Chapter 31: Fractures of the Shaft of the Tibia and Fibula

James F. Mooney, III; William L. Hennrikus

Chapter Outline

Epidemiology of Fractures of the Shaft of the Tibia and Fibula

Tibial and fibular fractures are the third most common pediatric long bone injuries (15%) after radial/ulnar and femoral fractures.63,114,140,149 The prevalence of tibial fractures in both boys and girls has increased since 1950.82 The average age of occurrence is 8 years, and the frequency of occurrence does not change significantly with age.63 Seventy percent of pediatric tibial fractures are isolated injuries; ipsilateral fibular fractures occur with 30% of tibial fractures.20,149,159 Fifty percent to 70% of tibial fractures occur in the distal third, and 19% to 39% in the middle third. The least commonly affected portion of the tibia is the proximal third, yet these may be the most problematic. Thirty-five percent of pediatric tibial fractures are oblique, 32% comminuted, 20% transverse, and 13% spiral.140 Tibial fractures in children under 4 years of age usually are isolated spiral or short oblique fractures in the distal and the middle one-third of the bone. Most tibial fractures in older children and adolescents are in the distal third. 
Rotational forces produce an oblique or a spiral fracture, and are responsible for approximately 81% of all tibial fractures that present without an associated fibular fracture.12,20,51,102,140 Most tibial fractures in children of 4 to 14 years of age are the result of sporting or traffic accidents.12,20,53,82,102,140 More than 50% of ipsilateral tibial and fibular fractures result from vehicular trauma. Most isolated fibular fractures result from a direct blow.63,150 The tibia is the second most commonly fractured long bone in abused children. Approximately 11% to 26% of all abused children with a fracture have an injured tibia.85,98,120 Nine percent of pediatric tibial fractures are open. Concomitant fractures of the ankle and foot are the most common injuries associated with fractures of the tibia and fibula, followed by humeral, femoral, and radial/ulnar fractures.15 In a 1994 report, the average Injury Severity Score of a child with a tibial fracture was 10 (range, 0 to 45) with an average hospital stay of 6.5 days (range, 1 to 50 days).15 There have been no updates of this information in the recent English literature; however, it would seem certain that the current average hospital stay is significantly less. 

Classification of Fractures of the Shaft of the Tibia and Fibula

Nonphyseal injuries of the tibia and the fibula can be classified into three major categories based on the combination of bones fractured and the location of the injuries. These include fractures of the proximal or distal tibial metaphysis, and those involving the diaphyseal region. 

Surgical Anatomy of Fractures of the Shaft of the Tibia and Fibula

Bony Structure of the Tibia and Fibula

The tibia (“flute”) is the second largest bone in the body. There are two concave condyles at the proximal aspect of the tibia. The medial condyle is larger, deeper, and narrower than the lateral condyle. An elevated process, the tibial tubercle, located between the two condyles, is the site of attachment of the patellar tendon. The shaft of the tibia is prismoid, with a broad proximal extent that decreases in size until the distal third, where it gradually increases again in size. The tibial crest is prominent medially from the tibial tubercle to the tibial plafond and is subcutaneous without the overlying musculature.51 
The tibia develops from three ossification centers: One in the shaft and one in each epiphysis. The tibial diaphysis ossifies at 7 weeks of gestation and expands both proximally and distally. The proximal epiphyseal center appears shortly after birth and unites with the shaft between 14 and 16 years of age. The distal epiphyseal ossification center appears in the second year of life, and the distal tibial physis closes between 14 and 15 years of age. Additional ossification centers are found occasionally in the medial malleolus and in the tibial tubercle.51 
The tibia articulates with the condyles of the femur proximally, with the fibula at the knee and the ankle, and with the talus distally.49 Twelve muscles have either their origin or insertion on the tibia (Table 31-1). The fibula articulates with the tibia and the talus. The fibular diaphysis ossifies at about 8 weeks of gestation. The distal epiphysis is visible at 2 years of age, and the proximal secondary ossification center at 4 years. The distal fibular physis closes at approximately 16 years; the proximal physis closes later, between the ages of 15 and 18 years.51 Nine muscles have either their origin or insertion on the fibula (Table 31-2).51 
 
Table 31-1
Muscle Origins and Insertions on the Tibia
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Table 31-1
Muscle Origins and Insertions on the Tibia
Muscle Origins and Insertions on the Tibia
Muscle Origin or Insertion
Semimembranosus Inserts on the inner tuberosity of the proximal tibia
Tibialis anterior, EDL, biceps femoris Attach to lateral condyle of the tibia
Sartorius, gracilis, semitendinosus Insert on the proximal medial surface of the tibial metaphysis
Tibialis anterior Arises on the lateral surface of the tibial diaphysis
Popliteus, soleus, FDL, tibialis posterior Attaches to the posterior diaphysis of the tibia
Patellar tendon Inserts into the tibial tubercle
Tensor fascia lata Attaches to Gerdy tubercle, the lateral aspect of the proximal tibial metaphysis
Secondary slip of the tensor fascia lata Occasionally inserts into the tibial tubercle
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Table 31-2
Muscle Origins and Insertions on the Fibula
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Table 31-2
Muscle Origins and Insertions on the Fibula
Muscle Insertions and Origins on the Fibula
Muscle Origin or Insertion
Soleus, FHL Arise from the posterior aspect of the fibular diaphysis
Peroneus longus, peroneus brevis Arise from the lateral aspect of the fibular diaphysis
Biceps femoris, soleus, peroneus longus Attach to the head of the fibula
Extensor digitorum longus, peroneus tertius, EHL Attach to the anterior surface of the fibular shaft
Tibialis posterior Arise from the medial aspect of the fibular diaphysis
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Vascular Anatomy of Fractures of the Shaft of the Tibia and Fibula

The popliteal artery descends vertically between the condyles of the femur and passes between the medial and lateral heads of the gastrocnemius muscle. It ends at the distal border of the popliteus muscle, where it divides into the anterior and posterior tibial arteries. The anterior tibial artery passes between the tibia and the fibula over the proximal aspect of the intraosseous membrane, and enters the anterior compartment of the lower leg. The posterior tibial artery divides several centimeters distal to this point, giving rise to the peroneal artery (Fig. 31-1).51 
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Figure 31-1
Vascular anatomy of the proximal tibia.
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Neural Anatomy of the Tibia and Fibula

The posterior tibial nerve runs adjacent and posterior to the popliteal artery in the popliteal fossa, and then enters the deep posterior compartment of the leg. This nerve provides innervation to the muscles of the deep posterior compartment and sensation to the plantar aspect of the foot. The common peroneal nerve passes laterally around the proximal neck of the fibula. It divides into the deep and superficial branches, and then passes into the anterior and the lateral compartments of the lower leg, respectively. Each branch innervates the muscles within its compartment. The deep peroneal nerve provides sensation to the first web space. The superficial branch is responsible for sensation across the dorsal and lateral aspects of the foot. 

Fascial Compartments

The lower leg has four fascial compartments (Fig. 31-2). The anterior compartment contains the extensor digitorum longus, the extensor hallucis longus, and the tibialis anterior muscles; the anterior tibial artery and deep peroneal nerve run in this compartment. The lateral compartment contains the peroneus longus and brevis muscles. The superficial peroneal nerve runs through this compartment. The superficial posterior compartment contains the soleus and gastrocnemius muscles. The deep posterior compartment contains the flexor digitorum longus, the flexor hallucis longus, and the tibialis posterior muscles. The posterior tibial artery, peroneal artery, and posterior tibial nerve run in this compartment.51 
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Figure 31-2
Fibroosseous compartments of the leg.
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Fractures of the Proximal Tibial Metaphysis

The peak incidence for proximal tibia metaphyseal fractures is between the ages of 3 and 6 years. The most common mechanism of injury is a low energy force applied to the lateral aspect of the extended knee generating a valgus moment. The cortex of the medial tibial metaphysis fails in tension, often resulting in an incomplete greenstick fracture. Compression (torus) and complete fractures can occur in this area, but are less common. The fibula generally escapes injury, although plastic deformation may occur.4,6,23,24,53,75,79,84,116,134,142,148,153,158,163,164 
Children with proximal tibia metaphyseal fractures present with pain, swelling, and tenderness in the region of the fracture. Motion of the knee causes moderate pain, and in most cases the child will not walk. Crepitance is seldom identified on physical examination, especially if the fracture is incomplete.4,6,23,24,53,75,79,84,116,134,142,148,153,158,164 Radiographs usually show a complete or incomplete fracture of the proximal tibial metaphysis. The medial aspect of the fracture often is widened, producing a valgus deformity. 
A possible sequela of a proximal tibial metaphyseal fracture is development of a progressive valgus deformity (Fig. 31-3). In 1953, Cozen24 was the first to report valgus deformity following a proximal tibial metaphyseal fracture. He described four patients with valgus deformities after fractures in this area. In two cases, the valgus was present at the time of cast removal, suggesting loss of reduction as a potential cause of the deformity. In the other two patients the tibia valga developed gradually during subsequent growth of the patient. Since that time, many other investigators6,23,52,53,75,79,94,116,149,153,158 have reported development of tibia valga, even in fractures without any significant malalignment at the time of initial treatment. Nenopoulos reported a 90% incidence of progressive tibial valgus deformity in patients with minimally or nondisplaced proximal tibia metaphyseal fractures.113 
Figure 31-3
 
A: Anteroposterior and lateral radiographs of the proximal tibial metaphyseal fracture with an intact fibula in a 3-year-old child. B: Anteroposterior and lateral radiograph in the initial long-leg cast demonstrate an acceptable alignment. C: Posttraumatic tibia valga is present 1 year after fracture union.
 
(From Sharps CH, Cardea JA. Fractures of the shaft of the tibia and fibula. In: MacEwen GD, Kasser JR, Heinrich SD, eds. Pediatric Fractures: A Practical Approach to Assessment and Treatment. Baltimore, MD: Williams & Wilkins, 1993:321, with permission.)
A: Anteroposterior and lateral radiographs of the proximal tibial metaphyseal fracture with an intact fibula in a 3-year-old child. B: Anteroposterior and lateral radiograph in the initial long-leg cast demonstrate an acceptable alignment. C: Posttraumatic tibia valga is present 1 year after fracture union.
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Figure 31-3
A: Anteroposterior and lateral radiographs of the proximal tibial metaphyseal fracture with an intact fibula in a 3-year-old child. B: Anteroposterior and lateral radiograph in the initial long-leg cast demonstrate an acceptable alignment. C: Posttraumatic tibia valga is present 1 year after fracture union.
(From Sharps CH, Cardea JA. Fractures of the shaft of the tibia and fibula. In: MacEwen GD, Kasser JR, Heinrich SD, eds. Pediatric Fractures: A Practical Approach to Assessment and Treatment. Baltimore, MD: Williams & Wilkins, 1993:321, with permission.)
A: Anteroposterior and lateral radiographs of the proximal tibial metaphyseal fracture with an intact fibula in a 3-year-old child. B: Anteroposterior and lateral radiograph in the initial long-leg cast demonstrate an acceptable alignment. C: Posttraumatic tibia valga is present 1 year after fracture union.
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Many theories have been proposed to explain the development of a valgus deformity after a proximal tibial metaphyseal fracture (Table 31-3). In some cases, proximal tibia valga can be the result of an inadequate reduction or the loss of satisfactory reduction in the weeks following the manipulation.142,163 Lehner and Dubas94 suggested that an expanding medial callus produced a valgus deformity, whereas Goff47 and Keret et al.84 believed that the lateral aspect of the proximal tibial physis was injured at the time of the initial fracture (Salter–Harris type V injury), resulting in asymmetric growth. Taylor153 believed that the valgus deformity was secondary to postfracture stimulation of the tibial physis without a corresponding stimulation of the fibular physis. Pollen122 suggested that premature weight bearing produced an angular deformity of the fracture before union. Rooker and Salter130 believed that the periosteum was trapped in the medial aspect of the fracture, producing an increase in medial physeal growth and a developmental valgus deformity. 
 
Table 31-3
Proposed Etiologies of Trauma-induced Tibia Valgus
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Table 31-3
Proposed Etiologies of Trauma-induced Tibia Valgus
Proximal Tibia Metaphyseal Fractures
Proposed Etiologies of Postfracture Valgus Deformity
Overgrowth of medial proximal tibial physis/physeal arrest of lateral physis
Inadequate reduction
Interposed soft tissue (medial collateral ligament/pes anserinus)
Loss of tethering effect of pes anserinus
Tethering effect of fibula
Early weight bearing producing developmental valgus
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Another theory postulates that the progressive valgus deformity occurs secondary to an increase in vascular flow to the medial proximal tibial physis after fracture, producing an asymmetric physeal response that causes increased medial growth.79 Support for this theory includes quantitative bone scans performed months after proximal tibia metaphyseal fractures that have shown increased tracer uptake in the medial aspect of the physis compared with the lateral aspect.163 Ogden116 identified an increase in the collateral geniculate vascularity to the medial proximal tibia in a cadaver angiography study of a 5-year-old child with a previous fracture. This further supports the theory that medial overgrowth occurs secondary to an increase in the blood flow supplying the medial aspect of the proximal tibia following injury. 
Recent studies suggest that the postfracture tibia valga is the result of an injury to the pes anserinus tendon plate. It is suggested that the pes anserinus tethers the medial aspect of the physis, just as the fibula appears to tether the lateral aspect of the proximal tibial physis. Multiple authors believe that the proximal tibial fracture disrupts the tendon plate, producing a loss of the tethering effect. This, then, may lead to medial physeal overgrowth and a functional hemichondrodiastasis (physeal lengthening).6,27,29,158,164 Exploration of the fracture, followed by removal and repair of the infolded periosteum that forms the foundation of the pes anserinus tendon plate, has been suggested as an approach that may decrease the risk of a developmental valgus deformity. This theory is supported by the work of Houghton and Rooker, who demonstrated that division of the periosteum around the medial half of the proximal tibia in rabbits induced a valgus deformity. They hypothesized that the increasing valgus angulation was because of a mechanical release of the restraints that the periosteum imposes on activity of the physis.71 
Developmental tibia valga has been reported to occur after simple excision of a bone graft from the proximal tibial metaphysis,153 proximal tibial osteotomy,4,75 and osteomyelitis of the proximal tibial metaphysis.4,153 Tibia valga deformity can occur after healing of a nondisplaced fracture, and can recur after corrective tibial osteotomy, further supporting the premise that asymmetric physeal growth is the cause of most posttraumatic tibia valga deformities.163 
The natural history of postfracture proximal tibia valga is one of slow progression of the deformity, followed by gradual restoration of normal alignment over time. The deformity usually is apparent by 5 months post injury, and may progress for up to 18 to 24 months. Zionts and MacEwen164 followed seven children with progressive valgus deformities of the tibia for an average of 39 months after metaphyseal fractures (Fig. 31-4). Most of the deformity developed during the first year after injury. The tibia continued to angulate at a slower rate for up to 17 months after injury. Six of their seven patients had spontaneous clinical corrections. At follow-up, all children had less than a 10-degree deformity. 
Figure 31-4
 
