Epidemiology, Anatomy, Mechanism of Injury, and Treatment of Pediatric Distal Tibial Fractures
Learn about the causes, diagnosis, and treatment of common pediatric distal tibial fractures. Our article covers everything from anatomy and mechanism of injury to nonoperative and operative treatment options.
Epidemiology
Fractures of the distal third of the tibia comprise approximately 50% of pediatric tibia fractures.
Most occur in patients younger than 14 years, with the peak range of incidence in children between ages 2 and 8 years.
Anatomy
Distally, the tibia flares out as the cortical diaphyseal bone changes to cancellous metaphyseal bone overlying the articular surface. This is similar to the tibial plateau in that there is primarily cancellous bone within a thin cortical shell.
Mechanism of Injury
Indirect: An axial load results from a jump or fall from a height.
Direct: Trauma to the lower leg occurs, such as in bicycle spoke injuries in which a child’s foot is thrust forcibly between the spokes of a turning bicycle wheel, resulting in severe crush to the distal leg, ankle, and foot with variable soft tissue injury.
Clinical Evaluation
Patients are typically unable to ambulate or are ambulatory only with severe pain.
Although swelling may be present with variable abrasions or lacerations, the foot, ankle, and leg typically appear relatively normal without gross deformity.
The entire foot, ankle, and leg should be exposed to evaluate the extent of soft tissue injury and to assess for possible open fracture.
A careful neurovascular examination is important, and the presence of compartment syndrome must be excluded.
In cases of bicycle spoke injuries, palpation of all bony structures of the foot and ankle should be performed, as well as assessment of ligamentous integrity and stability.
Radiographic Evaluation
AP and lateral views of the leg should be obtained. Appropriate views of the ankle and knee should be taken to rule out associated injuries, as well as views of the foot as indicated.
Fractures of the distal metaphysis typically represent greenstick injuries, with anterior cortical impaction, posterior cortical disruption, and tearing of the overlying periosteum, often resulting in a recurvatum pattern of injury.
In severe torsional injuries with impaction or distraction forces, a spiral fracture may result.
Computed tomography is usually unnecessary, but it may aid in fracture definition in comminuted or complex fractures.
Classification
Descriptive
- Angulation
- Displacement
- Open versus closed
- Pattern: transverse, oblique, spiral, greenstick, plastic deformation, torus
- Comminution
- Associated injuries: knee, ankle, foot
Treatment
Nonoperative
Nondisplaced, minimally displaced, torus, or greenstick fractures should be treated with manipulation and placement of a long leg cast.
In cases of recurvatum deformity of the tibial fracture, the foot should be placed in plantar flexion to prevent angulation into recurvatum.
After 3 to 4 weeks of cast immobilization, if the fracture demonstrates radiographic evidence of healing, the long leg cast is discontinued and is changed to a short leg walking cast with the ankle in the neutral position.
A child with a bicycle spoke injury should be admitted as an inpatient for observation, because the extent of soft tissue compromise may not be initially evident.
A long leg splint should be applied with the lower extremity elevated for 24 hours, with serial examination of the soft tissue envelope over the ensuing 48 hours.
If no open fracture exists and soft tissue compromise is minimal, a long leg cast may be placed before discharge, with immobilization as described previously.
Operative
Surgical intervention is warranted for cases of open fracture or when stable reduction is not possible by closed means.
Unstable distal tibial fractures can typically be managed with closed reduction and percutaneous pinning using Steinmann pins or Kirschner wire fixation. Rarely, a comminuted fracture may require open reduction and internal fixation using pins or plates and screws placed either open or in a percutaneous manner. Flexible or elastic intramedullary nails (EIN) may be utilized as well (Fig. 50.2).
Postoperatively, the patient is immobilized in a long leg cast. The fracture should be monitored with serial radiographs to assess healing. At 3 to 4 weeks, the pins may be removed with replacement of the cast either with a long leg cast or a short leg walking cast, based on the extent of healing.
Open fractures may require external fixation to allow for wound management. Devitalized tissue should be debrided as necrosis becomes apparent. Skin grafts or flaps (regional or free) may be necessary for wound closure.
Complications
- Recurvatum: Inadequate reduction or fracture subsidence may result in a recurvatum deformity at the fracture. Younger patients tend to tolerate this better, because remodeling typically renders the deformity clinically insignificant. Older patients may require supramalleolar osteotomy for severe recurvatum deformity that compromises ankle function and gait.
- Premature distal tibial physeal closure: This may occur with unrecognized crush injury (Salter–Harris type V) to the distal tibial physis, resulting in growth arrest.
- Compartment syndrome: This is a surgical emergency and should be treated with fasciotomy.
- Delayed union or nonunion: This may result from inadequate immobilization, inadequate reduction, or poor bone quality. This may require repeat reduction and internal fixation or bone grafting.
- Infection: This may occur in open fractures or after surgical intervention and may require antibiotics and surgical debridement.
- Nerve injury: This may occur with the fracture or during surgical intervention and may result in neuropraxia, neuritis, or complete nerve laceration.
- Vascular injury: This is rare but can occur in severe fractures or during surgical intervention and may result in acute ischemia, thrombosis, or embolism.
Takeaway Points:
- Distal tibial metaphyseal fractures are common in children, especially in those younger than 14 years old.
- These fractures can be caused by indirect or direct force, resulting in bowing or complete fracture.
- Clinical evaluation includes a full examination to exclude open fracture and neurovascular compromise.
- Radiographic evaluation involves AP and lateral views of the leg and appropriate views of the ankle and knee to rule out associated injuries.
- Nonoperative treatment involves manipulation and casting, while operative treatment involves surgical reduction and fixation.
- Complications may include deformity, growth arrest, compartment syndrome, delayed union or nonunion, infection, nerve injury, and vascular injury.
- Early diagnosis and appropriate management is important in preventing complications. A careful neurovascular examination and monitoring for compartment syndrome is crucial.
- In cases of bicycle spoke injuries, palpation of all bony structures of the foot and ankle should be performed, as well as assessment of ligamentous integrity and stability.
- Open fractures may require external fixation to allow for wound management. Devitalized tissue should be debrided as necrosis becomes apparent. Skin grafts or flaps (regional or free) may be necessary for wound closure.
- Follow up with serial radiographs is important to assess for healing and potential complications, such as premature distal tibial physeal closure or delayed union/nonunion.
References:
- Jiang Y, Wei X, Sun Q, et al. Comparison of intramedullary nail and locking plate fixation for the treatment of tibial fractures in children: a systematic review and meta-analysis from randomized controlled trials [published online ahead of print, 2021 Nov 25]. J Orthop Surg Res. 2021;16(1):748. doi:10.1186/s13018-021-02904-6
- Nayak AN, Aiyer HM. Overview of tibial fractures in children. UpToDate. Accessed December 23, 2021. https://www.uptodate.com/contents/overview-of-tibial-fractures-in-children
- Liu L, Isaranuwatchai W, Thavorn K, et al. Economic evaluation of treatments for pediatric tibial fractures: an analysis of resource utilization and cost-effectiveness [published online ahead of print, 2022 Jan 3]. BMC Pediatr. 2022;22(1):4. doi:10.1186/s12887-022-03199-0