Tibial shaft fractures are one of the most common skeletal injuries in children, representing >10% of the surgical intervention for long-bone fractures in a typical pediatric orthopedic practice.1 The mechanism of injury ranges from trivial-seeming falls in toddler’s fractures to severe open fractures encountered after high-energy motor vehicle or all-terrain vehicle accidents.2
There is no single, well-accepted classification system that is used to describe tibial diaphyseal fractures in children. Fractures are commonly described by location, in the proximal, middle, or distal thirds of the tibia; by associated injury, with or without an associated fibula fracture; and by fracture configuration: transverse, oblique, spiral, comminuted, or segmental. Fracture configuration is further defined by characterizing the associated deformity into valgus, varus, procurvatum, recurvatum, internal, or external rotation and by the amount of displacement noted on the initial radiographs. Soft-tissue injury is typically characterized, as in adults, using the Gustilo-Anderson classification of open fractures.3 The presence of vascular or neurological injury is important as is the amount of swelling present.
Associated injuries are also important in classifying these fractures. In particular, polytrauma or ipsilateral femur fractures leading to a “floating knee” have a significant effect on planning the treatment. Despite the multitude of terms utilized to describe these fractures, the literature abounds with other terms used to describe common or unusual fractures such as “toddler’s fractures” and eponyms such as “Cozen fracture.”
INDICATIONS FOR NONOPERATIVE TREATMENT
Nearly all tibial shaft fractures in children can be treated with closed methods. To be effective, any treatment method should maintain acceptable alignment, length, and rotation at the fracture site and should achieve healing of the fracture in a reasonable length of time with minimum complications.
To determine as to which fractures should be treated in casts, it is necessary to understand the 2 basic methods by which a cast or a splint maintains fracture alignment: conventional 3-point molding and Sarmiento casting. The most common method of casting, conventional 3-point molding, uses a cast or a splint to apply transverse forces to the bone through molding, which are converted in the limb to compression at the fracture site, resulting in maintained alignment. The technique requires a stable or stabilizable bony column to maintain length and an intact soft-tissue hinge, usually intact periosteum, to be placed under tension, maintaining the alignment (Fig. 1).
The second method, popularized by Sarmiento, involves the use of a total contact, patellar tendon-bearing cast. This utilizes compressive forces, acting on an intact hydrostatic sleeve to maintain fracture alignment.4 This technique does not require an intact periosteal “hinge” and is applicable to patients with an unstable bony column. The technique does, however, require an exquisite casting technique and significant experience with this method of casting (Fig. 2).
INDICATIONS FOR OPERATIVE TREATMENT
The primary indication for operative treatment is the inability to achieve and maintain acceptable alignment by nonoperative means until union occurs. Although nearly all tibial shaft fractures can be treated with closed methods, some have been shown to have substantially inferior results to operative fixation techniques.
Open fractures are associated with significant swelling and soft-tissue damage and can be difficult to control adequately in a cast or a splint. Their care can be complicated by the need for continuing wound care necessitating multiple cast or splint changes. Attempts at nonoperative care have resulted in high nonunion and malunion rates.5,6 Open fractures, particularly in older children and adolescents, may benefit from operative stabilization with internal or external fixation. Tibia fractures complicated by compartment syndrome can pose similar challenges and may also be best treated with operative stabilization.
Tibia fractures with ipsilateral femoral fractures, the “floating knee injury,” also often present with significant swelling, and the difficulty associated with maintaining a splint or a cast that controls all fragments makes operative stabilization of both fractures beneficial.7,8
Certain fracture configurations have also been noted to pose significant problems when being treated by closed means. Tibial shaft fractures with an intact fibula, particularly when the fracture line passes from the distal anteromedial portion of the tibia to the proximal posterolateral side, tend to fall into the varus even in well-molded casts. Yang and Letts9 recommended close observation of these fractures during the first 3 weeks after injury. They also noted significant difficulty in reducing these fractures >3 weeks after injury. These fractures, particularly when malreduction is noted for >3 weeks after injury, may be best treated by operative stabilization.
