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Chapter 30 Pediatric Tibial Fractures

IMAGING AND OTHER DIAGNOSTIC STUDIES ■ Standard anteroposterior (AP) and lateral radiographic views should be obtained. ■ For complex fractures, dedicated knee and ankle films can be helpful to evaluate for extension into the physeal or articular regions. ■ Computed tomography can be helpful to assess these regions if radiographs do not provide sufficient clarity. ■ Contralateral full-length films are helpful for determining length in comminuted fractures. DIFFERENTIAL DIAGNOSIS

Table 1 Acceptable Deformity for Fractures of the Tibia Acceptable Deformity by Patient Age Parameter Under 8 Years 8 Years or Older Valgus 5 degrees 5 degrees Varus 10 degrees 10 degrees Apex anterior/posterior

Angulation Shortening Malrotation

10 degrees 10 mm 5 degrees

5 degrees 5 mm 5 degrees

Adapted from Heinrich SD. Fractures of the shaft of the tibia and fibula. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children, ed 5. Philadelphia: Lippincott Williams & Wilkins, 2001:1077–1119; Wilkins KE. Principles of fracture remodelling in children. Injury 2005;36(suppl 1):A3–A11.

■ Isolated tibial fracture ■ Floating knee ■ Pathologic fracture ■ Intra-articular or intraphyseal injury ■ Compartment syndrome ■ Child abuse NONOPERATIVE MANAGEMENT

PATIENT HISTORY AND PHYSICAL FINDINGS ■ The history should include mechanism of injury, anteced- ent pain, neurologic symptoms, and other areas of pain (eg, femur, abdominal pain, headache). ■ A high-energy injury should also prompt a full trauma workup using standard Advanced Trauma Life Support protocols. ■ The physical examination should focus on assessing initial displacement and skin condition (ie, open injury) as well as swelling of the compartments. ■ The limb should be splinted, in the case of gross deformity, before obtaining films using a material that permits high- quality radiographs. ■ A thorough neurovascular examination is needed to assess for vascular injury or compartment syndrome. 1 ■ Pulses should be palpated or obtained with Doppler assistance. ■ Sensation in the deep and superficial peroneal nerve and tibial nerve distributions should be assessed as well as motor function (toe flexors–extensors). ■ Pain with passive motion of the toes may represent an evolving compartment syndrome. More specifically, increasing pain, or pain out of proportion to the in- jury, is often the first early warning sign and should be taken seriously. Splitting or removal of casting material should be performed if any question exists. In young children, anxiety and fearfulness may be the presenting feature. ■ Compartment pressure measurements should be obtained in cases of concern ( FIG 1A ). ■ Compartment syndrome is signaled by tense swelling of the compartment, pain with gentle squeezing of the com- partment, pain with passive extension–flexion of toes, and paresthesias in involved nerve distributions. Loss of pulse is a late finding. ● Patients with any of these signs should be considered at risk. ■ A low threshold should be present for measuring compart- ment pressures and performing fasciotomy as needed. ■ Vigilance is required to prevent permanent sequelae due to missed compartment syndrome.

■ Most tibial fractures can be managed with closed reduction and cast immobilization in an above-the-knee cast. ■ The cast should be molded to the anatomy of the tibia. ■ A supracondylar “squeeze” mold above the knee and 15 to 20 degrees of knee flexion can prevent cast slippage. ■ To truly avoidweight bearing, however, the cast must be flexed at least 70 to 80 degrees (if appropriate for a specific fracture). ■ In cases of acute fracture, the cast can be univalved or bivalved to allow for swelling. It can then be overwrapped before initiating weight bearing. ■ Weekly radiographs are obtained for the first 3 weeks, with the cast being wedged or changed as needed for loss of alignment. ■ Weight bearing is dictated by patient comfort. ■ The cast is changed to a short-leg or patellar-bearing cast after 4 to 6 weeks, and immobilization is continued until healing is complete. ■ Surgical management is required for inability to maintain satisfactory alignment (see Table 1). SURGICAL MANAGEMENT ■ Indications for surgical treatment of tibial fractures in chil- dren include open injuries, compartment syndrome, multiple injuries, and fractures for which closed treatment fails. ■ Treatment in mature adolescents is the same as for adults with reamed, locked intramedullary nails. ■ Younger children’s open physes require techniques that avoid the proximal and distal tibia, such as external fixation, plate fixation, and elastic intramedullary nailing. ■ Traditionally, external fixation was used primarily for frac- tures with significant comminution or soft tissue injury, where intramedullary fixation was considered impractical. However, recent work challenges this paradigm for surgeons experienced with elastic nailing. 12 ■ Rapid stabilization of the multiply injured child is often accomplished using external fixation as well. 4,7,9,13 ■ Plate fixation is a helpful technique for fractures not ame- nable to elastic nail fixation. ■ It is particularly helpful in patients who present with late loss of reduction and require an open approach to remove callus and align the fracture.