Although the vast majority of tibial shaft fractures in children heal quickly with simple cast immobilization, flexible nail fixation has become more popular, especially in the adolescent population.1–5 However, there have been significant complications reported with the use of flexible nails in pediatric tibia fractures, including compartment syndrome,6,7 malunion, nonunion, and nail migration.7,8
At the author’s institution, casting continues to be the mainstay of treatment of all closed tibial shaft fractures, including in the adolescent population. In our report of 75 adolescent tibial shaft fractures treated with reduction and casting, only 3 patients failed cast treatment and subsequently underwent surgical fixation, although 61% of patients required longer than 3 months of immobilization (which included removable boots).9 In addition, the only reported complication in this cohort was a single heel ulcer that healed uneventfully. There were no compartment syndromes.
Although individual adolescents can vary greatly in their skeletal maturity, many surgeons define an adolescent as girls aged 10 years or above and boys aged 12 years or above.9 At this age, there is <4 years of skeletal growth remaining, and remodeling is limited compared with younger patients, making anatomic alignment more of a consideration.
PRINCIPLES OF MANAGEMENT
Before discussion of management, the parameters of acceptable alignment for tibial fractures must be defined. The seminal works of Sarmiento10 clearly define acceptable limits for cast/functional brace treatment of adult tibial shaft fractures as 5 degrees of coronal angulation, 10 to 15 degrees of sagittal angulation, <50% displacement, and 10 to 15 mm of shortening,11 and these parameters continue to be accepted today.12,13 Interestingly, the acceptable parameters for alignment for tibial diaphyseal fractures in pediatric patients below 8 years of age are not much more than for adults, with 10 degrees of coronal and sagittal angulation, 50% translation, and 10 mm of shortening as published guidelines.14,15 It follows that adolescent tibial shaft fracture guidelines must fall somewhere between the parameters for children and adults although there are no published studies relating final radiographic alignment in this age group with clinical outcomes or arthritis.
When considering cast treatment, thought must be given to the energy of injury, surrounding soft tissue swelling, pattern of the fracture, other concomitant injuries, the size of the leg and the patient, and whether the fracture is open or closed. In general, most surgeons will treat adolescent tibia shaft fractures with surgery in the following situations:
- open fractures,
- large, obese children that are difficult to cast and are at increased risk for compartment syndrome,7
- severe swelling with a concern for compartment syndrome,
- segmental fractures,
- floating knees, and
- patterns that cannot be controlled in the cast (especially >10 degree varus with an intact fibula).16
Patients and parents should be warned that cast treatment may require longer than 3 months of immobilization, and that the return to full activities occurs at an average of 15 weeks.9 However, it has not been demonstrated that time to union and time to return to activities are sooner for tibia shaft fractures treated with flexible nailing.5,6,17
For patients who do not required formal reduction of a minimally displaced fracture, a well molded long-leg cast can be placed with postcasting radiographs to verify maintenance of alignment. When the fracture requires manipulation, this is best accomplished with the child under conscious sedation in the emergency room or operating room, with fluoroscopy to check the alignment after the initial application of cast material. A qualified, experienced assistant such as a cast technician is extremely helpful, especially in unstable patterns and large legs. Careful padding around areas of prominence (especially the Achilles insertion and calcaneus) can avoid skin breakdown. A 3-point mold is crucial in counteracting the deforming forces, which is typically varus, especially in tibia fractures with an intact fibula. Unlike adults, Achilles contractures are not typically encountered after casting in the pediatric population, and 15 to 20 degrees of plantar flexion can be helpful. Knee flexion of 30 to 45 degrees in the cast helps to provide rotational control and prevent a noncompliant teenager from weight-bearing. If fiberglass is used for the cast, the author strongly recommends univalving the cast to allow for expected swelling and to decrease the risk of compartment syndrome.
Our institution routinely admits to the hospital tibia fractures that require reduction and casting for soft tissue monitoring, elevation, and neurovascular monitoring to assess for any changes in examination. These patients are discharged with a large pillow to elevate the leg and remain on bedrest for 48 hours after casting to ensure continued elevation. They are instructed to call the clinic (or return to the emergency department if after hours or on the weekend) if the child develops pain or swelling that does not improve with elevation and oral pain medications.
After casting, close radiographic monitoring is required for the first 1 to 2 weeks as there may be some loss of alignment as the soft tissue swelling resolves. Some fractures may require 3 consecutive weeks of radiographic monitoring. Wedging casts in the clinic is an essential component to successful cast treatment as this can improve angulation in the first few weeks without the need for further sedation.9,14 The author recommends an opening wedge technique to avoid the risk of fracture shortening and skin impingement that can occur with a closing wedge technique. A cast saw is used to carefully cut circumferentially around the cast, perpendicular to the long axis of the tibia, at the level of the apex of the fracture (Fig. 1). Small commercially available spacers up to 1 cm in width can be used to open the wedge on the cast side opposite the location of the fracture apex.
