Tibial Shaft Fractures in Children

The worlds of Pediatrics and Orthopedics commingle often (after all “Ortho – Pedic” stems from “straightening” of the “child“). Appropriately, the PedEMMorsels have addressed > 70 Orthopedic topics over the past 12 years. While there are several unique pediatric fractures (ex, Supracondylar fractures, Toddler Fractures, Salter-Harris Fractures, SCFE), we should also be aware of how to manage the other injuries as well. Recently one of our stellar 3rd year EM Residents at CMC, Dr. Lena (who just so happens to be going into Ped EM Fellowship next year), reminded me of one of these possible fractures that deserve our attention. Let us digest a morsel of information on Tibial Fractures in Children:

Tibial Shaft Fractures in Children: Basics

Tibial Shaft Fractures are common. [Hogue, 2019]
  • 3rd most common long bone injuries in children.
    • ~15% of all long bone injuries.
    • 3rd most common fracture seen in the patient with poly-trauma.
    • Femur and Radius/Ulna fractures are most common.
  • Location Matters: [Cruz, 2019]
    • 40% of tibial fractures occur in the diaphysis (AKA the shaft).
    • 50% occur in the distal 1/3.
    • 10% occur in the proximal 1/3.
  • Mechanism matters:
    • Younger children typically have Torsional Forces
      • Rotation of leg while foot is stationary.
      • Leads to incomplete and spiral fracture patterns.
    • Older children / Adolescents have have mechanisms that involve greater forces.
      • Sporting-related and Motor Vehicle Collisions
      • Leads to more comminuted fractures
  • ~30% of tibial fractures occur in association with fibular fracture.
    • Contractile force of the anterior and lateral compartments cause varus or valgus deforming forces based on the integrity of the fibula.
      • With fibular fractureValgus Deforming forces (away from midline)
      • WithOUT fibular fracture – Varus Deforming forces (toward midline)
    • ~60% of children without fibular fracture will develop varus deformity in the 1st 2 weeks.
    • THIS IS WHY MOLDING OF THE CAST IS IMPORTANT.
Tibial fractures in children presentations include: [Hogue, 2019]
  • Most will have:
    • Pain
    • Swelling
    • Inability to bear weight
  • Younger children with incomplete fractures (like Toddler’s Fracture) may simply refuse to bear weight fully.
    • May toe-touch walk
    • On the Ddx of the limping child.
  • Performing a thorough vascular and neurologic exam are always important… but…
    • Neurologic injury, initially, is uncommon.
    • Neurologic exam initially will help detect evolving compartment syndrome though!
      • Important to remember that Compartment Syndrome in children may not present with the “5 Ps.”
      • Look for the “3 As:”
        • Anxiety
        • Agitation
        • Analgesia, increasing requirements

Tibial Shaft Fractures in Children: Management

  • For the majority of tibia fractures in children closed reduction and casting is appropriate.
    • Historically, Long Leg Cast had been used.
    • Evidence that Short Leg Cast is just as effective for distal third tibial shaft fractures. [Barnett, 2021]
    • Most children have uneventful recovery with excellent outcomes and return to full activities. [Cruz, 2019]
  • Immobilization is typically for 4 – 6 weeks, but with close follow-up (within 1 week) to ensure no evolving valgus / varus deformity.
  • Surgery indicated for:
    • Open Fractures
    • Concomitant Vascular or Neurologic Impairment
    • “Floating Knee” fractures
    • Poly-trauma requiring other surgical repair
    • Unsuccessful close reduction
    • Developing Compartment Syndrome

Tibial Shaft Fractures in Children: Slides to Review

Dr. Kelsey Lena (with help from Drs. Danielle Sutton, Virginia Casey, and Michael Gibbs) has posted the useful slide set below on www.EMGuidewire.com along with other great imaging cases. Take a look.

https://www.emguidewire.com/cmc-imaging-mastery-project.html

Moral of the Morsel

  • Tibial fractures are common! Fortunately, conservative management is most often successful.
  • The fibula is important! We often dismiss the fibula, but whether the fibula is fractured along with the tibial fracture helps determine possible deforming forces and how the cast should be molded.
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Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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