PEDIATRIC SHAFT FRACTURE MANAGEMENT

2. PEDIATRIC TIBIAL SHAFT
FRACTURE
MANAGEMENT
DR:IRSHAD BHUTTO
ASSOCIATE PROFESSOR

3. EPIDEMIOLOGY
 Incidence: 15% of all pediatric fracture
 Demographics: boys > girls average age:8 years
39% of tibia fractures occur in the mid-diaphysis
40% of tibial fractures occur in the diaphysis (AKA the shaft).
50% occur in the distal 1/3.
10% occur in the proximal 1/3.

4. 30% of tibial fractures occur in association with fibular
fracture.Contractile force of the anterior and lateral compartments
cause varus or valgus deforming forces based on the integrity of the
fibula.
◦ With fibular fracture – Valgus Deforming forces (away from midline)
◦ WithOUT fibular fracture – Varus Deforming forces (toward midline
~60% of children without fibular fracture will develop varus deformity in the 1st
2 weeks.
THIS IS WHY MOLDING OF THE CAST IS IMPORTANT

5. ANATOMY
TIBIA
Triangular shaped bone with apex anteriorly that broadens distally
The anteromedial border is subcutaneous
Tibial flare distally leads to primarily cancellous bone and a thin cortical shell
 MUSCLE
The anterior and lateral compartment musculature produce valgus deforming forces when both the
tibia and fibula are fractured
 Blood supply
posterior tibial a. provides nutrient and periosteal vessels
the anterior tibial artery is vulnerable to injury as it passes through the interosseous membrane

6. MECHANISM
Younger children typically have Torsional Forces
Rotation of leg while foot is stationary.
Leads to incomplete and spiral fracture patterns.
Older children / Adolescents have have mechanisms that involve greater forces.
Sporting-related and Motor Vehicle Collisions
Leads to more comminuted fractures

7. CLINICAL PRESNETATION
 Pain
 Bruising
 Limping or refusal to bear weight
 Swelling over fracture site
 Tender over fracture site
 Pain on ankle dorsiflexion

8. IMAGING
AP and lateral views of the tibia and fibula are required
ipsilateral knee and ankle must be evaluated to rule out concomitant injury
optional views
contralateral films of the uninjured leg
CT:
Concern for physeal or intra-articular extension, pathologic lesion
Distal third tibia fractures may propagate to physis or articular surface
MRI
suspicion for pathologic or stress fracture
rule out an occult fracture

9. CLASSIFICATION
 Classification based on fracture location (proximal, midshaft, distal) and pattern
PEDIATRIC TIBIAL SHAF FRACTURE PATTERN
Incomplete GREENSTICK # OF TIBIA & OR FIBULA
COMPLETE Complete fracture of the tibia with or
without ipsilateral fibula fracture or
plastic deformation
Tibial spiral fracture (Toddler's Fracture Nondisplaced spiral or fracture of the
tibia with intact fibula in a child under 2.5
years of age

10. Complete fractures

11. CONTD:
GREENSTICK FRACTURE TODDLERS FRACTURE

12. TREATMENT
INDICATION FOR SURGERY:
Open Fractures
Concomitant Vascular or Neurologic Impairment
“Floating Knee” fractures
Poly-trauma requiring other surgical repair
Unsuccessful close reduction
Developing COMPARTMENT SYNDEROME

13. TREATMENT
 NON OPERATIVE
LONG LEG CASTING almost all Toddler's fracture ,Greenstick fractures
CLOSED REDUCTION AND LONG LEG CASTING
 DISPLACED WITH ACCEPTABLE REDUCTION CRITERIA 
50% translation
< 1 cm of shortening
< 5-10 degrees of angulation in the sagittal and coronal planes
 FOLLOWUP
serial radiographs are performed to monitor for developing deformity
serial followup if physeal extension to monitor for growth disturbance

14. TREATMENT
OPERATIVE:
EXTERNAL FIXATION open or closed fractures with extensive soft tissue injury, length
unstable fractures, or poly-trauma patients
FLEXIBLE INTRAMEDULLARY NAILS open or closed fractures in skeletally immature patients
multiple long bone fractures or floating knee
PERCUTANEOUS PINNING noncomminuted, unstable oblique fractures
may be used with casting.
PLATE FIXATIONopen or closed fractures with physeal or articular extension
length unstable fractures
nonunions or malunions

15. COMPLICATIONS
Compartment syndrome
Leg-length discrepancy
Angular deformity
Associated physeal injury
Delayed union and nonunion