A–C: Anteroposterior radiographs demonstrating the development and subsequent spontaneous correction of postfracture tibia valga.
A–C: Anteroposterior radiographs demonstrating the development and subsequent spontaneous correction of postfracture tibia valga.
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Figure 31-4
A–C: Anteroposterior radiographs demonstrating the development and subsequent spontaneous correction of postfracture tibia valga.
A–C: Anteroposterior radiographs demonstrating the development and subsequent spontaneous correction of postfracture tibia valga.
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Robert et al.127 analyzed 25 patients with proximal tibial fractures. Twelve children with a greenstick or a complete fracture developed valgus deformities, whereas no child with a torus fracture developed a deformity. Altered growth at the distal tibial physis appeared to compensate for the proximal tibia valga in three children. Corrective osteotomies were performed in four children. The valgus deformity recurred in two of these four children, and two had iatrogenic compartment syndromes. If surgical correction is deemed necessary, it is important to remember that tibial osteotomy is not a benign procedure, and has a risk of significant complications. Gradual correction of the deformity with a proximal medial tibial hemiepiphysiodesis may be more appropriate, and certainly safer, treatment for recalcitrant postfracture tibia valga in a child with significant growth remaining.12,117,127,133,148,153 

Author's Preferred Treatment

Nondisplaced proximal tibia metaphyseal fractures should be stabilized in a long-leg cast with the knee in 5 to 10 degrees of flexion and with a varus mold (Fig. 31-5). Displaced proximal tibial fractures require closed reduction with general anesthesia in the operating room or in an emergency room setting with adequate sedation. An anatomic reduction or slight varus positioning should be verified radiographically. If an acceptable closed reduction cannot be obtained, open reduction is indicated. Open reduction includes removal of any soft tissue interposed within the fracture site and repair of the pes anserinus plate if ruptured. After reduction, either closed or open, the child is placed into a long-leg, straight-knee cast with a varus mold, and the alignment is checked once again radiographically. In rare instances, percutaneous fixation with smooth pins, or an external fixator, may be required (Fig. 31-6). 
The knee is casted in extension which facilitates accurate measurements of fracture alignment.
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Figure 31-5
Anteroposterior and lateral radiographs of the proximal tibia and distal femur in a child who sustained a nondisplaced fracture of the proximal tibial and fibular metaphysis.
The knee is casted in extension which facilitates accurate measurements of fracture alignment.
The knee is casted in extension which facilitates accurate measurements of fracture alignment.
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The tibia fracture was stabilized with a modified uniplanar external fixator.
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Figure 31-6
Anteroposterior radiograph of a 3-year-old female with a severe closed head injury, ipsilateral femur, and proximal tibia metaphyseal fractures.
The tibia fracture was stabilized with a modified uniplanar external fixator.
The tibia fracture was stabilized with a modified uniplanar external fixator.
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When the child initially presents for treatment of a tibia fracture at risk of developing genu valgum, it is crucial that the possibility of this unpredictable postfracture problem is discussed with the family. Regular follow-up visits are required to verify maintenance of the reduction. If there is loss of reduction, cast wedging or repeat reduction efforts may be indicated. The cast is removed approximately 6 weeks after injury. The child may return to normal activities after recovery of normal knee and ankle range of motion. Long-term follow-up with forewarning to the family of the possibility of progressive tibial deformity is mandatory. 
A child with a posttraumatic valgus deformity is followed until adequate spontaneous correction occurs. This may take 18 to 36 months. Surgical intervention may be indicated in patients more than 18 months post injury with a mechanical axis deviation greater than 10 degrees as a result of tibial valgus. Tibial osteotomies are not recommended in patients with postfracture valgus if they have significant growth remaining (Fig. 31-7). Instead, a proximal tibial medial hemiepiphysiodesis can restore alignment without many of the risks of osteotomy. Hemiepiphysiodesis may be accomplished through a variety of methods utilizing staples, screws, or tension band plate and screw devices (Fig. 31-8A,B).104,148 Bracing does not alter the natural history of posttraumatic tibia valga and are not recommended.74 Because the valgus deformity usually is associated with some element of overgrowth, a contralateral shoe lift of appropriate size may make the deformity appear less apparent. 
Figure 31-7
Developmental valgus after a proximal tibial metaphyseal fracture and subsequent corrective osteotomy.
 
A: Radiograph taken 6 months after a fracture of the proximal tibia. The injury was nondisplaced. The scar from the initial proximal metaphyseal fracture is still seen (arrow). This child developed a moderate valgus deformity of the tibia within 6 months of fracture. B: A proximal tibial corrective osteotomy was performed. C: Two months postoperatively, the osteotomy was healed and the deformity corrected. D: Five months later, there was a recurrent valgus deformity of 13 degrees.
 
(Courtesy of John J.J. Gugenheim, MD.)
A: Radiograph taken 6 months after a fracture of the proximal tibia. The injury was nondisplaced. The scar from the initial proximal metaphyseal fracture is still seen (arrow). This child developed a moderate valgus deformity of the tibia within 6 months of fracture. B: A proximal tibial corrective osteotomy was performed. C: Two months postoperatively, the osteotomy was healed and the deformity corrected. D: Five months later, there was a recurrent valgus deformity of 13 degrees.
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Figure 31-7
Developmental valgus after a proximal tibial metaphyseal fracture and subsequent corrective osteotomy.
A: Radiograph taken 6 months after a fracture of the proximal tibia. The injury was nondisplaced. The scar from the initial proximal metaphyseal fracture is still seen (arrow). This child developed a moderate valgus deformity of the tibia within 6 months of fracture. B: A proximal tibial corrective osteotomy was performed. C: Two months postoperatively, the osteotomy was healed and the deformity corrected. D: Five months later, there was a recurrent valgus deformity of 13 degrees.
(Courtesy of John J.J. Gugenheim, MD.)
A: Radiograph taken 6 months after a fracture of the proximal tibia. The injury was nondisplaced. The scar from the initial proximal metaphyseal fracture is still seen (arrow). This child developed a moderate valgus deformity of the tibia within 6 months of fracture. B: A proximal tibial corrective osteotomy was performed. C: Two months postoperatively, the osteotomy was healed and the deformity corrected. D: Five months later, there was a recurrent valgus deformity of 13 degrees.
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Figure 31-8
 
A: Anteroposterior image of a Salter–Harris type II fracture of the proximal tibia. Notice the valgus alignment. B: This fracture was treated with percutaneous pin fixation after reduction. C: This patient developed tibia valga over a period of approximately 2 years following the injury. D: A medial proximal tibial hemiepiphysiodesis using a staple was performed.
A: Anteroposterior image of a Salter–Harris type II fracture of the proximal tibia. Notice the valgus alignment. B: This fracture was treated with percutaneous pin fixation after reduction. C: This patient developed tibia valga over a period of approximately 2 years following the injury. D: A medial proximal tibial hemiepiphysiodesis using a staple was performed.
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Figure 31-8
A: Anteroposterior image of a Salter–Harris type II fracture of the proximal tibia. Notice the valgus alignment. B: This fracture was treated with percutaneous pin fixation after reduction. C: This patient developed tibia valga over a period of approximately 2 years following the injury. D: A medial proximal tibial hemiepiphysiodesis using a staple was performed.
A: Anteroposterior image of a Salter–Harris type II fracture of the proximal tibia. Notice the valgus alignment. B: This fracture was treated with percutaneous pin fixation after reduction. C: This patient developed tibia valga over a period of approximately 2 years following the injury. D: A medial proximal tibial hemiepiphysiodesis using a staple was performed.
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Diaphyseal Fractures of the Tibia and Fibula

Seventy percent of pediatric tibial fractures are isolated injuries.140,159 The fractures can be incomplete (torus, greenstick) or complete. Most tibial fractures in children under 11 years of age are caused by a torsional force and occur in the distal third of the tibial diaphysis. These oblique and spiral fractures occur when the body rotates with the foot in a fixed position on the ground. The fracture line generally starts in the distal anteromedial aspect of the bone and propagates proximally in a posterolateral direction. If there is not an associated fibula fracture, the intact fibula prevents significant shortening of the tibia; however, varus angulation develops in approximately 60% of isolated tibial fractures within the first 2 weeks after injury (Fig. 31-9).161 In these cases, forces generated by contraction of the long flexor muscles of the lower leg are converted into an angular moment by the intact fibula producing varus malalignment (Fig. 31-10A). Isolated transverse and comminuted fractures of the tibia most commonly are caused by direct trauma. Transverse fractures of the tibia with an intact fibula generally are stable, and seldom displace significantly.14,80 Comminuted or segmental tibial fractures with an intact fibula tend to drift into varus alignment similar to oblique and spiral fractures.14,80,161 
Figure 31-9
Anteroposterior radiograph of a distal one-third tibial fracture without concomitant fibular fracture in a 10-year-old child.
 
A: The alignment in the coronal plane is acceptable (note that the proximal and distal tibial growth physes are parallel). B: A varus angulation developed within the first 2 weeks after injury. C: A 10-degree varus angulation was present after union.
A: The alignment in the coronal plane is acceptable (note that the proximal and distal tibial growth physes are parallel). B: A varus angulation developed within the first 2 weeks after injury. C: A 10-degree varus angulation was present after union.
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Figure 31-9
Anteroposterior radiograph of a distal one-third tibial fracture without concomitant fibular fracture in a 10-year-old child.
A: The alignment in the coronal plane is acceptable (note that the proximal and distal tibial growth physes are parallel). B: A varus angulation developed within the first 2 weeks after injury. C: A 10-degree varus angulation was present after union.
A: The alignment in the coronal plane is acceptable (note that the proximal and distal tibial growth physes are parallel). B: A varus angulation developed within the first 2 weeks after injury. C: A 10-degree varus angulation was present after union.
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Figure 31-10
 
A: Fractures involving the middle third of the tibia and fibula may shift into a valgus alignment because of the activity of the muscles in the anterior and the lateral compartments of the lower leg. B: Fracture of the middle tibia without an associated fibular fracture tend to shift into varus because of the force created by the anterior compartment musculature of the lower leg and the tethering effect of the intact fibula.
A: Fractures involving the middle third of the tibia and fibula may shift into a valgus alignment because of the activity of the muscles in the anterior and the lateral compartments of the lower leg. B: Fracture of the middle tibia without an associated fibular fracture tend to shift into varus because of the force created by the anterior compartment musculature of the lower leg and the tethering effect of the intact fibula.
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Figure 31-10
A: Fractures involving the middle third of the tibia and fibula may shift into a valgus alignment because of the activity of the muscles in the anterior and the lateral compartments of the lower leg. B: Fracture of the middle tibia without an associated fibular fracture tend to shift into varus because of the force created by the anterior compartment musculature of the lower leg and the tethering effect of the intact fibula.
A: Fractures involving the middle third of the tibia and fibula may shift into a valgus alignment because of the activity of the muscles in the anterior and the lateral compartments of the lower leg. B: Fracture of the middle tibia without an associated fibular fracture tend to shift into varus because of the force created by the anterior compartment musculature of the lower leg and the tethering effect of the intact fibula.
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Approximately 30% of pediatric tibial diaphyseal fractures have an associated fibular fracture.142,159,161 The fibular fracture may be either complete or incomplete with some element of plastic deformation. A tibial diaphyseal fracture with an associated displaced fracture of the fibula often results in valgus malalignment because of the action of the muscles in the anterolateral aspect of the leg (see Figs. 31-10B and 31-11). Any fibular injury must be identified and corrected to minimize the risk of recurrence of angulation after reduction (Fig. 31-12AC). 
Figure 31-11
 
A: Nondisplaced distal tibia fracture with a plastic deformation of the fibula. B: The tibia fracture displaced in a cast 1 week later from the knee exerted by the plastically deformed fibula.
A: Nondisplaced distal tibia fracture with a plastic deformation of the fibula. B: The tibia fracture displaced in a cast 1 week later from the knee exerted by the plastically deformed fibula.
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Figure 31-11
A: Nondisplaced distal tibia fracture with a plastic deformation of the fibula. B: The tibia fracture displaced in a cast 1 week later from the knee exerted by the plastically deformed fibula.
A: Nondisplaced distal tibia fracture with a plastic deformation of the fibula. B: The tibia fracture displaced in a cast 1 week later from the knee exerted by the plastically deformed fibula.
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Figure 31-12
 
A: Anteroposterior and lateral radiograph of the lower leg in a 12-year-old child showing a comminuted tibial fracture with a concomitant plastic deformation of the fibula. Note the valgus alignment of the tibia. B: This patient had a closed manipulation and casting correcting the valgus alignment in the tibia and partially correcting the plastic deformation of the fibula. C: At union, there is an anatomic alignment of the tibia with a mild residual plastic deformation of the fibula.
A: Anteroposterior and lateral radiograph of the lower leg in a 12-year-old child showing a comminuted tibial fracture with a concomitant plastic deformation of the fibula. Note the valgus alignment of the tibia. B: This patient had a closed manipulation and casting correcting the valgus alignment in the tibia and partially correcting the plastic deformation of the fibula. C: At union, there is an anatomic alignment of the tibia with a mild residual plastic deformation of the fibula.
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Figure 31-12
A: Anteroposterior and lateral radiograph of the lower leg in a 12-year-old child showing a comminuted tibial fracture with a concomitant plastic deformation of the fibula. Note the valgus alignment of the tibia. B: This patient had a closed manipulation and casting correcting the valgus alignment in the tibia and partially correcting the plastic deformation of the fibula. C: At union, there is an anatomic alignment of the tibia with a mild residual plastic deformation of the fibula.
A: Anteroposterior and lateral radiograph of the lower leg in a 12-year-old child showing a comminuted tibial fracture with a concomitant plastic deformation of the fibula. Note the valgus alignment of the tibia. B: This patient had a closed manipulation and casting correcting the valgus alignment in the tibia and partially correcting the plastic deformation of the fibula. C: At union, there is an anatomic alignment of the tibia with a mild residual plastic deformation of the fibula.
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An isolated fracture of the fibular shaft is rare in children, and results most commonly from a direct blow to the lateral aspect of the leg (Fig. 31-13). Most isolated fractures of the fibular shaft are nondisplaced and heal quickly with symptomatic care and immobilization (Fig. 31-14). 
Figure 31-13
 
