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Chapter 30 Pediatric Tibial Fractures

T E C H N I Q U E S

TECH FIG 1 ● A. External fixation in a patient with a compart- ment syndrome. Arrows mark the proximal and distal growth plates. The proximal pins start fairly distally to avoid the tubercle physis. B. In this patient, an external fixator was used for a grade 2 open fracture treated with delayed closure. The patient also had a degloving injury requiring a flap and skin graft over the medial ankle. The frame was extended to the first metatarsal to immobi- lize the foot during healing. Although somewhat bulky, the “double stack” configuration of the frame allows for easy dynamization.

A

B

■ Plate Fixation ■ Treatment is essentially the same as for adult injuries, but several points bear emphasis. ■ It is helpful to make the incision slightly laterally over the anterior compartment so it will not lie directly over a medially placed plate ( TECH FIG 2A ). ■ The fracture is reduced using standard techniques. Care should be taken to avoid unnecessary stripping of the fracture. ■ I prefer to make an incision over the fracture large enough to reduce the fragments but not the entire length of the plate. ■ The plate can be slid under the skin, over the periosteum, and the screws placed through stab incisions, as for percu- taneous plating in adults ( TECH FIG 2B ). ■ For larger children, many adult fracture systems include precon- toured 3.5-mm plates for the distal tibia. ■ For smaller children, a small fragment plate may be con- toured to fit appropriately. ■ It is important to avoid injury to the perichondral ring at the distal extent of the plate. ■ If the plate is applied on the medial side of the tibia, as it often is for fractures with valgus angulation, it will usually need to be removed after healing due to prominence. ■ If applied laterally, I usually make a longer incision because per- cutaneously placed screws will traverse the anterior compart- ment and potentially injure the neurovascular bundle. I prefer open placement in this case. ■ The wound is closed using standard techniques. A posterior splint is applied to protect the soft tissues.

Lag screw Plate

Stab incisions for screws

A B TECH FIG 2 ● A. Incision for open reduction and internal fixation is made laterally over the anterior compartment, and the skin can then be mobilized to gain access to the fracture site. It is important not to incise the skin directly over the proposed location of the plate. B. Medial view of internally fixed tibia. A lag screw compresses the fragment, and the plate stops short of the physis. The skin incision is centered over the fracture to allow an accurate reduction, but the proximal and distal screws can be placed percutaneously through a medially applied plate. It is helpful to make one stab incision for every two holes, centered between them.