Tibia fractures that are length unstable are non–weight-bearing until callus is present (generally 4 to 6 wk). At this time, patients may be transitioned into a short leg cast or a removable fracture boot, with gradual return to weight-bearing as per the patient’s comfort.
The treating practitioner must be aware that this can be a labor intensive process, requiring multiple follow-up radiographs and clinic visits to ensure alignment is maintained, and that interventions such as wedging or even completely replacing an ill-fitting cast may be needed. This must be discussed with the family before embarking on cast treatment. Any pain in the cast must be investigated by the treating practitioner. Compartment syndrome must be strongly considered in the setting of increasing, unrelenting pain and swelling that occurs in the first 48 to 72 hours. It has been shown that increasing agitation, anxiety, and need for analgesic medication are the most sensitive indicators of compartment syndrome in the pediatric population.18 After the swelling has subsided, pain in the cast may be because of skin irritation from the cast rubbing, and this may lead to ulcerations and pressure sores if not remedied. Objects placed in the cast by the child, such as pencils, erasers, coins, and even small toys (the author has encountered a dinosaur inside a cast) may also be offenders and must be removed.
As treatment of pediatric long-bone fractures becomes increasingly more surgical, casting is in danger of becoming a lost art. The advantages of flexible nailing over casting of adolescent tibia fractures are unclear, especially since all of the reports regarding flexible nails in pediatric tibias combine both open and closed injuries, leading to bias in these reports.
Duration of Immobilization
Sarmiento initially transitioned his adult patients from a long-leg cast to a functional brace at an average of 3.8 weeks.11 Our institution reported an average duration of immobilization of 13.8 weeks with the majority of patients transitioned to a short leg cast or boot at the 6-week mark.9 Many tibia fractures require a cast even after surgical stabilization. Sankar et al5,6 reported that all surgically stabilized tibia fractures were immobilized, with an average of 7 weeks in a cast.
In the author’s institution’s casted pediatric population, the mean return to activities was at 15 weeks, which compares favorably to a mean union time of 18.1 weeks for casted adults.11 Union time with flexible nails has been reported by Sankar et al5,6 to be between 11 and 13 weeks, but Srivastava et al17 reported a union time of 22.5 weeks for 9 closed tibial fractures treated with flexible nails.
Sarmiento reported an 11% rate of angulation >7 degrees in the coronal plane, 5% rate of angulation >10 degrees in the sagittal plane, and 1.4% rate of shortening >20 mm in adults treated with casting.10 The author’s reported experience in adolescent casted tibias was 5% rate of angulation >5 degrees in the coronal plane and 3% rate of angulation >10 degrees in the sagittal plane.9 Goodwin et al1 published that 10% of their pediatric tibia fractures treated with flexible nails had angular deformity >10 degrees, and Sankar et al6 similarly reported a 12% rate of malangulation >10 degrees.
The only complication in our reported adolescent series was 1 heel ulcer.9 No patient suffered a compartment syndrome. Three of 75 patients (4%) failed cast treatment and were treated with surgical stabilization (all 3 of these were involved in vehicular collisions). During the study time period (7 y), only 6 other patients underwent immediate surgical stabilization. Pandya et al7 reported a 20% rate of compartment syndrome in their patients treated with flexible nails, and Sankar et al6 reported a 2% rate of compartment syndrome with another 2% of patients requiring an unplanned return to the operating room. It must be emphasized that the flexible nail cohorts included open fractures, which suffered higher energy injuries and therefore may these groups may have already been biased toward more complications.
It has not been demonstrated that closed pediatric tibia fractures treated with flexible nails have faster union rates, decreased complications, or improved functional outcomes when compared with casting, although selection bias makes it impossible to compare the groups. The possibility for prolonged casting in adolescents may be minimized by transitioning to a fracture brace instead of a short leg cast or boot. There is no data comparing the quality/value/safety of flexible nailing versus casting of adolescent tibia fractures.
In short, successful casting is accomplished by the following:
- establishing a common understanding between the treating practitioner and family regarding expected treatment duration, need for clinic and radiographic follow-up, and need for possible clinic interventions;
- having a low threshold for hospital admission to monitor for swelling and pain;
- strict elevation of the fractured leg for at least 48 hours after casting;
- experienced assistants present for cast application(in the author’s institution, these are certified cast technicians);
- experience in the art of casting with special expertise in molding and wedging;
- meticulous attention to padding prominent areas in the cast; and
- immediate investigation of any pain reported in the cast.
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