A: Anteroposterior and lateral radiograph of a 7-year-old child with an isolated open fibula fracture secondary to a bite by a pit bull. B: Anteroposterior radiograph 6 weeks after injury demonstrating consolidation at the fracture site. C: Lateral radiograph showing bridging callus 6 weeks after injury.
A: Anteroposterior and lateral radiograph of a 7-year-old child with an isolated open fibula fracture secondary to a bite by a pit bull. B: Anteroposterior radiograph 6 weeks after injury demonstrating consolidation at the fracture site. C: Lateral radiograph showing bridging callus 6 weeks after injury.
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Figure 31-13
A: Anteroposterior and lateral radiograph of a 7-year-old child with an isolated open fibula fracture secondary to a bite by a pit bull. B: Anteroposterior radiograph 6 weeks after injury demonstrating consolidation at the fracture site. C: Lateral radiograph showing bridging callus 6 weeks after injury.
A: Anteroposterior and lateral radiograph of a 7-year-old child with an isolated open fibula fracture secondary to a bite by a pit bull. B: Anteroposterior radiograph 6 weeks after injury demonstrating consolidation at the fracture site. C: Lateral radiograph showing bridging callus 6 weeks after injury.
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Figure 31-14
There is moderate new bone formation 6 weeks after injury (left).
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Figure 31-14
Distal one-third fibular fracture in an 8-year-old who was struck on the lateral side of the leg (right).
There is moderate new bone formation 6 weeks after injury (left).
There is moderate new bone formation 6 weeks after injury (left).
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Signs and Symptoms of Fractures of the Tibia and Fibula

The signs and symptoms associated with tibial and fibular diaphyseal fractures vary with the severity of the injury and the mechanism by which it was produced. Pain is the most common symptom. Children with fractures of the tibia or fibula have swelling at the fracture site, and the area is tender to palpation. Almost all children with any type of tibia fracture will refuse to ambulate on the injured limb. If there is significant injury to the periosteum and fracture displacement, a bony defect or prominence may be palpable. Immediate neurologic impairment is rare except with fibular neck fractures causing injury to the common peroneal nerve. 
Although arterial disruption is uncommon in pediatric tibial and fibular diaphyseal fractures, both the dorsalis pedis and the posterior tibial pulses should be assessed, and a Doppler examination should be performed if they are not palpable. Capillary refill, sensation, and pain response patterns, particularly pain with passive motion, should be monitored. Concomitant soft tissue injuries must be evaluated carefully. Open fractures must be treated aggressively to reduce the risk of late complications. 

Radiographic Evaluation of Fractures of the Tibia and Fibula

Anteroposterior and lateral radiographs that include the knee and ankle joints (Fig. 31-15) should be obtained whenever a tibial and/or fibular shaft fracture is/are suspected. Though uncommon, tibial shaft fractures may occur in combination with transitional fractures involving the distal tibial metaphysis, and as such, close evaluation of the ankle radiographs is essential (Fig. 31-16AD). Comparison views of the uninvolved leg normally are not indicated. Children with suspected fractures not apparent on the initial radiographs may need to be treated with supportive splinting or casting to control symptoms associated with the injuries. Technetium radionuclide scans obtained at least 3 days after injury are useful to identify fractures that are unapparent on radiographs; however, in most cases, patients with clinical findings consistent with a fracture are treated as though a fracture is present. Periosteal new bone formation evident on plain radiographs obtained 10 to 14 days after injury confirms the diagnosis in most cases. 
Figure 31-15
 
A: Spiral fracture of the distal tibia. The fracture is difficult to identify on the anteroposterior radiograph. B: The fracture is easily identified on the lateral radiograph.
A: Spiral fracture of the distal tibia. The fracture is difficult to identify on the anteroposterior radiograph. B: The fracture is easily identified on the lateral radiograph.
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Figure 31-15
A: Spiral fracture of the distal tibia. The fracture is difficult to identify on the anteroposterior radiograph. B: The fracture is easily identified on the lateral radiograph.
A: Spiral fracture of the distal tibia. The fracture is difficult to identify on the anteroposterior radiograph. B: The fracture is easily identified on the lateral radiograph.
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Figure 31-16
 
A: Anteroposterior radiograph of an adolescent patient with a tibial shaft fracture. B–D: Anteroposterior, lateral, and mortise views of the ankle demonstrate an associated triplane fracture.
A: Anteroposterior radiograph of an adolescent patient with a tibial shaft fracture. B–D: Anteroposterior, lateral, and mortise views of the ankle demonstrate an associated triplane fracture.
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Figure 31-16
A: Anteroposterior radiograph of an adolescent patient with a tibial shaft fracture. B–D: Anteroposterior, lateral, and mortise views of the ankle demonstrate an associated triplane fracture.
A: Anteroposterior radiograph of an adolescent patient with a tibial shaft fracture. B–D: Anteroposterior, lateral, and mortise views of the ankle demonstrate an associated triplane fracture.
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Treatment for Fractures of the Tibia and Fibula

Cast Immobilization

The vast majority of uncomplicated pediatric diaphyseal tibial shaft factures, with/or without associated fibular shaft fractures, can be treated by closed manipulation and casting.67 Fractures of the tibial shaft without concomitant fibular fracture may develop varus malalignment. Valgus angulation and shortening can present a significant problem in children who have complete fractures of both the tibia and the fibula. 
Displaced fractures should be managed with reduction under appropriate sedation, using fluoroscopic assistance when available. This can be done in the emergency room or in the operating room depending on the availability of sedation and fluoroscopy. A reduction plan should be made before manipulation based on review of the deforming forces associated with the specific fracture pattern. A short-leg cast is applied with the foot in the appropriate position with either a varus or valgus mold, depending on the fracture pattern and alignment. The cast material is taken to the inferior aspect of the patella anteriorly and to a point 2 cm distal to the popliteal flexion crease posteriorly. It may be best to use plaster for the initial cast because of its ability to mold to the contour of the leg and the ease with which it can be manipulated while setting. The alignment of the fracture is reassessed after the short-leg cast has been applied. The cast is then extended to the proximal thigh with the knee flexed. Most children with complete, unstable diaphyseal tibial fractures are placed into a bent-knee (45 degree) long-leg cast to control rotation at the fracture site and to assist in maintaining non–weight-bearing status during the initial healing phase. The child's ankle initially may be left in some plantar flexion (20 degrees for fractures of the middle and distal thirds, 10 degrees for fractures of the proximal third) to prevent generation of apex posterior angulation (recurvatum) at the fracture site. In a child, there is little risk of developing a permanent equinus contracture, as any initial plantar flexion can be corrected at a cast change once the fracture becomes more stable. 
The alignment of the fracture should be checked weekly during the first 3 weeks after the cast has been applied. Muscle atrophy and a reduction in tissue edema may cause the fracture to drift into unacceptable alignment. Cast wedging may be performed in an attempt to improve alignment, and in some cases a second cast application with remanipulation of the fracture under general anesthesia may be necessary to obtain acceptable alignment. Acceptable position is somewhat controversial and varies based on patient age as well as location and direction of the deformity.37 Remodeling of angular deformity is limited in the tibia. (Table 31-4) No absolute numbers can be given, but the following general guidelines may be beneficial in decision making. 
 
Table 31-4
Indications for Surgical Stabilization
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Table 31-4
Indications for Surgical Stabilization
Diaphyseal Tibia Fractures
Surgical Indications
Absolute Relative
Failure to attain or maintain adequate closed reduction Open fracture
Fracture associated with significant soft tissue injury
Fracture associated with compartment syndrome
Floating knee
Fracture associated with closed head injury and/or multitrauma
X
  •  
    Varus and valgus deformity in the upper and midshaft tibia remodel slowly, if at all. Up to 10 degrees of deformity can be accepted in patients less than 8 years old, and a little more than 5 degrees of angulation in those older than 8 years of age.
  •  
    Moderate translation of the shaft of the tibia in a young child is acceptable, whereas in an adolescent, at least 50% apposition is recommended.
  •  
    Up to 10 degrees of apex anterior angulation may be tolerated, although remodeling is slow.
  •  
    Minimal apex posterior angulation (recurvatum) can be accepted, as this forces the knee into extension at heel strike during gait.
  •  
    Up to 1 cm of shortening is acceptable.

Cast Wedging

Patients with a loss of fracture reduction and unacceptable angulation may benefit from remanipulation of the fracture. This can be attempted in the clinic setting through the use of cast “wedging.” Fracture alignment in the cast can be altered by creation of a closing wedge, an opening wedge, or a combination of wedges. Unfortunately, this technique is labor intensive and has become something of a lost art. The location for wedge placement is determined by evaluating the child's leg radiographically, and marking the midpoint of the tibial fracture on the outside of the cast. If fluoroscopy is not available, a series of paper clips are placed at 2-cm intervals on the cast and anteroposterior and lateral radiographs are then taken. The paper clips define the location of the fracture and the location most suitable for cast manipulation. 
Closing Wedge Technique
A wedge of cast material is removed which encompasses 90% of the circumference of the leg with its base over the apex of the fracture. The exact width of the wedge is proportional to the amount of correction desired and therefore varies in each patient, and can be determined geometrically utilizing the amount of desired angular correction and the width of the cast in the location of the wedge. The cast is left intact opposite the apex of the fracture in the plane of proposed correction. The edges of the cast are brought together to correct the angulation at the fracture. This wedging technique may produce mild fracture shortening, and care must be taken to avoid pinching the skin at the site of cast reapproximation. Theoretically, the closing wedge technique may increase exterior constrictive pressure, as the total volume of the cast is reduced. In light of these concerns, it may be preferable to use the opening wedge technique whenever possible. 
Opening Wedge Technique
The side of the cast opposite the apex of the fracture is cut perpendicular to the long axis of the bone. A small segment of the cast is left intact directly over the apex of the malaligned fracture (∼25%). A cast spreader is used to “jack” or spread the cast open. Plastic shims (Fig. 31-17) or a stack of tongue depressors of the appropriate size are placed into the open segment to maintain the distraction of the site, and the cast is wrapped with new casting material after the alignment has been assessed radiographically (Fig. 31-18). When using any wedging material, it is imperative that the edges do not protrude into the cast padding or cause pressure on the underlying skin. This wedging technique effectively lengthens the tibia while correcting the malalignment (Figs. 31-19AD). 
Figure 31-17
 
A,B: Blocks used to hold casts open after wedge corrections of malaligned fractures. The wings on the blocks prevent the blocks from migrating toward the skin.
A,B: Blocks used to hold casts open after wedge corrections of malaligned fractures. The wings on the blocks prevent the blocks from migrating toward the skin.
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Figure 31-17
A,B: Blocks used to hold casts open after wedge corrections of malaligned fractures. The wings on the blocks prevent the blocks from migrating toward the skin.
A,B: Blocks used to hold casts open after wedge corrections of malaligned fractures. The wings on the blocks prevent the blocks from migrating toward the skin.
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Figure 31-18
Comminuted fracture of the tibia and fibula in a 12-year-old boy struck by a car (left).
 
Notice the extension of the fracture into the metaphysis from the diaphyseal injury. The fracture is in a valgus alignment. The fracture could not be maintained in an acceptable alignment (right). The cast was wedged with excellent result.
Notice the extension of the fracture into the metaphysis from the diaphyseal injury. The fracture is in a valgus alignment. The fracture could not be maintained in an acceptable alignment (right). The cast was wedged with excellent result.
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Figure 31-18
Comminuted fracture of the tibia and fibula in a 12-year-old boy struck by a car (left).
Notice the extension of the fracture into the metaphysis from the diaphyseal injury. The fracture is in a valgus alignment. The fracture could not be maintained in an acceptable alignment (right). The cast was wedged with excellent result.
Notice the extension of the fracture into the metaphysis from the diaphyseal injury. The fracture is in a valgus alignment. The fracture could not be maintained in an acceptable alignment (right). The cast was wedged with excellent result.
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Figure 31-19
 
A: Anteroposterior and lateral tibial radiographs of an 11-year-old boy who was struck by an automobile, sustaining a markedly comminuted tibial fracture without concomitant fibular fracture. B: Despite the comminution, length and alignment were maintained in a cast. C: The patient's fracture shifted into a varus malalignment that measured 10 degrees (right). The cast was wedged, resulting in the re-establishment of an acceptable coronal alignment (left). D: The patient's fracture healed without malunion.
A: Anteroposterior and lateral tibial radiographs of an 11-year-old boy who was struck by an automobile, sustaining a markedly comminuted tibial fracture without concomitant fibular fracture. B: Despite the comminution, length and alignment were maintained in a cast. C: The patient's fracture shifted into a varus malalignment that measured 10 degrees (right). The cast was wedged, resulting in the re-establishment of an acceptable coronal alignment (left). D: The patient's fracture healed without malunion.
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Figure 31-19
A: Anteroposterior and lateral tibial radiographs of an 11-year-old boy who was struck by an automobile, sustaining a markedly comminuted tibial fracture without concomitant fibular fracture. B: Despite the comminution, length and alignment were maintained in a cast. C: The patient's fracture shifted into a varus malalignment that measured 10 degrees (right). The cast was wedged, resulting in the re-establishment of an acceptable coronal alignment (left). D: The patient's fracture healed without malunion.
A: Anteroposterior and lateral tibial radiographs of an 11-year-old boy who was struck by an automobile, sustaining a markedly comminuted tibial fracture without concomitant fibular fracture. B: Despite the comminution, length and alignment were maintained in a cast. C: The patient's fracture shifted into a varus malalignment that measured 10 degrees (right). The cast was wedged, resulting in the re-establishment of an acceptable coronal alignment (left). D: The patient's fracture healed without malunion.
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After any cast wedging, especially early after injury when there may be residual leg swelling, it is recommended to observe the patient for a short period of time to be certain that signs and symptoms of compartment syndrome do not develop. Cast wedging may be somewhat painful for a brief period of time, but that discomfort should subside. The family should be alerted that if increasing pain develops after cast wedging, the patient should return urgently for evaluation. 

