Pediatric Tibial Shaft Fracture S82.209A 823.20

ICD-9	Classification / Treatment
Etiology / Natural History	Associated Injuries / Differential Diagnosis
Anatomy	Complications
Clinical Evaluation	Follow-up Care
Xray / Diagnositc Tests	Review References

synonyms:

Pediatric Tibial Shaft Fx ICD-10

S82.201A - Unspecified fracture of shaft of right tibia, initial encounter for closed fracture
S82.202A - Unspecified fracture of shaft of left tibia, initial encounter for closed fracture
S82.209A - Unspecified fracture of shaft of unspecified tibia, initial encounter for closed fracture

A- initial encounter for closed fracture

B- initial encounter for open fracture type I or II

C- initial encounter for open fracture type IIIA, IIIB, or IIIC

D- subsequent encounter for closed fracture with routine healing

E- subsequent encounter for open fracture type I or II with routine healing

F- subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

G- subsequent encounter for closed fracture with delayed healing

H- subsequent encounter for open fracture type I or II with delayed healing

J- subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

K- subsequent encounter for closed fracture with nonunion

M- subsequent encounter for open fracture type I or II with nonunion

N- subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

P- subsequent encounter for closed fracture with malunion

Q- subsequent encounter for open fracture type I or II with malunion

R- subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

S- sequela

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

Proximal tibia fracture (Cozen's Fracture)
Compartment Syndrome
anterior tibial artery disruption (more common with displaced proximal metaphyseal fractures)
Child Abuse
Pediatric Femur Fracture
Floating Knee (Yue JJ, CORR 2000;376:124)

Pediatric Tibial Shaft Fx Complications

Compartment Syndrome
Delayed Union / Nonunion: union usually occurs withint 8-12 weeks. Evalaute for infection with ESR, CRP. (Liow RY JPO 2002; 22: 754)
Malunion
Growth disturbance. Overgrowth after tibial shaft fracture generally does not exceed 5mm. Premature physeal closure is uncommon, but can occur. (Navascués JA, JPO 2000;20:193)

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