Pediatric Tibial Shaft Fracture
synonyms:
Pediatric Tibial Shaft Fx ICD-9
- 823.20(closed)
- 823.22(closed with fibula fx)
- 823.30(open)
Pediatric Tibial Shaft Fx Etiology / Epidemiology / Natural History
- common injury
- average age = 8, Male > females (Shannak AO, JPO 1988;8:306)
- Direct blow or twisting injury.
Pediatric Tibial Shaft Fx Anatomy
- Valgus angulation and shortening are common for displaced tibia and fibula fractures and is caused by anterior and lateral compartment muscle forces.
- Isolated minimally displaced tibia fractures may drift into varus angulation with shortening due to posterior compartment muscle forces.
Pediatric Tibial Shaft Fx Clinical Evaluation
- pain, tenderness +/- gross deformity of leg after trauma
- limp, decreased movement of leg or refusal to bear weight
- always evaluate for associated injuries and child abuse
- evaluate hip, knee, ankle, soft tissue injury, neurovascular status
- Evaluate for Compartment Syndrome
Pediatric Tibial Shaft Fx Xray / Diagnositc Tests
- A/P and lateral views of tibia including the knee and ankle are indicated.
- Evaluate for pathologic fracture in low energy injuries
- Toddlers fracture xrays may be normal. If clinical suspicion is high, the patient should be immobilized and followed with weekly xrays.
Pediatric Tibial Shaft Fx Classification / Treatment
- Nondisplaced without significant soft tissue injury = Non-weight bearing long leg cast for 4-6 weeks followed by progressive weight bearing in a short leg cast for 4-6 weeks. Toddlers fractures often only need 4weeks of casting. Isolated tibia minimally displaced fractures can drift into varus with casting. Weekly follow-up x-rays are indicated initially.
- Displaced without significant soft tissue injury = closed reduction and long leg casting. Consider placing ankle in slight plantar flexion, especially for distal 1/3 fractures, to prevent apex posterior angulation. Knee is placed in 30-60 degrees of flexion. Consider bivalving cast dependeding on soft tissue injury. Any fracture requiring reduction should be monitored for at least 24 hours for compartment syndrome.
- Acceptable Reduction >8years old: 5 degrees of varus or valgus angulation, <5 degrees of sagittal angulation, 1cm of shortenging, and 50% translation.
- Acceptable Reduction <8years old: Up to 10 degrees of varus or valgus, 10 degrees sagittal angulation and translation of the entire shaft may be tolerated.
- Failed Closed Reduction: flexible intramedullary nails. (Kubiak EN, JBJS 2005;87A:1761).
- Severally comminuted / unstable / severe soft tissue injury = External Fixation. Consider elastic titanium nails.
- Open Fractures: urgent I&D and stabilization with appropriate antibiotics/tetnus prophylaxis. Small, clean wounds may be closed primarily. Consider wound vac for larger wounds (Webb LX JAAOS 2002; 10: 303). Early skin graft/muscle flap for converage of extensive wounds.
Pediatric Tibial Shaft Fx Associated Injuries / Differential Diagnosis
Pediatric Tibial Shaft Fx Complications
Pediatric Tibial Shaft Fx Follow-up Care
- Fractures should be followed weekly with serial xrays for first 3weeks to ensure maintenance of reduction. Cast wedging vs repeat reduction can improve aligment within first 3 weeks.
- Wedging: Closing wedge = remove 1-2cm of cast material from side of the apex of the deformity (may cause shortengin). Opening wedge = cast is cut perpendicular to the axis of the tibia on the side opposite the apex of the deformity and small blocks or appropriate size are placed to correct deformity.
- Elastic nails are generally removed in the OR 4-6 months after injury
- External fixators may be removed and converted to SLC 4-6 weeks after injury.
Pediatric Tibial Shaft Fx Review References
Pediatric Tibial Shaft Fx References
|