Operative Treatment

Historically, operative treatment has been recommended infrequently for tibial shaft fractures in children. Weber et al.159 reported that only 29 (4.5%) of 638 pediatric tibial fractures in their study required surgical intervention. However, in the last decade there has been an increasing interest in surgical stabilization, particularly for unstable closed tibial shaft fractures as well as open fractures or those with associated soft tissue injuries. The current indications for operative treatment include open fractures, most fractures with an associated compartment syndrome, some fractures in children with spasticity (head injury or cerebral palsy), fractures in which open treatment facilitates nursing care (floating knee, multiple long bone fractures, multiple system injuries), and unstable fractures in which adequate alignment cannot be either attained or maintained (Table 31-5).5,11,26,38,41,44,54,72,83 Common methods of fixation for tibial fractures requiring operative treatment include percutaneous metallic pins, bioabsorbable pins,8 external fixation,30,110,138 and plates with screws; the use of flexible intramedullary titanium or stainless steel nails or, in some cases, intramedullary Steinmann pins, is becoming increasingly common.45,48,50,91,110,115,124,132,155 Kubiak et al.91 compared the use of titanium flexible nails with external fixation in a mixed group of patients with open and closed tibial fractures. Although the groups were not matched and were reviewed retrospectively, the authors reported a clinically significant decrease in time to union with titanium nails compared to external fixation. Gordon et al.49 retrospectively reviewed 60 pediatric patients with open or closed tibial shaft fractures managed with flexible nails. They found an 18% complication rate; the most common complication was delayed union. In this study, those patients with delayed time to union tended to be older (mean age 14.1 years) versus the mean age of the study population (11.7 years). Srivastava et al.146 reviewed a mixed group of 24 patients with open or closed tibial shaft fractures managed with titanium nails. All patients went on to union at an average of 20.4 weeks. The total complication rate was 20%, including two patients with mild sagittal plane malunions at final follow-up. 
Table 31-5
Acceptable Alignment of a Pediatric Diaphyseal Tibial Fracture
Patient Age <8 Years ≥8 Years
Valgus 5 degrees 5 degrees
Varus 10 degrees 5 degrees
Angulation anterior 10 degrees 5 degrees
Posterior angulation 5 degrees 0 degrees
Shortening 10 mm 5 mm
Rotation 5 degrees 5 degrees
X

Open Tibial Fractures

Most open tibial fractures in children involve the diaphyseal region, and are treated similarly to comparable injuries in adults. In addition, these fractures and associated soft tissue injuries are classified utilizing the Gustilo and Anderson System (Fig. 31-20).57 Most open fractures of the tibia result from high-velocity/high-energy injuries.19,129 
Figure 31-20
Gustilo and Anderson classification of open fractures.
 
Grade I: The skin wound measures less than 1 cm long, usually from within, with little or no skin contusion. Grade II: The skin wound measures more than 1 cm long, with skin and soft tissue contusion but no loss of muscle or bone. Grade IIIA: There is a large severe skin wound with extensive soft tissue contusion, muscle crushing or loss, and severe periosteal stripping. Grade IIIB: Like grade IIIA but with bone loss and nerve or tendon injury. Grade IIIC: Like grade IIIA or B with associated vascular injury.
 
(From Alonso JE. The initial management of the injured child: Musculoskeletal injuries. In: MacEwen GD, Kasser J, Heinrich SD, eds. Pediatric Fractures: A Practical Approach to Assessment and Treatment. Baltimore, MD: Williams & Wilkins; 1993:32, with permission.)
Grade I: The skin wound measures less than 1 cm long, usually from within, with little or no skin contusion. Grade II: The skin wound measures more than 1 cm long, with skin and soft tissue contusion but no loss of muscle or bone. Grade IIIA: There is a large severe skin wound with extensive soft tissue contusion, muscle crushing or loss, and severe periosteal stripping. Grade IIIB: Like grade IIIA but with bone loss and nerve or tendon injury. Grade IIIC: Like grade IIIA or B with associated vascular injury.
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Figure 31-20
Gustilo and Anderson classification of open fractures.
Grade I: The skin wound measures less than 1 cm long, usually from within, with little or no skin contusion. Grade II: The skin wound measures more than 1 cm long, with skin and soft tissue contusion but no loss of muscle or bone. Grade IIIA: There is a large severe skin wound with extensive soft tissue contusion, muscle crushing or loss, and severe periosteal stripping. Grade IIIB: Like grade IIIA but with bone loss and nerve or tendon injury. Grade IIIC: Like grade IIIA or B with associated vascular injury.
(From Alonso JE. The initial management of the injured child: Musculoskeletal injuries. In: MacEwen GD, Kasser J, Heinrich SD, eds. Pediatric Fractures: A Practical Approach to Assessment and Treatment. Baltimore, MD: Williams & Wilkins; 1993:32, with permission.)
Grade I: The skin wound measures less than 1 cm long, usually from within, with little or no skin contusion. Grade II: The skin wound measures more than 1 cm long, with skin and soft tissue contusion but no loss of muscle or bone. Grade IIIA: There is a large severe skin wound with extensive soft tissue contusion, muscle crushing or loss, and severe periosteal stripping. Grade IIIB: Like grade IIIA but with bone loss and nerve or tendon injury. Grade IIIC: Like grade IIIA or B with associated vascular injury.
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Treatment Principles for Open Tibial Fractures

Management principles for open tibial fractures include: 
  •  
    Timely debridement, irrigation, and initiation of appropriate antibiotic therapy121
  •  
    Fracture reduction followed by stabilization with either internal or external devices
  •  
    Intraoperative angiography (after rapid fracture stabilization) and management of possible elevation of compartment pressures when sufficiency of the vascular perfusion is unclear
  •  
    Open wound treatment with loose gauze packing or other methods30,108
  •  
    Staged debridement of necrotic soft tissue and bone in the operating room as needed until the wounds are ready for closure or coverage.
  •  
    Delayed closure or application of a split thickness skin graft when possible; use of delayed local or free vascularized flaps as needed
  •  
    Cancellous bone grafting (autologous or allograft) for bone defects or delayed union after maturation of soft tissue coverage
     
    These principles are similar to those utilized in adult patients. However, there is evidence that differences exist between pediatric and adult fracture patients. As such, the principles of treatment for open tibial fractures in adults are altered somewhat by the unique characteristics of the pediatric skeleton. These differences include the following.5,22,26,48,56,145
  •  
    Comparable soft tissue and bony injuries heal more reliably in children than in adults, particularly in patients less than 11 years of age.78
  •  
    Devitalized uncontaminated bone that can be covered with soft tissue can incorporate into the fracture callus, and in some cases may be left within the wound.
  •  
    External fixation can be maintained, when necessary, until fracture consolidation with fewer concerns about delayed or nonunions than in adults.
  •  
    Retained periosteum can regenerate bone, even after segmental bone loss in younger children.
  •  
    After thorough irrigation and debridement, many uncontaminated grade I open wounds may be closed primarily without an increased risk of infection.
Buckley et al.16 reported 41 children with 42 open fractures of the tibia (18 grade II, 6 grade IIIA, 4 grade IIIB, and 2 grade IIIC). Twenty-two (52%) of the fractures were comminuted. All wounds were irrigated and debrided, and antibiotics were administered for at least 48 hours. Twenty-two fractures were treated with reduction and cast application, and 20 with external fixation. Three children had early infections, and one of these patients developed late osteomyelitis. All infections had resolved at final reported follow-up. The average time to union was 5 months (range, 2 to 21 months). The time to union was directly proportional to the severity of the soft tissue injury. Fracture pattern also had an effect on time to union. Segmental bone loss, infection, and the use of an external fixation device were associated with delayed union. Four angular malunions of more than 10 degrees occurred, three of which spontaneously corrected. Four children had more than 1 cm of overgrowth. 
In a series of 40 open lower extremity diaphyseal fractures in 35 children, Cramer et al.25 reported 22 tibial fractures (1 grade I, 10 grade II, and 11 grade III). External fixation was used for 15 fractures, casting for five, and internal fixation for two. Two children required early amputation, four required soft tissue flap coverage, and 13 children had skin grafts. Two additional children with initially closed injuries required fasciotomy for compartment syndrome and were included in the group of open tibial fractures. Ten of the 24 injuries healed within 24 weeks. Five children required bone grafting before healing. 
Hope and Cole69 reported the results of open tibial fractures in 92 children (22 grade I, 51 grade II, and 19 grade III). Irrigation and debridement were performed on admission, intravenous (IV) antibiotics were given for 48 hours, and tetanus prophylaxis was administered when necessary. Primary closure was performed in 51 children, and 41 traumatic wounds were left open. Eighteen soft tissue injuries healed secondarily, and 23 required either a split thickness skin graft or a tissue flap. Sixty-five (71%) of the 92 fractures were reduced and immobilized in an above-the-knee plaster cast. External fixation was used for unstable fractures, injuries with significant soft tissue loss, and fractures in patients with multiple system injuries. Early complications of open tibial fractures in these children were comparable with those in adults. Primary closure did not increase the risk of infection if the wound was small and uncontaminated. At reevaluation 1.5 to 9.8 years after injury, the authors found that 50% of the patients complained of pain at the fracture site; 23% reported decreased abilities to participate in sports, joint stiffness, and cosmetic defects; and 64% had leg length inequalities. Levy et al.96 found comparable late sequelae after open tibial fractures in children, including a 25% prevalence of nightmares surrounding the events of the accident. Blasier and Barnes10 and Song et al.145 found that most late complications associated with pediatric open tibial fractures occurred in children over the age 12 and 11 years, respectively. 
Skaggs et al.141 reviewed their experience with open tibial fractures and found no increased incidence of infection in patients initially debrided more than 6 hours after injury when compared to children treated similarly less than 6 hours after fracture. However, it appears that fractures with more severe soft tissue injuries were more likely to receive more expedient treatment, thereby complicating the analysis. This apparent selection bias in some ways limits the overall usefulness of the study. 
There is some published data that provides concerns about the use of external fixators in tibia fractures in pediatric patients. Myers et al.110 reviewed 31 consecutive high-energy tibia fractures in children treated with external fixation. Nineteen of the fractures were open, with mean follow-up of 15 months. The authors found a high rate of complications in this patient population, including delayed union (particularly in patients of at least 12 years of age), malunion, leg-length discrepancy, and pin tract infections. However, Monsell et al. reported no nonunions and no complications in a group of 10 pediatric patients with open diaphyseal tibia fractures managed with a programmable circular external fixator. In addition, they had no patients with deep infection, nor were there any cases of refracture after fixator removal.107 To date, there are no published studies which directly and prospectively compare the use of flexible intramedullary nails with external fixation for open pediatric tibial shaft fractures. 
Overall, a recent systematic review of the literature demonstrates that the philosophy of treatment on pediatric open tibia fracture has remained essentially unchanged over the last 30 years.3 The authors found a strong correlation between Gustilo–Anderson classification and the incidence of infection, and that the fracture union rate was influenced negatively by the extent of the associated soft tissue injury.3 

Open Tibia Fractures—Associated Issues

Soft Tissue Closure

Expedient coverage of an open tibial fracture that cannot be closed primarily reduces the morbidity associated with this injury.46,86,109 Delayed primary closure can be performed if the wound is clean and does not involve significant skin and muscle loss. In such cases, it is imperative that closure under tension is avoided. Other options include a wide variety of local rotational or pedicled myocutaneous flaps. Vascularized free flaps are viable options in cases for which no other method of closure is appropriate. 
Most of the literature addressing the subject of soft tissue coverage for open tibia fractures involves adult patients, and as such, must be extrapolated to pediatric fracture management.58 In a series of 168 open tibial fractures with late secondary wound closure, Small and Mollan143 found increased complications with early pedicled or rotational fasciocutaneous flaps and late free flaps, but no complications with fasciocutaneous flaps created more than 1 month after injury. Complications associated with free flaps were decreased if the procedure was performed within 7 days of injury. Hallock et al.60 reviewed 11 free flaps for coverage in pediatric patients. They reported a 91% success rate, which was similar to their rate in adults. However, they reported a significant rate of complications at both the donor and the recipient sites.60 Rinker et al.126 reported their experience with free vascularized muscle transfers for traumatic lower extremity trauma in pediatric patients performed between 1992 and 2002. At their institution, 26 patients received 28 flaps during that period. The latissimus dorsi was used most commonly as the origin of the transfer. Twelve of the flaps were performed for coverage of open tibia fractures. There was a 62% overall complication rate, with infection and partial skin-graft loss being the most common problems. The authors concluded that patients receiving free flap coverage within 7 days of injury had a statistically significant lower complication rate than those covered later.126 
Ostermann et al. reported 115 grade II and 239 grade III tibial fractures in a series of 1,085 open fractures. All patients were treated with early broad-spectrum antibiotics, serial debridements, and the application of an external fixation device. Tobramycin-impregnated polymethylmethacrylate was placed into the wounds, and dressings were changed every 48 to 72 hours until the wounds spontaneously closed, underwent delayed primary closure, or received flap coverage. No infections occurred in grade I fractures; approximately 3% of grade II fractures and 8% of grade III fractures developed infections. No infections occurred in patients who had the wound closed within 8 days of injury. On the basis of these and other analyses, it is now recommended that wounds associated with open tibial fractures be covered within 7 days of injury whenever possible.18,19,21,82,118,156 
Multiple authors have reported on the use of subatmospheric pressure dressings in the management of soft tissue injuries in pediatric patients. Dedmond et al.30 reviewed the Wake Forest experience with negative pressure dressings in pediatric patients with type III open tibia fractures. They found that use of this device decreased the need for free tissue transfer to obtain coverage in this patient population. When focusing on the rate of infection, Halvorson et al.62 found that use of negative pressure dressings in the management of open fractures, including open tibia fractures, appeared to be safe and effective when compared to historical controls. 

