Pediatric Tibial Fractures Research Articles

Comparison of clinical and radiological outcomes of titanium elastic nail and Kirschner wire in the treatment of pediatric tibia diaphyseal fractures

Purpose: The aim of this study was to compare the clinical and radiological results of paediatric tibia shaft fractures treated by intramedullary fixation with Kirschner (K) wire and titanium elastic nail (TEN). Materials and Methods: Thirtynine patients were evaluated retrospectively. Included 20 patients treated with TEN (group 1) and 19 patients treated with K-wire (group 2). At the end of the 1-year follow-up, radiological measurements for malalignment and the Flynn TEN outcome scoring system were used to compare the clinical results. Results: According to the Flynn classification, in group 1, results were excellent in 75% and good in 25%, and in group 2, excellent in 70% and good in 30%. In any cases has not been experienced physeal early closure or refracture, nor did they need re-manipulation or re-operation, and no implant insufficiency was detected. Malalignment was found in four patients in group 1, and in two patients in group 2 of lesser than 10 degrees. Conclusions: Even though two methods showed similar clinical and radiological results, fixation paediatric tibial fractures with K-wire may have some advantages as lower-cost and easy accessibility according to TEN.

Leg length discrepancy, overgrowth, and associated risk factors after a pediatric tibial shaft fracture

BackgroundThis study was performed to investigate leg length discrepancy (LLD), overgrowth, and associated risk factors after pediatric tibial shaft fractures.Materials and methodsThis study included 103 patients younger than 14 years of age (mean age 7.1 years; 75 boys, 28 girls) with unilateral tibial shaft fracture and a minimum follow-up of 24 months. LLD was calculated as the difference between the lengths of the injured and uninjured limbs. Overgrowth was calculated by adding the fracture site shortening from the LLD. Risk factors were assessed in patients with LLD < 1 cm and ≥ 1 cm and overgrowth < 1 cm and ≥ 1 cm.ResultsCasting and titanium elastic nailing (TEN) were performed on 64 and 39 patients, respectively. The mean LLD and overgrowth were 5.6 and 6.4 mm, respectively. There were significant differences in sex (p = 0.018), age (p = 0.041), fibular involvement (p = 0.005), injury mechanism (p = 0.006), and treatment methods (p < 0.001) between patients with LLDs < 1 cm and ≥ 1 cm. There were significant differences in sex (p = 0.029), fibular involvement (p = 0.002), injury mechanism (p = 0.008), and treatment methods (p < 0.001) between patients with overgrowth < 1 cm and ≥ 1 cm. Sex and treatment methods were risk factors associated with LLD ≥ 1 cm and overgrowth ≥ 1 cm following pediatric tibial shaft fracture. The boys had a 7.4-fold higher risk of LLD ≥ 1 cm and 5.4-fold higher risk of overgrowth ≥ 1 cm than the girls. Patients who underwent TEN had a 4.3-fold higher risk of LLD ≥ 1 cm and 4.8-fold higher risk of overgrowth ≥ 1 cm than those treated by casting.ConclusionsPatients undergoing TEN showed greater LLD and overgrowth than those undergoing casting, with boys showing greater LLD and overgrowth than girls. Surgeons should consider the possibility of LLD and overgrowth after pediatric tibial shaft fractures, especially when performing TEN for boys.Level of evidenceLevel III

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort

Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. Level III-retrospective cohort study.

Improving Lower Extremity Casting Quality by Providing an Experienced Assistant in Pediatric Tibia Fractures Managed by Trainees.

Background: The value of employing an orthopedic technician or advanced practice provider (OT/APP) to assist trainees during on-call hours has not been assessed. As the third most common pediatric long bone fracture, most tibial fractures can be managed with closed reduction and casting. Purpose: We sought to determine whether clinical outcomes could be positively affected for traumatic childhood tibia fractures by using an experienced OT/APP to aid orthopedic surgery residents with closed reduction and casting. Methods: We performed a retrospective chart review of tibial shaft fractures that occurred between 2010 and January 2017. Fractures undergoing manipulation and closed reduction by orthopedic surgery residents (post-graduate year 2 to 4) in the emergency department were included and differentiated into 2 cohorts: (1) residents who performed the procedure alone and (2) residents who were assisted by an OT/APP. Comparisons in cast quality and treatment success were made using univariate statistics followed by a multivariate Classification and Regression Tree (CART) analysis. Results: Of the 73 patients who met our criteria, 38 received treatment by a resident alone and 35 by a resident assisted by an OT/APP. Evidence to support our hypothesis was found with the resident-alone group "over" padding the casts posteriorly. Univariate analysis demonstrated that the rate of subsequent surgical intervention was more than double in the resident-alone group (31% vs 14%), yet OT/APP castings underwent more wedging at follow-up (17% vs 0%). CART analysis revealed initial fracture severity and lack of OT/APP assistance as predictors of surgical intervention with terminal nodes, in increasing order of risk of requiring surgical intervention: lower translation on sagittal and anteroposterior (AP), lower sagittal translation with greater AP translation, greater sagittal translation with OT/APP assistance, and greater sagittal translation without assistance. The initiation of a cast application-training program in 2015 decreased the need for surgical treatment in the resident-only group (pre-program 38.5% vs post-program 17%), although this was not statistically significant. Conclusion: When residents were assisted by OT/APP with initial tibia closed reduction and casting, subsequent loss of reduction was more likely to be managed with cast wedging; when this assistance was not available, there was a higher rate of fractures needing surgical intervention due, in part, to poor casting technique. The reduction in the rate of surgical intervention after an internal training program was implemented suggests that trainees may improve their casting ability without added help of an experienced assistant. Future study should be performed on distal radius fractures to determine if the presented findings are valid across casting types.

