Small Jumps, Big Breaks
Author: Oleg Uryasev, MD
Peer-Reviewer and Final Editor: Alex Tomesch, MD, CAQ-SM
A previously healthy 7 year old male was downhill skiing and jumped off a ski feature, called a box, landing on his right leg. He developed immediate pain in his mid tibia and was unable to bear weight on his right leg. On arrival in the ED he has tenderness over the mid tibia with edema and ecchymosis. No tenderness over the ankle, knee, femur and no evidence of injury elsewhere. He is Neurovascularly intact distal to the injury. XRs of the tibia were done in the ED (Image 1).
What is the diagnosis?
Tibial shaft fracture with greenstick fracture of the mid shaft of the fibula.
In children under eight have a highly vascular periosteum is responsible for rapid remodeling and healing, allowing for greater ability to manage non-operatively even with rotational and overlap deformities as compared to older children. [1]
- Pearl: Tibial shaft fractures are among the most common pediatric long bone fractures. The diaphysis being the most common site of injury [2,3].
What is the mechanism of injury?
Tibial shaft fractures are most common in school aged children, usually as a result of outdoor activities and sports. These fractures are from high energy force directed at the bone.
- Pearl: Transverse tibial fractures should not be confused with spiral tibial shaft fractures or "toddler's fractures" [3, 4]. In younger populations low energy twisting injuries are more typically responsible for spiral fractures.
- Pearl: Non-accidental trauma should be considered in spiral fractures of toddler aged children where mechanism is inconsistent, or there is a delay in seeking healthcare. Undiagnosed non-accidental trauma can have serious consequences for the patient [7].
What physical exam findings are expected?
On examination tibial shaft fractures will present with tenderness over the shaft of the tibia. Patients should be evaluated for vascular injury given the close proximity of the posterior tibial artery, and should be monitored for compartment syndrome [5, 8].
Which imaging modalities can be used?
Plain radiographs of the tibia are usually sufficient for diagnosis. In the setting of high clinical suspicion CT imaging or more rarely MRI can be obtained with a negative XR. For suspected occult fractures immobilization with subsequent repeat imaging every week is also an acceptable alternative treatment modality [5].
What is the management in the ED
Emergent management involves reduction of the tibia, subsequently long leg cast with the ankle and knee at 90 degrees of flexion. If there is significant displacement of the fracture and subsequent unsuccessful emergent reduction, then surgical intervention with flexible intramedullary nail or external fixation may be necessary, though this is uncommon in school aged children. Even with rotational deformities or incomplete reduction high remodeling capacity in children will usually lead to good outcomes with minimal to no residual morbidity [9, 10].
When should you consult Orthopedics?
Orthopedics should be consulted for pediatric tibial shaft fractures, unless the ED provider has significant prior experience in placing long leg casts/splints and tibial shaft reduction. Typically the patient will require sedation for the reduction and casting. Any evidence of neurovascular compromise or open fractures should be an immediate consult as well.
References
[1] Cruz AIJ, Raducha JE, Swarup I, Schachne JM, Fabricant PD. Evidence-based update on the surgical treatment of pediatric tibial shaft fractures. Current Opinion in Pediatrics. 2019;31(1):92-102.
[2] Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Orthop Surg. 2005 Sep;13(5):345-52. doi: 10.5435/00124635-200509000-00008. PMID:16148360.
[3] Gogi N, Deriu L. Common paediatric lower limb injuries. Surgery (Oxford). 2017;35(1):27-32.
[4] Weber B, Kalbitz M, Baur M, Braun CK, Zwingmann J, Pressmar J. Lower leg fractures in children and adolescents-comparison of conservative vs. ECMES treatment. Frontiers in Pediatrics. 2021;9.
[5] Patel NK, Horstman J, Kuester V, Sambandam S, Mounasamy V. Pediatric tibial shaft fractures. Ind J Orthopaedics. 2018;52:522-8.
[6] Raducha JE, Swarup I, Schachne JM, Cruz Jr AI, Fabricant PD. Tibial shaft fractures in children and adolescents. JBJS Reviews. 2019;7(2):e4.
[7] Williams R, Hardcastle N. Best evidence topic reports. Tibial fractures in very young children and child abuse. Emerg Med J. 2006;23(6):473-4.
[8] Almansour H, Armoutsis E, Reumann MK, Nikolaou K, Springer F. The anatomy of the tibial nutrient artery canal-an investigation of 106 patients using multi-detector computed tomography. J Clin Med. 2020;9(4).
[9] Khan H, Monsell F, Duffy S, Trompeter A, Bridgens A, Gelfer Y. Paediatric tibial shaft fractures: an instructional review for the FRCS exam. European Journal of Orthopaedic Surgery & Traumatology. 2023;33(6):2663-6.
[10] Patel I, Young J, Washington A, Vaidya R. Malunion of the Tibia: A Systematic Review. Medicina (Kaunas). 2022;58(3). Ho CA. Tibia shaft fractures in adolescents: how and when can they be managed successfully with cast treatment? Journal of Pediatric Orthopaedics. 2016;36:S15-8.