Vascular Injuries

Vascular injuries have been reported in approximately 5% of children with open tibial fractures. Arterial injuries associated with open tibial fractures include those to the popliteal artery, the posterior tibial artery, the anterior tibial artery, and the peroneal artery. Complications are common in patients with open tibial fractures and associated vascular injuries. Amputation rates as high as 79% have been reported with grade IIIC fractures. Isolated anterior tibial and peroneal artery injuries generally have a good prognosis, whereas injuries of the posterior tibial and popliteal arteries have much less satisfactory prognoses, and more commonly require vascular repairs or reconstructions.1,59,68 Patients with open tibial fractures and vascular disruption may benefit from temporary arterial, and possibly venous, shunting before the bony reconstruction is performed. This approach allows meticulous debridement and repair of the fracture, while maintaining limb perfusion until the primary vascular repair is performed.44 However, in most cases, rapid fracture stabilization, usually utilizing external fixation, can be performed before vascular reconstruction without the need for temporary shunts. 

Author's Preferred Treatment

Closed Diaphyseal Fractures

Simple pediatric diaphyseal tibial fractures unite quickly in most cases, and cast immobilization can be used without affecting the long-term range of motion of the knee and the ankle. A bent-knee, long-leg cast provides maximal comfort to the patient and controls rotation of the fracture fragments. The cast should be bivalved initially to limit the effect of any swelling. Children with nondisplaced or minimally displaced fractures that do not require manipulation generally are not admitted to the hospital. Children with more extensive injuries should be admitted for neurovascular observation and instruction in wheelchair, crutch, or walker use. 
Significantly displaced fractures disrupt the surrounding soft tissues and produce a large hematoma in the fascial compartments of the lower leg. Circulation, sensation, and both active and passive movement of the toes should be monitored carefully after injury. The child should be admitted to the hospital, and reduction should be performed with adequate sedation and fluoroscopy if available. Most fractures are casted after reduction, and the cast may be bivalved or split to allow room for swelling. The fracture must be evaluated clinically and radiographically within a week of initial manipulation to verify maintenance of the reduction. The cast can be wedged to correct minor alignment problems. Significant loss of reduction requires repeat reduction with adequate anesthesia and/or utilization of a more rigid fixation method. The long-leg cast may be changed to a short-leg, weight-bearing cast at 4 to 6 weeks after injury. Children over 11 years of age may be placed into a patellar tendon-bearing cast after removal of the long-leg cast.135 Weight-bearing immobilization is maintained until sufficient callus is evident. 
Fractures in patients with complicating factors including spasticity, a floating knee, multiple long-bone fractures, an associated transitional ankle fracture, extensive soft tissue damage, multiple system injuries, or an inability to obtain or maintain an acceptable reduction should be stabilized with a more rigid fixation method, such as external fixation or flexible intramedullary nails (Figs. 31-21 and 31-22). It is the author's preference to use either stainless steel or titanium flexible intramedullary nails, if at all possible, in these situations. In closed fractures, external fixation is reserved for comminuted or highly unstable fracture patterns and is used infrequently. 
Figure 31-21
 
A: Anteroposterior and lateral radiographs of a 12-year old who was involved in a motor vehicle accident sustaining a grade I open middle one-third tibial and fibular fractures. B: This injury was treated with intramedullary nail fixation. C: At union, the patient has an anatomic alignment and no evidence of a growth disturbance.
A: Anteroposterior and lateral radiographs of a 12-year old who was involved in a motor vehicle accident sustaining a grade I open middle one-third tibial and fibular fractures. B: This injury was treated with intramedullary nail fixation. C: At union, the patient has an anatomic alignment and no evidence of a growth disturbance.
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Figure 31-21
A: Anteroposterior and lateral radiographs of a 12-year old who was involved in a motor vehicle accident sustaining a grade I open middle one-third tibial and fibular fractures. B: This injury was treated with intramedullary nail fixation. C: At union, the patient has an anatomic alignment and no evidence of a growth disturbance.
A: Anteroposterior and lateral radiographs of a 12-year old who was involved in a motor vehicle accident sustaining a grade I open middle one-third tibial and fibular fractures. B: This injury was treated with intramedullary nail fixation. C: At union, the patient has an anatomic alignment and no evidence of a growth disturbance.
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Figure 31-22
Anteroposterior radiograph of a 14-year old who was involved in a motor vehicle accident sustaining a distal one-third tibial fracture and comminuted distal fibular fracture.
This was stabilized with titanium elastic nails.
This was stabilized with titanium elastic nails.
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Open Tibia Fractures

Open tibial fractures of any grade should have a thorough and expedient irrigation and debridement of the wound, although there is some evidence that infection rate is similar in injuries managed at less than 6 hours after injury and those treated later.145 The patient's tetanus status is determined, and prophylaxis is administered as indicated. Appropriate IV antibiotic treatment is initiated as soon as possible and maintained as required based on the severity of the open fracture. In the operating room, the soft tissue wounds should be extended to be certain that the area is cleansed and debrided of all nonviable tissue and foreign material. Devitalized bone may be left in place if it is clean and can be covered by soft tissue, and this is determined on a case-by-case basis. The operative wound extension may be closed along with the open segment in clean grade I injuries. The traumatic wound is allowed to heal by secondary intention if there is moderate contamination after irrigation and debridement. Patients with uncomplicated grade I fractures can be placed in a splint or a cast, or simple smooth pin fixation will prevent displacement of the fracture (Fig. 31-23). Use of this limited fixation does not preclude supplemental splinting or casting. Wounds associated with grade II and III fractures are debrided of devitalized tissue and foreign material. Most children with grade II and all children with grade III wounds require more rigid fracture stabilization. External fixation or intramedullary nails may be used at the surgeon's discretion based on fracture stability and personal experience. More rigid fixation limits the need for significant external splinting, thereby allowing better access for wound care and sequential compartment evaluation as needed. 
Figure 31-23
 
A: Anteroposterior radiograph of a grade I open distal one-third tibial fracture in a 7-year-old child. B: Two percutaneous pins were used to stabilize this fracture after irrigation and débridement. C: Good fracture callus was present and the pins were removed 4 weeks after injury.
A: Anteroposterior radiograph of a grade I open distal one-third tibial fracture in a 7-year-old child. B: Two percutaneous pins were used to stabilize this fracture after irrigation and débridement. C: Good fracture callus was present and the pins were removed 4 weeks after injury.
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Figure 31-23
A: Anteroposterior radiograph of a grade I open distal one-third tibial fracture in a 7-year-old child. B: Two percutaneous pins were used to stabilize this fracture after irrigation and débridement. C: Good fracture callus was present and the pins were removed 4 weeks after injury.
A: Anteroposterior radiograph of a grade I open distal one-third tibial fracture in a 7-year-old child. B: Two percutaneous pins were used to stabilize this fracture after irrigation and débridement. C: Good fracture callus was present and the pins were removed 4 weeks after injury.
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The most versatile and most widely available external fixation device for open pediatric tibial fractures is a unilateral frame (Fig. 31-24). The unilateral frame is easy to apply and allows minor corrections in angular alignment and length. Secondary pins can be used for added support (Fig. 31-25); these are connected to the standard pins or the body of the external fixation device. This allows control of segmental fragments as needed. Fracture reduction tools can be applied to the pin clamps to assist in manipulating the fracture. A small-pin or thin-wire circular frame may be indicated for complicated fractures adjacent to the joint.22 Unilateral frames may be placed to span the joint in question so as to use ligamentotaxis as an indirect reduction method to establish and maintain alignment (Fig. 31-26). 
Figure 31-24
 
A,B: Type II open fracture of the tibia in a 5-year-old boy treated with débridement, unilateral external fixation, and split thickness skin graft. C: Four months after removal of the external fixation.
A,B: Type II open fracture of the tibia in a 5-year-old boy treated with débridement, unilateral external fixation, and split thickness skin graft. C: Four months after removal of the external fixation.
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Figure 31-24
A,B: Type II open fracture of the tibia in a 5-year-old boy treated with débridement, unilateral external fixation, and split thickness skin graft. C: Four months after removal of the external fixation.
A,B: Type II open fracture of the tibia in a 5-year-old boy treated with débridement, unilateral external fixation, and split thickness skin graft. C: Four months after removal of the external fixation.
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Figure 31-25
 
A: Anteroposterior and lateral radiographs of the tibia of a 12-year-old boy who was struck by a car. This child sustained a grade IIIB open middle one-third tibial fracture, a Salter–Harris type II fracture of the distal tibial physis with associated distal fibular fracture (closed arrows), and a tibial eminence fracture (open arrow). B: Irrigation and débridement and application of an external fixation device were performed. C: The fracture of distal tibial physis was stabilized with a supplemental pin attached to the external fixation device. Open reduction and internal fixation of the fibula was performed to enhance the stability of the external fixator in the distal tibia. D: Anteroposterior and lateral radiographs of the tibia approximately 9 months after injury demonstrate healing of the tibial eminence fracture, the comminuted middle one-third tibial fracture, and the distal tibial physeal fracture. The distal tibial physis remains open at this time.
A: Anteroposterior and lateral radiographs of the tibia of a 12-year-old boy who was struck by a car. This child sustained a grade IIIB open middle one-third tibial fracture, a Salter–Harris type II fracture of the distal tibial physis with associated distal fibular fracture (closed arrows), and a tibial eminence fracture (open arrow). B: Irrigation and débridement and application of an external fixation device were performed. C: The fracture of distal tibial physis was stabilized with a supplemental pin attached to the external fixation device. Open reduction and internal fixation of the fibula was performed to enhance the stability of the external fixator in the distal tibia. D: Anteroposterior and lateral radiographs of the tibia approximately 9 months after injury demonstrate healing of the tibial eminence fracture, the comminuted middle one-third tibial fracture, and the distal tibial physeal fracture. The distal tibial physis remains open at this time.
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Figure 31-25
A: Anteroposterior and lateral radiographs of the tibia of a 12-year-old boy who was struck by a car. This child sustained a grade IIIB open middle one-third tibial fracture, a Salter–Harris type II fracture of the distal tibial physis with associated distal fibular fracture (closed arrows), and a tibial eminence fracture (open arrow). B: Irrigation and débridement and application of an external fixation device were performed. C: The fracture of distal tibial physis was stabilized with a supplemental pin attached to the external fixation device. Open reduction and internal fixation of the fibula was performed to enhance the stability of the external fixator in the distal tibia. D: Anteroposterior and lateral radiographs of the tibia approximately 9 months after injury demonstrate healing of the tibial eminence fracture, the comminuted middle one-third tibial fracture, and the distal tibial physeal fracture. The distal tibial physis remains open at this time.
A: Anteroposterior and lateral radiographs of the tibia of a 12-year-old boy who was struck by a car. This child sustained a grade IIIB open middle one-third tibial fracture, a Salter–Harris type II fracture of the distal tibial physis with associated distal fibular fracture (closed arrows), and a tibial eminence fracture (open arrow). B: Irrigation and débridement and application of an external fixation device were performed. C: The fracture of distal tibial physis was stabilized with a supplemental pin attached to the external fixation device. Open reduction and internal fixation of the fibula was performed to enhance the stability of the external fixator in the distal tibia. D: Anteroposterior and lateral radiographs of the tibia approximately 9 months after injury demonstrate healing of the tibial eminence fracture, the comminuted middle one-third tibial fracture, and the distal tibial physeal fracture. The distal tibial physis remains open at this time.
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Figure 31-26
 
A and B: Anteroposterior and lateral radiographs of a grade IIIB open tibia/fibula fractures sustained by a 9-year-old male in an agricultural accident. C,D,E: Anteroposterior/lateral radiographs, and clinical image of a patient 8 weeks after placement of spanning monolateral external fixator with additional percutaneous pin fixation, and delayed coverage with anterior thigh free flap. F and G: Anteroposterior and lateral radiographs of a patient 9 months post injury. Patient had excellent clinical result.
A and B: Anteroposterior and lateral radiographs of a grade IIIB open tibia/fibula fractures sustained by a 9-year-old male in an agricultural accident. C,D,E: Anteroposterior/lateral radiographs, and clinical image of a patient 8 weeks after placement of spanning monolateral external fixator with additional percutaneous pin fixation, and delayed coverage with anterior thigh free flap. F and G: Anteroposterior and lateral radiographs of a patient 9 months post injury. Patient had excellent clinical result.
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Figure 31-26
A and B: Anteroposterior and lateral radiographs of a grade IIIB open tibia/fibula fractures sustained by a 9-year-old male in an agricultural accident. C,D,E: Anteroposterior/lateral radiographs, and clinical image of a patient 8 weeks after placement of spanning monolateral external fixator with additional percutaneous pin fixation, and delayed coverage with anterior thigh free flap. F and G: Anteroposterior and lateral radiographs of a patient 9 months post injury. Patient had excellent clinical result.
A and B: Anteroposterior and lateral radiographs of a grade IIIB open tibia/fibula fractures sustained by a 9-year-old male in an agricultural accident. C,D,E: Anteroposterior/lateral radiographs, and clinical image of a patient 8 weeks after placement of spanning monolateral external fixator with additional percutaneous pin fixation, and delayed coverage with anterior thigh free flap. F and G: Anteroposterior and lateral radiographs of a patient 9 months post injury. Patient had excellent clinical result.
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If at all possible, external fixation pins are placed no closer than 1 cm to the physis. The external fixation device is applied, and a reduction maneuver is performed. All of the connections in the external fixation device are tightened after reduction has been obtained. Secondary pins to improve fracture stability are placed at this time. Limited internal fixation of the fracture can be used to aid in controlling fracture alignment. A posterior splint may be applied to prevent the foot from dropping into plantar flexion. This splint should be easy to remove for subsequent pin care and dressing changes of the open injury. Splinting to maintain position of the ankle and foot can be avoided by external fixation, be it unilateral or circular, to the forefoot. 
Intramedullary fixation is performed most commonly in children using prebent stainless steel Enders nails or titanium elastic nails. In most cases, the implants are placed in a proximal to distal fashion from medial and lateral proximal insertion points. Retrograde fixation through the medial malleolus may be used in rare instances because of soft tissue injuries about the planned proximal insertion sites. Fluoroscopy is required for accurate placement. Care must be taken to avoid injury to the proximal tibial physes, including the tibial tubercle apophysis. Use of supplemental external splinting is at the discretion of the treating surgeon (Tables 31-6 and 31-7). There are some older teenaged patients who may be managed with reamed or unreamed tibial nails. There is no data in the literature that looks specifically at which skeletal age this would be considered acceptable, and at which age the possible risk of injury to the proximal tibial physis is minimized. However, the authors generally reserve these “adult style” devices for patients with a bone age of 15 years or greater, or with a radiographically closed, or closing, proximally tibial physis. 
 
