Pediatric Tibial Shaft Fx ICD-10
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
Pediatric Tibial Shaft Fx ICD-9
- 823.22(closed with fibula fx)
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
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
- Lovell and Winter's Pediatric Orthopaedics 2012
- Mashru RP, Herman MJ, Pizzutillo PR. Tibial Shaft Fractures in Children and Adolescents. JAAOS 2005;13:345-352
- Rockwood and Green's Fractures in Adults 6th ed, 2006
- Buckley SL, Smith G, Sponseller PD, Thompson JD, Griffin PP: Open fractures of the tibia in children. J Bone Joint Surg Am 1990; 72: 1462- 1469.
- Cramer KE, Limbird TJ, Green NE: Open fractures of the diaphysis of the lower extremity in children: Treatment, results, and complications. J Bone Joint Surg Am 1992; 74: 218- 232.
- Cullen MC, Roy DR, Crawford AH, Assenmacher J, Levy MS, Wen D: Open fracture of the tibia in children. J Bone Joint Surg Am 1996; 78: 1039- 1047.
- Grimard G, Naudie D, Laberge LC, Hamdy RC: Open fractures of the tibia in children. Clin Orthop 1996; 332: 62- 70.
- Hope PG, Cole WG: Open fractures of the tibia in children. J Bone Joint Surg Br 1992; 74: 546- 553
- King J, Diefendorf D, Apthorp J, Negrete VF, Carlson M: Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 1988; 8: 585- 589
- Kreder HJ, Armstrong P: A review of open tibia fractures in children. J Pediatr Orthop 1995; 15: 482- 488
- Liow RY, Montgomery RJ: Treatment of established and anticipated nonunion of the tibia in childhood. J Pediatr Orthop 2002; 22: 754- 760.
- Navascués JA, González-López JL, López-Valverde S, Soleto J, Rodriguez-Durantez JA, García-Trevijano JL: Premature physeal closure after tibial diaphyseal fractures in adolescents. J Pediatr Orthop 2000; 20: 193- 196
- Norman D, Peskin B, Ehrenraich A, Rosenberg N, Bar-Joseph G, Bialik V: The use of external fixators in the immobilization of pediatric fractures. Arch Orthop Trauma Surg 2002; 122: 379- 382.
- Pankovich AM, Tarabishy IE, Yelda S: Flexible intramedullary nailing of tibial-shaft fractures. Clin Orthop 1981; 160: 185- 195.
- Shannak AO: Tibial fractures in children: Follow-up study. J Pediatr Orthop 1988; 8: 306- 310.
- Song KM, Sangeorzan B, Benirschke S, Browne R: Open fractures of the tibia in children. J Pediatr Orthop 1996; 16: 635- 639.
- Yang JP, Letts RM: Isolated fractures of the tibia with intact fibula in children: A review of 95 patients. J Pediatr Orthop 1997; 17: 347- 351.