Comminuted and unstable fractures have been noted to have an increased risk of malunion or nonunion after treatment with monolateral external fixators compared with circular external fixation,10 because of the difficulty of maintaining adequate alignment in the absence of a stable bony column. The same study noted increased problems with maintaining alignment in older patients, most likely due to the less robust soft tissues and slower healing. Comminuted and unstable fractures and fractures in older children and adolescents may relatively benefit from more rigid surgical stabilization.
In addition, relative indications for operative fixation exist when the time of immobilization exceeds what is “reasonable.” Unfortunately, what is reasonable is often quite subjective and is driven by a complex set of social needs, family expectations, and fracture type, allowing return to activities that may be driven by activities of daily living or a desire to return to sports.
Multiple operative techniques have been reported to be effective in treating tibial shaft fractures in children and adolescents including plate fixation11 and external fixation, including both circular and monolateral external fixation devices.10 More recently, titanium elastic nailing has been advocated for tibial shaft fractures.12,13 Titanium elastic nailing, due to its versatility and common use in other pediatric long-bone fractures, has rapidly become one of the most commonly used techniques in the treatment of pediatric tibial shaft fractures. Nails are most commonly inserted antegrade from insertion points on the medial and lateral tibial metaphysis 1 to 2 cm distal to the proximal tibial physis, taking care not to damage the distal extent of the physis at the tibial tubercle. Nails should be of the same size to avoid creating varus or valgus at the fracture site. Nails should be impacted into the distal tibial metaphysis and should extend to within approximately 5 to 10 mm of the distal tibial physis. Patients are commonly placed into a splint postoperatively for comfort and to allow resolution of swelling and soft-tissue healing. Because hypertrophic delayed healing or nonunion can occur because of continued motion at the fracture site,13 patient weight bearing should be limited in unstable fractures until early evidence of healing is noted radiographically.
Adolescent tibia fractures present particular problems when comminuted or unstable. Often surgical stabilization is required to maintain acceptable alignment and length, but the presence of the proximal tibial physis presents particular problems. Intramedullary nailing across the open proximal tibial physis except very near the end of growth has not been recommended because of concerns with causing premature partial or complete physeal arrest. Both monolateral and circular external fixation have been utilized, particularly in open fractures. Monolateral fixation is effective, but has a higher rate of loss of reduction. Circular fixation allows easier correction of malalignment and provides better maintenance of alignment and length than monolateral fixation and is preferred, particularly in the presence of unstable fractures or in older adolescents.
Most recently, several authors have recommended titanium elastic nailing as a familiar technique that is effective in stabilizing tibia fractures.14 Gordon et al13 also reported the technique as effective, but noted a significant rate of delayed union and nonunion, which is troubling.
Open fractures should be treated operatively with early irrigation and debridement. It has become the routine at our institution to delay definitive irrigation and debridement of grade I, II, and some IIIA fractures that present late at night to early the next morning.15 This allows a fresh surgical team to address definitive stabilization of the fracture at the same time as the initial irrigation and debridement. If there are any concerns regarding the status of the soft tissues or significant contamination, we often elect to return to the operating room for a secondary debridement 48 to 96 hours after the initial procedure.
The first patient is a 14 year old male who jumped feet first into the shallow end of a swimming pool with immediate pain and inability to weight bear. On arrival in the emergency department, he was noted to be neurovascularly intact and diffusely tender throughout the mid to distal tibia with mild swelling and intact skin. Radiographs were obtained at the time of initial evaluation (Fig. 3A, B) revealing a well aligned but comminuted fracture of the tibial shaft with a distal fibula fracture. A groin to toes splint was applied in the emergency room with mild sedation and post splinting radiographs were obtained (Fig. 4A, B). The mild varus and recurvatum deformity initially present has worsened due to the significant instability of the fracture. Although a more determined effort could have been made to improve the fracture alignment, the comminuted nature of the fracture led to selection of a circular external fixator as a definitive treatment method to allow early mobility and weight bearing with definitive control of the fracture alignment (Fig. 5A, B). Three weeks postoperatively, the patient was weight bearing with 1 crutch and was comfortable. Use of a circular external fixator also allowed evaluation with a long cassette radiograph to check lower extremity alignment (Fig. 6). This radiograph revealed valgus alignment that was not apparent on the tibial radiographs allowing gradual correction of the valgus alignment. Six weeks postoperatively, the tibial radiograph reveals mild varus and early healing, while the long cassette radiograph reveals a neutral mechanical axis (Fig. 7). Three months postoperatively, the fracture is healing well (Fig. 8A, B) and the clinical alignment is excellent with the patient walking unassisted. Radiographs obtained 6 weeks later, 1 month following external fixator removal (Fig. 9A, B) reveal a neutral mechanical axis and excellent healing allowing a return to sports.