Table 31-6
Surgical Stabilization of Diaphyseal Tibia Fractures
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Table 31-6
Surgical Stabilization of Diaphyseal Tibia Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Supine with a small bump under ipsilateral hip
  •  
    Fluoroscopy location: Contralateral side for flexible nails, ipsilateral side for ex fix
  •  
    Equipment: Flexible nails or external fixator of choice
  •  
    Tourniquet (sterile/nonsterile): Nonsterile, but do not elevate unless necessary
  •  
    Preoperative antibiotics
Note: Must have general anesthesia with adequate muscle relaxation
Note: Must have femoral distractor available or adequate assistance for intraoperative traction
X
 
Table 31-7
Flexible IM Nailing of Diaphyseal Tibia Fractures
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Table 31-7
Flexible IM Nailing of Diaphyseal Tibia Fractures
Surgical Steps
  •  
    Supine position with ipsilateral bump on a radiolucent table
  •  
    Prep extremity toes-to-thigh tourniquet
  •  
    Have adequate soft blanket bumps or knee triangle available
  •  
    Medial and lateral proximal tibial incisions
    •  
      Distal aspect of incision at the point of proposed nail insertion sites
  •  
    Starting holes medially and laterally at, or just proximal to, the level of tibial tubercle. Use drill or awl
  •  
    Contour and pass nails to fracture site. Reduce fracture with traction and manipulation
    •  
      Pass nails into distal metaphysis. Ensure fracture does not distract
  •  
    Check lateral view on C-arm. Rotate nails as necessary to minimize possible recurvatum deformity
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Immobilization

The length of immobilization varies with the child's age and the type of fracture. The duration of immobilization was 8 to 10 weeks in the Steinert and Bennek series.149 Hansen et al.63 found that healing time ranged from 5 to 8 weeks for “fissures and infractions” and from 5 to 13 weeks for oblique, transverse, and comminuted fractures. Hoaglund and States66 reported that in 43 closed fractures in children, the average time in a cast was 2.5 months (range, 1.5 to 5.5 months), whereas the five children with open fractures were immobilized for 3 months. 
Kreder and Armstrong90 found an average time to union of 5.4 months (range, 1.5 to 24.8 months) in a series of 56 open tibial fractures in 55 children. The factor with the most effect on union time was the age of the patient. Grimard et al.56 reported that the age of the patient and the grade of the fracture were significantly associated with union time. Blasier and Barnes10 found that children under 12 years of age required less aggressive surgical treatment and healed faster than older children. They also found that younger children were more resistant to infection and had fewer complications than older children. 

Rehabilitation

Most children with a tibial fracture do not require extensive rehabilitation, beyond basic crutch or walker training. Most children limp with an out-toeing rotation gait on the involved extremity for several weeks to a month after external immobilization is removed. This is secondary to muscle weakness, joint stiffness, and a tendency to circumduct the limb during swing phase, rather than a malalignment of the fracture. As the muscle atrophy and weakness resolve, the limp improves. In very rare situations, formal physical therapy may be required for some children after a tibial fracture. Knee range-of-motion exercises and quadriceps strengthening may be useful in an older child progressing from a bent-knee cast to weight bearing on a short-leg cast. The child may return to sports when the fracture is healed and the patient has regained strength and function comparable to that of the uninjured leg. 

Complications Associated with Diaphyseal Fractures of the Tibia and Fibula

Compartment Syndrome

A compartment syndrome may occur after any type of tibia fracture, ranging from a seemingly minor closed fracture to a severe, comminuted fracture.93 The prevalence of compartment syndromes in adults with open tibial fractures ranges from 6% to 9%.11,31,92 The true incidence of compartment syndrome associated with open pediatric tibial fractures is unknown. Regardless, it is important to remember that compartment syndrome may occur in the face of significant soft tissue injury associated with extensively open fractures, as well as with closed injuries. Flynn et al. provided the most recent major review of a single hospital experience with lower leg compartment syndrome. In that study, 83% of all patients with compartment syndrome had an ipsilateral tibia fracture.42 Schrock139 described compartment syndromes after derotational osteotomies of the tibia in children, and compartment syndrome is a well-known complication of tibial osteotomy for angular deformity correction. 

Diagnosis

Patients with a compartment syndrome often complain of pain out of proportion to the apparent severity of the injury. Increasing pain, often noted as increasing analgesic requirements, is the most important early sign of potential compartment syndrome in children. Pain with passive range of motion appears to be an early and strong clinical finding. Late complications of untreated lower extremity compartment syndrome include clawed toes, dorsal bunion, and limited subtalar motion secondary to necrosis and subsequent fibrous contracture of the muscles originating in the deep posterior compartment.81 

Treatment

Any cast or splint should be bivalved or loosened, and the padding divided, in a patient with increased or increasing pain associated with treatment of a tibia fracture. If, after removal of all encircling wraps, there is no relief, compartment syndrome should be considered. Any child who has objective or subjective evidence of a compartment syndrome should undergo an emergent fasciotomy. Hyperesthesia, motor deficits, and decreased pulses are late changes and denote significant tissue injury. These signs occur only after the ischemia has been well established and the injury is permanent.81,160 Although, there is some controversy in the literature, symptomatic patients with compartment pressures greater than 30 mm Hg may benefit from fasciotomy.76,147,160 
The two-incision technique is used most widely for fasciotomies, although a single incision, perifibular release is favored at some centers (Fig. 31-27A,B).100,101 The fascia surrounding each compartment of concern should be opened widely. The wounds are left open and a delayed primary closure is performed when possible. Negative pressure wound dressings may be of benefit in the management of fasciotomy wounds before closure or coverage. Split thickness skin grafting of the wounds may be necessary in some cases. Fibulectomy has been recommended by some authors as a method by which all compartments can be released through a single approach. Most literature does not support its use, and this procedure should not be performed in skeletally immature patients because of potential proximal migration of the distal fibular remnant and resulting ankle valgus. Long-term ankle valgus may result in external tibial torsion, gait impairment, and potentially problematic foot and ankle deformity. 
Figure 31-27
 
A: Decompressive fasciotomies through a two-incision approach. The anterior lateral incision allows decompression of the anterior and lateral compartments. The medial incision allows decompression of the superficial posterior and the deep posterior compartments. B: A one-incision decompression fasciotomy can be performed through a lateral approach that allows a dissection of all four compartments.
A: Decompressive fasciotomies through a two-incision approach. The anterior lateral incision allows decompression of the anterior and lateral compartments. The medial incision allows decompression of the superficial posterior and the deep posterior compartments. B: A one-incision decompression fasciotomy can be performed through a lateral approach that allows a dissection of all four compartments.
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Figure 31-27
A: Decompressive fasciotomies through a two-incision approach. The anterior lateral incision allows decompression of the anterior and lateral compartments. The medial incision allows decompression of the superficial posterior and the deep posterior compartments. B: A one-incision decompression fasciotomy can be performed through a lateral approach that allows a dissection of all four compartments.
A: Decompressive fasciotomies through a two-incision approach. The anterior lateral incision allows decompression of the anterior and lateral compartments. The medial incision allows decompression of the superficial posterior and the deep posterior compartments. B: A one-incision decompression fasciotomy can be performed through a lateral approach that allows a dissection of all four compartments.
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In a long-term review of patients from the Children's Hospital of Philadelphia, Flynn et al. found that most children with lower extremity compartment syndrome, including those associated with tibia fractures, had good or excellent clinical results. This appeared to be true even in those patients with long time periods from injury to fasciotomy.42 

Vascular Injuries

Vascular injuries associated with tibial fractures are uncommon in children; however, when they do occur, the sequelae can be devastating. In an evaluation of 14 patients with lower extremity fractures and concomitant vascular injuries, Allen et al.1 noted that only three children returned to normal function. One factor leading to a poor outcome was a delay in diagnosis. Evaluation for vascular compromise is imperative in all children with tibial fractures. 
The displaced proximal tibial metaphyseal fracture is the pattern of injury most frequently associated with vascular injury, and often involves the anterior tibial artery as it passes between the fibula and the tibia into the anterior compartment.59,68 The anterior tibial artery may be injured with distal tibial fractures, as the vessel may be injured if the distal fragment translates posteriorly. Posterior tibial artery injuries are rare, except in fractures associated with crushing or shearing caused by accidents involving heavy machinery, or those secondary to gunshot wounds involving the lower leg and ankle region. 

Angular Deformity

Spontaneous correction of significant axial malalignment after a diaphyseal fracture of a child's forearm or femur is common. Remodeling of an angulated tibial shaft fracture, however, often is incomplete (Fig. 31-28).13 As such, the goal of treatment should be to obtain as close to anatomic alignment as possible. Swaan and Oppers151 evaluated 86 children treated for fractures of the tibia. The original angulation of the fracture was measured on radiographs in the sagittal and frontal projections. Girls 1 to 8 years of age and boys 1 to 10 years of age demonstrated moderate spontaneous correction of residual angulation after union. In girls 9 to 12 years of age and boys 11 to 12 years of age, approximately 50% of the angulation was corrected. No more than 25% of the deformity was corrected in children over 13 years of age. 
Figure 31-28
A 4 year 2 mo-old child with a middle one-third transverse tibial fracture and a plastically deformed fibular fracture.
 
A: Lateral view shows 20-degree posterior angulation. B: The deformity is still 15 degrees 4 years after the injury.
A: Lateral view shows 20-degree posterior angulation. B: The deformity is still 15 degrees 4 years after the injury.
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Figure 31-28
A 4 year 2 mo-old child with a middle one-third transverse tibial fracture and a plastically deformed fibular fracture.
A: Lateral view shows 20-degree posterior angulation. B: The deformity is still 15 degrees 4 years after the injury.
A: Lateral view shows 20-degree posterior angulation. B: The deformity is still 15 degrees 4 years after the injury.
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Bennek and Steinert7 found that recurvatum malunion of more than 10 degrees did not correct completely. In this study, 26 of 28 children with varus or valgus deformities at union had significant residual angular deformities at follow-up. Valgus deformities had a worse outcome because the tibiotalar joint was left in a relatively unstable position. Weber et al.159 demonstrated that a fracture with varus malalignment of 5 to 13 degrees completely corrected at the level of the physis. Most children with valgus deformities of 5 to 7 degrees did not have a full correction. 
Hansen et al.63 reported 102 pediatric tibial fractures, 25 of which had malunions of 4 to 19 degrees. Residual angular malunions ranged from 3 to 19 degrees at final follow-up, without a single patient having a complete correction. The spontaneous correction was approximately 13.5% of the total deformity. Shannak140 reviewed the results of treatment of 117 children with tibial shaft fractures treated in above-the-knee casts. Multiplanar deformities did not remodel as completely as those in a single plane. The least correction occurred in apex posterior angulated fractures, followed by fractures with valgus malalignment (Fig. 31-29). Spontaneous remodeling of malunited tibial fractures in children appears to be limited to the first 18 months after fracture.34,35,63 
Figure 31-29
 
A: Anteroposterior and lateral radiographs 2 months after injury in a 6-year-old boy reveal a valgus and anterior malunion at the fracture. B: One year later, the child still has a moderate valgus and anterior malalignment of the distal fractured segment. This malalignment produced painful hyperextension of the knee at heel strike during ambulation.
A: Anteroposterior and lateral radiographs 2 months after injury in a 6-year-old boy reveal a valgus and anterior malunion at the fracture. B: One year later, the child still has a moderate valgus and anterior malalignment of the distal fractured segment. This malalignment produced painful hyperextension of the knee at heel strike during ambulation.
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Figure 31-29
A: Anteroposterior and lateral radiographs 2 months after injury in a 6-year-old boy reveal a valgus and anterior malunion at the fracture. B: One year later, the child still has a moderate valgus and anterior malalignment of the distal fractured segment. This malalignment produced painful hyperextension of the knee at heel strike during ambulation.
A: Anteroposterior and lateral radiographs 2 months after injury in a 6-year-old boy reveal a valgus and anterior malunion at the fracture. B: One year later, the child still has a moderate valgus and anterior malalignment of the distal fractured segment. This malalignment produced painful hyperextension of the knee at heel strike during ambulation.
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Malrotation

Because rotational malalignment of the tibia does not correct spontaneously with remodeling,63 any malrotation should be avoided. A computerized tomographic (CT) evaluation of tibial rotation can be performed if there is any question about the rotational alignment of the fracture that is not evident on clinical examination. 
Rotational malunion of more than 10 degrees may produce significant functional impairment and may necessitate a subsequent derotational osteotomy of the tibia. Most commonly, derotational osteotomy of the tibia is performed in the supramalleolar aspect of the distal tibia. The fibula may be left intact, particularly for planned derotation of less than 20 degrees. Maintaining continuity of the fibula adds stability and limits the possibility of introducing an iatrogenic angular deformity to the distal tibia. 

