4 weeks after injury. Transverse fractures that heal with small areas of callus may require longer periods with the frame in place to prevent recurrent deformity. Once callus is confirmed radiographically and any associated wounds have healed, the external fixation device is removed and replaced with a long leg or PTB cast until fracture healing is complete.
Flexible intramedullary nailing has become a common method of treatment. The nail size should be selected so that approximately 80% of the tibial canal is filled by the nails. Care must be taken to avoid injury to the proximal tibial epiphysis and tibial tubercle during rod insertion. However, burying the pins beneath the skin obviates the need for pin care and enables access to the overlying soft tissues. Some patients do develop reactive bursae over the ends of the nails if they protrude from the bone too much.
Isolated Fractures of the Tibial Diaphysis
Fractures of the tibial shaft with an intact fibula are common in children. They can be either incomplete tension–compression (greenstick) or complete fractures. Shannak and Parrini and colleagues found fractures involving both the tibia and fibula to be the most common. Shannak reported that only 32 (27%) of 117 children with tibial fractures had isolated tibial diaphyseal fractures.
Teitz and colleagues reported that falls were the most common mechanism of injury, followed by skiing and motor vehicle accidents. Most fractures were spiral and involved the middle or distal third of the shaft. In 1997, a study by Yang and Letts found that the mean age at injury was 8.1 years (range, 0.3 to 17 years); 77 (81%) were due to indirect trauma, and 69 (73%) occurred in the distal third of the tibia. It therefore appears that fractures involving both the tibia and the fibula are more commonly the result of severe, high-energy accidents, such as motor vehicle accidents, whereas isolated tibial shaft fractures result from less severe types of trauma, such as falls or sporting accidents.
Isolated tibial fractures are caused predominantly by torsional forces, and most are localized in the distal third or at the junction of the middle and distal thirds of the tibia. The most common mechanism of torsion was lateral rotation of the body while the foot was in a fixed position on the ground. The fracture line began distally on the anteromedial surface of the tibia and progressed proximally to the posterolateral aspect. The intact fibula and periosteum prevent significant displacement or shortening. However, angulation can occur, especially varus angulation. When the fibula is intact, the tendency toward shortening is converted to a torsional deformity at the fracture site, and a varus deformity is produced. This abnormality is caused predominantly by the effect of the long flexor muscles across the fracture site inducing a rotational force. Yang and Letts found that secondary varus angulation was most likely to develop in oblique and spiral fractures. Transverse fractures tended not to angulate.
Teitz and colleagues corroborated clinical observations with biomechanical studies on tibial fractures with an intact fibula. They found that when the fibula remains intact, a tibiofibular length discrepancy develops and causes altered strain patterns in the tibia and fibula. These strain patterns may lead to delayed union, nonunion, or malunion of the tibia. They found a lower incidence of these complications in children and adolescents and attributed it to greater compliance of their fibulas and soft tissues.
Treatment of an isolated tibial shaft fracture is predominantly nonoperative and consists of immobilization in a long leg cast alone ( Fig. 16-4 ). Closed reduction may be necessary, especially if a varus deformity greater than 15° is present along with coexistent plastic deformation of the fibula. Flexing the knee 30° to 90° and placing the foot in some degree of plantar flexion during the first 2 or 3 weeks may negate some of the deforming force from the long toe flexors. Children should be monitored radiographically at weekly intervals for the first 3 weeks because secondary varus angulation can occur, especially in those with oblique and spiral fractures. A repeated attempt at closed reduction may be necessary if the angulation exceeds 15°. After fracture stability is achieved, a long leg weight-bearing cast with the knee in extension is applied. The cast is usually maintained until healing is complete. A PTB cast, fracture brace, or short leg cast can be used for distal fractures. Indications for surgical intervention in children with isolated tibial shaft fractures are limited. Even in children with multiple traumatic injuries, these fractures can be treated by simple immobilization with a long leg cast. Severe soft tissue damage, such as with burns or open fractures, or a diaphyseal fracture with significant residual angulation may be better managed by open reduction and internal fixation or an external fixator. Qidwai recently reported on 30 isolated tibial shaft fractures treated by intramedullary fixation with 2.5- to 3.5-mm K-wires. The fractures healed quickly, and no postoperative infections occurred in the closed fractures. Others have reported on successful use of flexible intramedullary nails.
