Courtesy: Kaye Wilkins MD, Lynn Staheli MD

 

Pediatric Tibial Fractures

Proximal Tibial Metaphyseal Fracture

Key complication

• Progressive valgus deformity (Cozen phenomenon).

Cause

• Biological overgrowth is the most common cause.
• Increased vascularity produces greater medial than lateral growth.
• Not always related to inadequate reduction.
• Fibular tether theory is no longer accepted.

Clinical features

• Valgus deformity appears months after injury.
• Maximum deformity develops during the first year.
• Limb overgrowth may reach approximately 1 cm.
• Harris growth arrest lines may demonstrate asymmetric growth.

Counseling

• Inform parents that temporary valgus deformity may develop during healing.

Natural history

• Valgus increases during the first year.
• Stabilizes by the second year.
• Most cases gradually correct with growth.

Treatment

Initial management

• Closed reduction and long leg cast.
• Apply a varus mold.

Established deformity

• Avoid early corrective osteotomy because recurrence is common.
• Observation is appropriate in most patients.
• Persistent deformity in older children may require guided growth using staples or an 8 plate.

Tibial Shaft Fractures

Assessment

• Evaluate soft tissue injury.
• Assess patient age and growth potential.
• Determine fracture pattern.
• Assess acceptable deformity.

Fracture patterns

Isolated tibial shaft fracture

• Usually spiral or oblique.
• Commonly caused by twisting injuries.

Tibia and fibula fracture

• Usually transverse.
• Commonly caused by bending forces.

Oblique fractures

• Higher risk of shortening.

Stress fractures

• Usually managed conservatively.

Deforming Forces

Isolated tibial fracture

• Varus angulation.
• Rotational deformity.

Both bone fractures

• Valgus deformity.

Oblique fractures

• Gastrosoleus muscle pull causes shortening.

Acceptable Alignment

Children younger than 8 years

• Angulation up to 10 degrees is acceptable.
• Greater remodeling potential.

Children older than 8 years

• Minimal angulation should be accepted.

Shortening

• Less than 1 cm is generally acceptable.

Conservative Management

Indications

• Most pediatric tibial fractures.

Technique

• Closed reduction and long leg cast.

Important principles

• Apply varus molding to prevent valgus deformity.
• Flex the knee and plantarflex the ankle to reduce gastrosoleus pull in oblique fractures.
• Repeat radiographs after 1 week.

Cast Modifications

• Cast wedging may correct residual angulation.
• Bayonet apposition is acceptable if limb length and alignment are maintained.

Plastic Deformation

Features

• Common in children.

Treatment

• Gradual correction under general anesthesia.
• Three point bending technique.

Operative Management

Indications

• Open fractures.
• Compartment syndrome.
• Polytrauma.
• Unstable fractures.
• Failure of conservative treatment.

Methods

Percutaneous pinning

• Temporary stabilization.

Elastic intramedullary nails

• Most commonly used surgical technique.
• Avoid physeal injury.

External fixation

• Indicated for open fractures.
• Indicated for compartment syndrome.
• Indicated for severe soft tissue injury.
• Indicated for bone loss.

Plate fixation

• Rarely required.
• Reserved for severe comminution or when rigid fixation is necessary.

Special Situations

Bone loss

• Bone transport using the Ilizarov technique.

Compartment syndrome

• Fasciotomy with external fixation.

Polytrauma

• Elastic intramedullary nailing is usually preferred.

Exam Pearls

• Proximal tibial metaphyseal fractures commonly lead to Cozen valgus deformity.
• Always counsel parents regarding possible valgus overgrowth.
• Avoid early corrective osteotomy for Cozen phenomenon.
• Most pediatric tibial fractures are treated conservatively.
• Oblique fractures have a higher risk of shortening.
• Isolated tibial fractures tend to develop varus deformity.
• Combined tibia and fibula fractures tend to develop valgus deformity.
• External fixation is indicated for open fractures and compartment syndrome.