Leg-length Discrepancy

Hyperemia associated with fracture repair may stimulate the physes in the involved leg, producing growth acceleration, particularly in younger children. Tibial growth acceleration after fracture is less than that seen after femoral fractures in children of comparable ages. Shannak140 showed that the average growth acceleration of a child's tibia after fracture is approximately 4.5 mm. Comminuted fractures appear to have the greatest risk of accelerated growth and overgrowth. 
Swaan and Oppers151 reported that young children have a greater chance for overgrowth than older children. Accelerated growth after tibial fracture generally occurs in children under 10 years of age, whereas older children may have a mild growth inhibition associated with the fracture.63 The amount of fracture shortening also has an effect on growth stimulation. Fractures with significant shortening have more physeal growth after fracture union than injuries without shortening at union.102 The presence of angulation at union does not appear to affect the amount of overgrowth.54 

Anterior Tibial Physeal Closure

Morton and Starr109 reported closure of the anterior tibial physis after fracture in two children. Both patients sustained a comminuted fracture of the tibial diaphysis without a concomitant injury of the knee. The fractures were reduced and stabilized with Kirschner wires reportedly placed distal to the tibial tubercle. A genu recurvatum deformity developed after premature closure of the anterior physis. Smillie144 reported one child who had an open tibial fracture complicated by a second fracture involving the supracondylar aspect of the femur. This patient also developed a recurvatum deformity secondary to closure of the anterior proximal tibial physis. At present, no universally acceptable explanation can be given for this phenomenon. 
Patients have demonstrated apparently iatrogenic closure after placement of a proximal tibial traction pin, the application of pins and plaster, and after application of an external fixation device. Some children may have an undiagnosed injury of the tibial physis at the time of the ipsilateral tibial diaphyseal fracture.87 Regardless of etiology, premature closure of the physis produces a progressive recurvatum deformity and loss of the normal anterior to posterior slope of the proximal tibia as the child grows. Management may require surgical intervention including proximal tibial osteotomy with all the inherent risks and potential complications of that procedure. 

Delayed Union and Nonunion

Delayed union and nonunion are uncommon after low-energy tibial fractures in children. The use of an external fixation device may lengthen the time to union in some patients, particularly those with open fractures resulting from high-energy injury.50,97,110 In patients treated with external fixation, care must be taken to advance weight bearing appropriately and to dynamize the fixator frame as soon as possible to maximize bone healing. Inadequate immobilization that allows patterned micro- or macromotion also can slow the rate of healing and lead to delayed or nonunion. In patients with a suspected delayed union or nonunion, a 1-cm fibulectomy will allow increased compression at the delayed union or nonunion site with weight bearing and often will induce healing (Fig. 31-30). Posterolateral bone grafting is an excellent technique to produce union in children (Fig. 31-31). Adolescents near skeletal maturity with a delayed or nonunion can be managed with a reamed intramedullary nail, concomitant fibular osteotomy, and correction of any angulation at the nonunion site as necessary (Fig. 31-32). 
Figure 31-30
 
A: Anteroposterior radiograph of the distal tibia and fibula in a 5-year-old boy with an open fracture. B: Early callus formation is seen 1 month after injury. C: The tibia has failed to unite 10 months after injury. D: The patient underwent a fibulectomy 4 cm proximal to the tibial nonunion. The tibial fracture united 8 weeks after surgery.
A: Anteroposterior radiograph of the distal tibia and fibula in a 5-year-old boy with an open fracture. B: Early callus formation is seen 1 month after injury. C: The tibia has failed to unite 10 months after injury. D: The patient underwent a fibulectomy 4 cm proximal to the tibial nonunion. The tibial fracture united 8 weeks after surgery.
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Figure 31-30
A: Anteroposterior radiograph of the distal tibia and fibula in a 5-year-old boy with an open fracture. B: Early callus formation is seen 1 month after injury. C: The tibia has failed to unite 10 months after injury. D: The patient underwent a fibulectomy 4 cm proximal to the tibial nonunion. The tibial fracture united 8 weeks after surgery.
A: Anteroposterior radiograph of the distal tibia and fibula in a 5-year-old boy with an open fracture. B: Early callus formation is seen 1 month after injury. C: The tibia has failed to unite 10 months after injury. D: The patient underwent a fibulectomy 4 cm proximal to the tibial nonunion. The tibial fracture united 8 weeks after surgery.
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Figure 31-31
 
A: Nonunion of an open tibial fracture. B: After posterolateral tibial bone graft.
A: Nonunion of an open tibial fracture. B: After posterolateral tibial bone graft.
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Figure 31-31
A: Nonunion of an open tibial fracture. B: After posterolateral tibial bone graft.
A: Nonunion of an open tibial fracture. B: After posterolateral tibial bone graft.
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Figure 31-32
 
A: Anteroposterior and lateral radiographs of a 14-year-old adolescent who was struck by a car, sustaining a grade IIIB open fracture of the tibia. B: Anteroposterior and lateral radiographs of the tibia after irrigation and débridement, and application of an external fixation device. C: The patient developed a nonunion at the tibia, which progressively deformed into an unacceptable varus alignment. D: The nonunion was treated with a fibular osteotomy followed by a closed angular correction of the deformity and internal fixation with a reamed intramedullary nail.
A: Anteroposterior and lateral radiographs of a 14-year-old adolescent who was struck by a car, sustaining a grade IIIB open fracture of the tibia. B: Anteroposterior and lateral radiographs of the tibia after irrigation and débridement, and application of an external fixation device. C: The patient developed a nonunion at the tibia, which progressively deformed into an unacceptable varus alignment. D: The nonunion was treated with a fibular osteotomy followed by a closed angular correction of the deformity and internal fixation with a reamed intramedullary nail.
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Figure 31-32
A: Anteroposterior and lateral radiographs of a 14-year-old adolescent who was struck by a car, sustaining a grade IIIB open fracture of the tibia. B: Anteroposterior and lateral radiographs of the tibia after irrigation and débridement, and application of an external fixation device. C: The patient developed a nonunion at the tibia, which progressively deformed into an unacceptable varus alignment. D: The nonunion was treated with a fibular osteotomy followed by a closed angular correction of the deformity and internal fixation with a reamed intramedullary nail.
A: Anteroposterior and lateral radiographs of a 14-year-old adolescent who was struck by a car, sustaining a grade IIIB open fracture of the tibia. B: Anteroposterior and lateral radiographs of the tibia after irrigation and débridement, and application of an external fixation device. C: The patient developed a nonunion at the tibia, which progressively deformed into an unacceptable varus alignment. D: The nonunion was treated with a fibular osteotomy followed by a closed angular correction of the deformity and internal fixation with a reamed intramedullary nail.
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Fractures of the Distal Tibial Metaphysis

Fractures of the distal tibial metaphysis are often greenstick injuries resulting from increased compressive forces along the anterior tibial cortex. This fracture often occurs secondary to an axial load on a dorsiflexed foot. The anterior cortex is impacted while the posterior cortex is displaced under tension, with a tear of the overlying periosteum. A combined valgus and recurvatum deformity may occur (Fig. 31-33). This fracture pattern was termed the “Robert Gillespie fracture” by Mercer Rang.125 
Figure 31-33
 
A: Fracture of the distal tibia in a 7-year-old child. The lateral radiograph demonstrates a mild recurvatum deformity. B: The ankle was initially immobilized in an ankle neutral position, producing an increased recurvatum deformity. The cast was removed and the ankle remanipulated into plantar flexion to reduce the deformity. C: The ankle was then immobilized in plantar flexion, which is the proper position for this type of fracture.
A: Fracture of the distal tibia in a 7-year-old child. The lateral radiograph demonstrates a mild recurvatum deformity. B: The ankle was initially immobilized in an ankle neutral position, producing an increased recurvatum deformity. The cast was removed and the ankle remanipulated into plantar flexion to reduce the deformity. C: The ankle was then immobilized in plantar flexion, which is the proper position for this type of fracture.
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Figure 31-33
A: Fracture of the distal tibia in a 7-year-old child. The lateral radiograph demonstrates a mild recurvatum deformity. B: The ankle was initially immobilized in an ankle neutral position, producing an increased recurvatum deformity. The cast was removed and the ankle remanipulated into plantar flexion to reduce the deformity. C: The ankle was then immobilized in plantar flexion, which is the proper position for this type of fracture.
A: Fracture of the distal tibia in a 7-year-old child. The lateral radiograph demonstrates a mild recurvatum deformity. B: The ankle was initially immobilized in an ankle neutral position, producing an increased recurvatum deformity. The cast was removed and the ankle remanipulated into plantar flexion to reduce the deformity. C: The ankle was then immobilized in plantar flexion, which is the proper position for this type of fracture.
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Reduction of these injuries should be performed with adequate sedation and maintained with a long-leg cast. In cases in which the fracture has angulated into recurvatum, the foot should be left in moderate plantar flexion to prevent recurrence of apex posterior angulation at the fracture site. The foot is brought up to neutral after 3 to 4 weeks, and a short-leg walking cast is applied. Nondisplaced fractures can be immobilized in either a short- or long-leg cast at the surgeon's discretion. Unstable, displaced fractures can be treated with closed reduction and percutaneous pins (Fig. 31-34), antegrade flexible nails, or with open reduction and internal fixation as needed (Fig. 31-35). Open reduction and internal fixation of an associated distal fibula fracture, may prevent malalignment in an unstable distal tibia fracture. 
Figure 31-34
 
A,B: Unstable distal metadiaphyseal fractures of the tibia and fibula in a 15-year-old girl. C: This fracture was stabilized with percutaneous pins because of marked swelling and fracture instability.
A,B: Unstable distal metadiaphyseal fractures of the tibia and fibula in a 15-year-old girl. C: This fracture was stabilized with percutaneous pins because of marked swelling and fracture instability.
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Figure 31-34
A,B: Unstable distal metadiaphyseal fractures of the tibia and fibula in a 15-year-old girl. C: This fracture was stabilized with percutaneous pins because of marked swelling and fracture instability.
A,B: Unstable distal metadiaphyseal fractures of the tibia and fibula in a 15-year-old girl. C: This fracture was stabilized with percutaneous pins because of marked swelling and fracture instability.
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Figure 31-35
 
A: Anteroposterior radiograph of a distal one-third tibial and fibular fractures in a 9-year-old girl with a closed head injury and severe spasticity. The initial reduction in a cast could not be maintained. B: Open reduction and internal fixation with a medial buttress plate was used to achieve and maintain the alignment.
A: Anteroposterior radiograph of a distal one-third tibial and fibular fractures in a 9-year-old girl with a closed head injury and severe spasticity. The initial reduction in a cast could not be maintained. B: Open reduction and internal fixation with a medial buttress plate was used to achieve and maintain the alignment.
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Figure 31-35
A: Anteroposterior radiograph of a distal one-third tibial and fibular fractures in a 9-year-old girl with a closed head injury and severe spasticity. The initial reduction in a cast could not be maintained. B: Open reduction and internal fixation with a medial buttress plate was used to achieve and maintain the alignment.
A: Anteroposterior radiograph of a distal one-third tibial and fibular fractures in a 9-year-old girl with a closed head injury and severe spasticity. The initial reduction in a cast could not be maintained. B: Open reduction and internal fixation with a medial buttress plate was used to achieve and maintain the alignment.
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Special Fractures

Toddler's Fractures

External rotation of the foot with the knee fixed in an infant or toddler can produce a spiral fracture of the tibia without a concomitant fibular fracture, and is termed a “toddler's fracture” (Fig. 31-36). This fracture pattern was first reported by Dunbar et al.36 in 1964. The traumatic episode often is unwitnessed by the parent or adult caretaker.119 Of those injuries that are witnessed, most caregivers report a seemingly minor, low-energy, twisting mechanism. For example, these injuries may occur when a toddler falls or attempts to extricate the foot from between the bars of a playpen or crib. Most children with this injury are under 6 years of age, and in one study the average age was 27 months. Sixty-three of 76 such fractures reported by Dunbar et al.36 were in children under 2.5 years of age. Toddler's fractures occur in boys more often than in girls and in the right leg more often than in the left. Occasionally, a child may sustain a toddler's fracture in a fall from a height.29,154 
Figure 31-36
 
A: Anteroposterior and lateral radiographs of an 18-month-old child who presented with refusal to bear weight on her leg. Note the spiral middle one-third “toddler's” fracture (arrow heads). B: This fracture healed uneventfully after 4 weeks of immobilization in a cast.
A: Anteroposterior and lateral radiographs of an 18-month-old child who presented with refusal to bear weight on her leg. Note the spiral middle one-third “toddler's” fracture (arrow heads). B: This fracture healed uneventfully after 4 weeks of immobilization in a cast.
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Figure 31-36
A: Anteroposterior and lateral radiographs of an 18-month-old child who presented with refusal to bear weight on her leg. Note the spiral middle one-third “toddler's” fracture (arrow heads). B: This fracture healed uneventfully after 4 weeks of immobilization in a cast.
A: Anteroposterior and lateral radiographs of an 18-month-old child who presented with refusal to bear weight on her leg. Note the spiral middle one-third “toddler's” fracture (arrow heads). B: This fracture healed uneventfully after 4 weeks of immobilization in a cast.
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Oujhane et al.119 analyzed the radiographs of 500 acutely limping toddlers and identified 100 in whom a fracture was the etiology of the gait disturbance. The most common site of fracture was the distal metaphysis of the tibia. 
The examination and physical findings of the patient with a possible toddler's fracture are often subtle. The child typically presents with a history of a new onset limp or refusal to bear weight on the limb. The examination should begin with an evaluation of the uninvolved side, as this serves as a control for the symptomatic extremity. The examination begins at the hip and proceeds to the thigh, knee, lower leg, ankle, and foot. It is important to note areas of point tenderness, any increase in local or systemic temperature, and any swelling or bruising of the leg.154 Radiographs of the tibia and fibula should be obtained in the anteroposterior, lateral, and internal rotation oblique projections. An internally rotated oblique view can be helpful in identifying a nondisplaced toddler's fracture. Occasionally, fluoroscopy may be beneficial in the identification of subtle fractures. In cases in which initial radiographs are negative, but the history and examination are consistent with diagnosis of a toddler's fracture, treatment with a cast is indicated.61,63 In these cases, follow-up radiographs will often demonstrate periosteal new bone formation approximately 10 to 14 days after injury (Fig. 31-37). Technetium radionuclide bone scan can assist in the diagnosis of unapparent fractures, but is rarely indicated. A bone scan of a patient with a toddler's fracture will demonstrate diffuse increased uptake of tracer throughout the affected bone (“black tibia”). This can be differentiated from infection as infection tends to produce a more localized area of increased tracer uptake.36 
Figure 31-37
 
A: Anteroposterior radiograph of the tibia in a 3-year-old child who refused to bear weight on the right leg 3 weeks before presentation. The history of obvious trauma was absent. The radiographs revealed periosteal new bone formation in the midshaft of the right tibia. There was also tenderness to palpation in the left midtibia as well despite normal radiographs. B: A bone scan showed increased uptake in both the left and right tibia. There was significantly less uptake on the left side (arrows) the more recent injury.
A: Anteroposterior radiograph of the tibia in a 3-year-old child who refused to bear weight on the right leg 3 weeks before presentation. The history of obvious trauma was absent. The radiographs revealed periosteal new bone formation in the midshaft of the right tibia. There was also tenderness to palpation in the left midtibia as well despite normal radiographs. B: A bone scan showed increased uptake in both the left and right tibia. There was significantly less uptake on the left side (arrows) the more recent injury.
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Figure 31-37
A: Anteroposterior radiograph of the tibia in a 3-year-old child who refused to bear weight on the right leg 3 weeks before presentation. The history of obvious trauma was absent. The radiographs revealed periosteal new bone formation in the midshaft of the right tibia. There was also tenderness to palpation in the left midtibia as well despite normal radiographs. B: A bone scan showed increased uptake in both the left and right tibia. There was significantly less uptake on the left side (arrows) the more recent injury.
A: Anteroposterior radiograph of the tibia in a 3-year-old child who refused to bear weight on the right leg 3 weeks before presentation. The history of obvious trauma was absent. The radiographs revealed periosteal new bone formation in the midshaft of the right tibia. There was also tenderness to palpation in the left midtibia as well despite normal radiographs. B: A bone scan showed increased uptake in both the left and right tibia. There was significantly less uptake on the left side (arrows) the more recent injury.
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A child with a toddler's fracture maybe immobilized in a long-leg or short-leg cast for approximately 3 to 4 weeks. Short-leg casts are sufficient for patients with fractures of the distal half of the tibia. The fracture is stable, and the patient may bear weight on the cast when comfortable. 