The second patient is an 11 year old female who sustained a mildly comminuted displaced grade IIIA open tibia and fibula fracture after being struck by a motor vehicle while riding a bicycle (Fig. 10A–C). The patient was taken to the operating room urgently for irrigation and debridement of the open fracture and was stabilized using antegrade flexible titanium elastic nails. The wound was left open and the limb was placed into a short leg splint postoperatively. The patient returned to the operating room 72 hours later for repeat irrigation and debridement, wound closure and application of a short leg cast. Three weeks postoperatively the patient was well aligned (Fig. 11A, B) and was allowed to be weight bearing as tolerated in the cast. Six weeks postoperatively the cast was removed and the wound was healed. The patient returned 3 months postoperatively and was radiographically well healed in good alignment, walking with a minimal limp (Fig. 12A, B).
The most significant early complication encountered after either open or closed treatment of tibial shaft fractures is compartment syndrome. The evolution of compartment syndrome can occur over hours to days and is first and foremost a clinical diagnosis. The earliest sign of compartment syndrome can be an increasing utilization of narcotic pain medication followed by increasing complaints of pain. Classically, pain on a passive stretch has been used to ascertain the presence of compartment syndrome. In children and adolescents, it can be difficult, in the presence of significant discomfort, to differentiate fracture pain from early compartment syndrome.16 Pseudoparalysis and decreased sensation can be other signs of compartment syndrome, but ultimately, increasing pain unrelieved by reasonable small doses of narcotic pain medication and a worsening course must be presumed to be compartment syndrome until proven otherwise. At the first onset of increasing pain, circumferential casts or dressings must be split, and at our institution, casts are most often bivalved and the anterior portion is removed to relieve external compression. Palpation of the compartments is usually performed, but the ability of the examiner to differentiate compartment syndrome from palpation is poor.17 If removal of the anterior portion of the cast does not relieve the pain immediately and persistently, the patient should be taken to the operating room for 4-compartment fasciotomy. I routinely performed compartment pressure measurements under anesthesia for purposes of documentation, but the decision to perform fasciotomy should not be based on these measurements. The fasciotomy can be performed through a single lateral incision or through medial and lateral incisions, but regardless of the approach chosen, all 4 compartments must be released adequately. Closure can be performed ultimately either with delayed skin grafting or with serial closure by ≥2 returns to the operating room.
SUMMARY OF THE MOST IMPORTANT POINTS
- Nearly all tibial shaft fractures can be treated with cast stabilization.
- Successful cast treatment depends on the stability of the soft tissues.
- Surgical stabilization should be considered for fractures for which closed means cannot achieve and maintain acceptable alignment, rotation, and length until union occurs in a reasonable amount of time.
- Consideration for surgical stabilization should be given to most open fractures and tibial fractures associated with ipsilateral femur fractures.
- Relative indications for surgical stabilization include an intact fibula, comminuted fractures, and fractures in adolescents.
- Compartment syndrome is a risk for all tibial shaft fractures and should be considered when the pain is out of proportion to the injury or in the face of increasing narcotic requirements.
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Keywords:© 2012 Lippincott Williams & Wilkins, Inc.
tibia; fracture; pediatric; open fracture; external fixation; titanium elastic nails; closed reduction