Floating Knee

Although uncommon in children, significant trauma can cause ipsilateral fractures involving both the tibia and the femur. The term “floating knee” describes the flail knee joint resulting from fractures of the shaft or metaphyseal region of the ipsilateral femur and tibia.2,95 The most common mechanism of trauma resulting in this injury pattern involves either a pedestrian or bicyclist struck by an automobile13,95 In the past, these injuries often were treated with traction and casting (Fig. 31-38). The extent of the injuries often left permanent functional deficits, including malunion, limb-length discrepancy, and knee stiffness when not managed aggressively.13 
Figure 31-38
 
A: Ipsilateral fractures of the distal femur and tibia without an ipsilateral fibular fracture in a 5-year old. B: The child was treated with tibial pin traction for the femoral injury (pin applied below the tibial tubercle) and a short-leg splint for the tibial fracture initially. C: The child was placed into a spica cast after 2 weeks of traction. The tibial traction pin was used to help stabilize both fractures.
A: Ipsilateral fractures of the distal femur and tibia without an ipsilateral fibular fracture in a 5-year old. B: The child was treated with tibial pin traction for the femoral injury (pin applied below the tibial tubercle) and a short-leg splint for the tibial fracture initially. C: The child was placed into a spica cast after 2 weeks of traction. The tibial traction pin was used to help stabilize both fractures.
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Figure 31-38
A: Ipsilateral fractures of the distal femur and tibia without an ipsilateral fibular fracture in a 5-year old. B: The child was treated with tibial pin traction for the femoral injury (pin applied below the tibial tubercle) and a short-leg splint for the tibial fracture initially. C: The child was placed into a spica cast after 2 weeks of traction. The tibial traction pin was used to help stabilize both fractures.
A: Ipsilateral fractures of the distal femur and tibia without an ipsilateral fibular fracture in a 5-year old. B: The child was treated with tibial pin traction for the femoral injury (pin applied below the tibial tubercle) and a short-leg splint for the tibial fracture initially. C: The child was placed into a spica cast after 2 weeks of traction. The tibial traction pin was used to help stabilize both fractures.
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Today most children with ipsilateral tibia and femoral fractures are treated with operative stabilization of the femur and either cast immobilization after closed reduction or operative fixation of the tibia.162 In pediatric patients, multiple treatment combinations can be utilized to care for a patient with floating knee injury. For example, the femoral fracture can be stabilized with a unilateral external fixator, plate and screw constructs, or flexible nails. Patients near skeletal maturity may be candidates for lateral entry reamed femoral nails, although the other options remain viable as well. Plate fixation, either open or percutaneous, is useful for fractures in the subtrochanteric or supracondylar area of the femur in adolescents, although external fixation may be useful in these areas as well. The tibial fracture is reduced and stabilized after the femoral fracture has been stabilized. Closed tibial fractures in these situations may be treated with cast immobilization or operative intervention. Open tibial fractures associated with an ipsilateral femoral fracture should be stabilized with an external fixator or flexible intramedullary nails whenever possible (Fig. 31-39). Stable fixation of both fractures allows early range of motion of the knee, earlier weight bearing, and improves overall function.162 
Figure 31-39
 
A,B: Floating knee injury in a 7-year-old boy. C: Femoral fracture was fixed with flexible intramedullary nails. D: Tibial fracture was stabilized with external fixation.
A,B: Floating knee injury in a 7-year-old boy. C: Femoral fracture was fixed with flexible intramedullary nails. D: Tibial fracture was stabilized with external fixation.
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Figure 31-39
A,B: Floating knee injury in a 7-year-old boy. C: Femoral fracture was fixed with flexible intramedullary nails. D: Tibial fracture was stabilized with external fixation.
A,B: Floating knee injury in a 7-year-old boy. C: Femoral fracture was fixed with flexible intramedullary nails. D: Tibial fracture was stabilized with external fixation.
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Stress Fractures of the Tibia and Fibula

Roberts and Vogt128 in 1939 reported an “unusual type of lesion” in the tibia of 12 children. All were determined to be stress fractures involving the proximal third of the tibial shaft. Since then, numerous reports of stress fractures involving the tibia and the fibula have been published.9,33,152 
The pattern of stress fractures in children differs from that in adults.32,33,137 In adults, the fibula is involved in stress fractures twice as often as the tibia; in children, the tibia is affected more often than the fibula (Fig. 31-40). The prevalence of stress fractures in boys and girls appears to be equal, although recently stress fractures have been reported to be increasingly common in females with eating disorders111 These injuries typically occur in pediatric and adolescent athletes older than 10 years of age, and have a history of insidious onset of pain that worsens with sporting activities.53,157 
Figure 31-40
Bilateral midtibial stress fractures in an adolescent with genu varus.
Flynn-ch031-image040.png
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Stress fractures occur when the repetitive force applied to a bone is exceeded by the bone's capacity to withstand it. Initially, osteoclastic tunnel formation increases. These tunnels normally fill with mature bone. With continued force, cortical reabsorption accelerates. Woven bone is produced to splint the weakened cortex. However, this bone is disorganized and does not have the strength of the bone it replaces. A fracture occurs when bone reabsorption outstrips bone production. When the offending force is reduced or eliminated, bone production exceeds bone reabsorption. This produces cortical and endosteal widening with dense repair bone that later remodels to mature bone.39,77,119 
A child with a tibial stress fracture usually has an insidious onset of symptoms.33,136 There is evidence of local tenderness that worsens with activity. The pain tends to be worse in the day and improves at night and with rest. The knee and the ankle have full ranges of motion. Usually, there is minimal, if any, swelling at the fracture site.17,33,40,70,88,128 
Initial radiographs may be normal. Radiographic changes consistent with a stress fracture generally become evident approximately 2 weeks after the onset of symptoms.33 Radiographic findings consistent with fracture repair can manifest in one of three ways: Localized periosteal new bone formation, endosteal thickening, or, rarely, a radiolucent cortical fracture line (Fig. 31-41).32,33,88,136 
Note the posteromedial stress fracture.
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Figure 31-41
Anteroposterior and lateral radiographs of the knee of a 15-year old with adolescent onset tibia vara.
Note the posteromedial stress fracture.
Note the posteromedial stress fracture.
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In cases in which the plain radiographs are normal, technetium radionuclide bone scanning may be helpful. When positive, the bone scan reveals a local area of increased tracer uptake at the site of the fracture (Fig. 31-42). CT rarely demonstrates the fracture line, but often delineates increased marrow density, endosteal and periosteal new bone formation, and may show soft tissue edema within the area of concern. Magnetic resonance (MR) imaging70,88 shows a localized band of very low signal intensity continuous with the cortex. These MR findings can be diagnostic for a stress fracture, and will differentiate such lesions from malignancy, thereby obviating the need for biopsy. 
Figure 31-42
 
A: Lateral radiograph of the proximal tibia in a 9-year old who complained of pain in the right leg. There was no history of trauma, and the radiographs were unremarkable. B: A bone scan 2 days after the onset of symptoms demonstrates increased tracer uptake in the proximal one-third of the tibia in both the anteroposterior and lateral projections (arrows). C: Increased bone density and subtle periosteal new bone formation was identified in the proximal tibia 3 weeks later (arrow).
 
(Courtesy of James Conway, MD.)
A: Lateral radiograph of the proximal tibia in a 9-year old who complained of pain in the right leg. There was no history of trauma, and the radiographs were unremarkable. B: A bone scan 2 days after the onset of symptoms demonstrates increased tracer uptake in the proximal one-third of the tibia in both the anteroposterior and lateral projections (arrows). C: Increased bone density and subtle periosteal new bone formation was identified in the proximal tibia 3 weeks later (arrow).
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Figure 31-42
A: Lateral radiograph of the proximal tibia in a 9-year old who complained of pain in the right leg. There was no history of trauma, and the radiographs were unremarkable. B: A bone scan 2 days after the onset of symptoms demonstrates increased tracer uptake in the proximal one-third of the tibia in both the anteroposterior and lateral projections (arrows). C: Increased bone density and subtle periosteal new bone formation was identified in the proximal tibia 3 weeks later (arrow).
(Courtesy of James Conway, MD.)
A: Lateral radiograph of the proximal tibia in a 9-year old who complained of pain in the right leg. There was no history of trauma, and the radiographs were unremarkable. B: A bone scan 2 days after the onset of symptoms demonstrates increased tracer uptake in the proximal one-third of the tibia in both the anteroposterior and lateral projections (arrows). C: Increased bone density and subtle periosteal new bone formation was identified in the proximal tibia 3 weeks later (arrow).
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Tibia

The most common location for a tibial stress fracture is in the proximal third.43,64 The child normally has a painful limp of gradual onset with no history of a specific injury. The pain is described as dull, occurring in the calf near the upper end of the tibia on its medial aspect, and occasionally is bilateral. Physical findings include local tenderness on one or both sides of the tibial crest with a varying degree of swelling. 
The treatment of a child with a stress fracture of the tibia begins with activity modification. An active child can rest in a prefabricated walking boot for 4 to 6 weeks followed by gradual increase in activity.112 Nonunions of stress fractures of the tibia have been described. Green53 reported six nonunions, each in the middle third of the tibia. Three of these nonunions were in children. Two required excision of the nonunion site with iliac crest bone grafting. The third was treated by electromagnetic stimulation. In cases of stress fractures involving female athletes with dietary, nutritional, and menstrual irregularities, collaboration between pediatric orthopedists, primary care physicians, endocrinologists, and nutritionist is recommended.65 

Fibula

Pediatric fibular stress fractures normally occur between the ages of 2 and 8 years.55,89 The fractures are normally localized to the distal third of the fibula. The child presents with a limp and may complain of pain. Tenderness is localized to the distal half of the fibular shaft. Swelling normally is not present. The obvious bony mass commonly seen in a stress fracture of the fibula in an adult is normally not seen in a comparable fracture in a child. 
Often the earliest plain radiographic sign of a stress fracture of the fibula is the presence of “eggshell” callus along the shaft of the fibula.17 The fracture itself cannot always be seen because the periosteal callus may obscure the changes in the narrow canal. Radionuclide bone imaging can help to identify stress fractures before the presence of radiographic changes (Fig. 31-43). 
Figure 31-43
 
A: Stress fracture of the diaphysis of the fibula in a 14-year-old girl with mild genu varum. B: Bone scan of stress fracture showing marked increased tracer uptake. C: MR image demonstrates new central bone formation and an inflammatory zone around the fibular cortex.
 
(From Sharps CH, Cardea JA. Fractures of the shaft of the tibia and fibula. In: MacEwen GD, Kasser JR, Heinrich SD, eds. Pediatric Fractures: A Practical Approach to Assessment and Treatment. Baltimore, MD: Williams & Wilkins; 1993:324, C, with permission.)
A: Stress fracture of the diaphysis of the fibula in a 14-year-old girl with mild genu varum. B: Bone scan of stress fracture showing marked increased tracer uptake. C: MR image demonstrates new central bone formation and an inflammatory zone around the fibular cortex.
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Figure 31-43
A: Stress fracture of the diaphysis of the fibula in a 14-year-old girl with mild genu varum. B: Bone scan of stress fracture showing marked increased tracer uptake. C: MR image demonstrates new central bone formation and an inflammatory zone around the fibular cortex.
(From Sharps CH, Cardea JA. Fractures of the shaft of the tibia and fibula. In: MacEwen GD, Kasser JR, Heinrich SD, eds. Pediatric Fractures: A Practical Approach to Assessment and Treatment. Baltimore, MD: Williams & Wilkins; 1993:324, C, with permission.)
A: Stress fracture of the diaphysis of the fibula in a 14-year-old girl with mild genu varum. B: Bone scan of stress fracture showing marked increased tracer uptake. C: MR image demonstrates new central bone formation and an inflammatory zone around the fibular cortex.
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The differential diagnosis includes sarcoma of bone, osteomyelitis, and a soft tissue injury without accompanying bony injury. A careful history, physical examination, laboratory workup, and use of necessary radiographic imaging can usually allow differentiation of a stress fracture from infection or neoplasm.157 Once a diagnosis of a fibular stress fracture is made, treatment is similar to that utilized in tibial injuries. 

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