Results of flexible nails for fixation of tibial diaphysis fractures in children

Background: Fracture tibia is one of the most common fractures in the pediatric age group. It accounts about 15% of cases. In majority of cases, close reduction and plaster application is the mainstay of treatment. Objectives: The objective was to assess the outcome of flexible nails in the treatment of tibial diaphysis fractures in children and to evaluate the results regarding the union rate and complications including limb length discrepancy, angular deformities, and pain. Materials and Methods: This prospective descriptive case–control study which included 30 children with 30 unilateral tibial diaphysis fractures in which the physis were open, all were closed, and open (type 1 and type 2) fractures, and with displaced transverse, short oblique, and spiral fractures, in which the trial of close reduction was failed. All patients are admitted and operated at West Erbil Emergency Hospital. Alignment of fractures, any infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, time of complete union, and skin irritation were assessed with minimum follow-up period of 6 months. Results: In the current study, the complete union was achieved in 9–11 weeks in 20 (66.7%) patients, while in 6 (20%) patients, achieved in 12 weeks, and in 4 (13.3) patients, achieved in 13–16 weeks that were regarded as a delayed union. In 6 (20%) patients, there were nail protrusion and skin irritation, no shortening more than 0.5 cm was recorded, shortening <0.5 cm recorded in 12 (40%) patients, and no lengthening was recorded. In 3 (10%) patients, the angulations in coronal and sagittal views were 5°–10°. There was no case of nonunion. Conclusion: Elastic nails are an effective way for the treatment of the pediatric tibial diaphysis fractures. It is a simple and easy method but with radiation risk, although elastic nails have complications, all are avoidable and minor that will be managed with minimal intervention.

Intramedullary Nailing of Paediatric Tibial Fractures: Comparison between Flexible and Rigid Nails.

To describe patient characteristics and to compare outcomes of children undergoing rigid intramedullary nailing of tibial fractures as compared with those operated on using elastic intramedullary nailing. A retrospective review of 26 children who have undergone flexible intramedullary nailing of tibial fractures and 30 children with rigid nailing at our university hospital between 2008 and 2017. The patient charts and radiographs were evaluated to identify demographic characteristics and several variables were measured preoperatively, as well as 6-12 weeks postoperatively in addition to final follow-up radiographs. Twenty-six patients (26/26, 100%) treated with a flexible nail and 14 patients (14/30, 46.7%) treated with a rigid nail had open proximal tibial physis (p < 0.001). An acceptable postoperative alignment was obtained in 20 patients (20/26, 76.9%) in the elastic stable intramedullary nail group and in 29 patients (29/30, 96.7%) in the rigid group (p = 0.026). Some complications occurred in four patients (4/26, 15%) in the elastic stable intramedullary nail population and seven patients (7/30, 23%) in the rigid intramedullary nail population (p = 0.46). Malunion occurred in six patients (6/26, 23%) in the elastic stable intramedullary nail group and in none of the patients treated with a rigid intramedullary nail (p = 0.005). Younger children with tibial fractures who weight 50 kg or less and with proximal tibial growth plates wide open can be treated with elastic stable intramedullary nail while more mature adolescents benefit from rigid intramedullary nailing.

Ender's nailing of displaced tibia shaft fractures in children - A nine-year experience.

Displaced fractures of the tibial shaft in children can be effectively treated with minimal complications with flexible nails. Our aim is to evaluate the outcome of displaced paediatric tibia shaft fractures treated with Ender's nails. We retrospectively reviewed the records of all unstable tibial fractures treated between 2010 and 2018, in our institution. Only children with a minimum of six months follow-up and complete clinical data were considered for the study. Of the 72 patients who fulfilled the inclusion-exclusion criteria, 8 were lost for follow-up and hence we had 64 patients included for the study. There were 54 boys and 10 girls, with an average age of 10.9 years(4 to 17 years). The average follow-up was 16.9 months (6 to 47 months). There were nine open fractures. Two nails were used in 52(81.25%) patients while a single nail was used in 6(9.37%) patients and three nails were used in 6(9.37%) patients. The union rate was 100% with an average union time of 10.6 weeks. There were 17 (26.5%) patients with delayed union but none required intervention. One (1.56%) child had a malunion >10° (recurvatum of 11.9° and varus of 8.1°). Radiographs at the final review demonstrated >5° of coronal plane malalignment in eight patients (12.5%) and >5° sagittal plane malalignment (recurvatum) in six patients (9.37%). There was an associated fibular fracture in 50 children and there was no significant association between the presence of fibular fracture and malalignment (p>0.05). All children who presented for implant removal had full range of movement at the knee and ankle joint and no limb length discrepancy. We report the largest series of paediatric tibial shaft fractures treated with Ender's nails. Ender's nail is a simple and cost-effective option for treating these fractures with excellent union rates and minimal complications.

Classification and Treatment of Pediatric Tibial Spine Fractures: Assessing Reliability Among a Tibial Spine Research Interest Group.

Treatment decisions for patients with tibial spine fractures depend heavily on radiographic measurements. The purpose of this study was to determine whether existing classification systems and radiographic measurements are reliable among a multicenter tibial spine research interest group. A secondary purpose was to evaluate agreement in treatment of tibial spine fractures. Using a deidentified radiographic imaging series and identical imaging software, we examined the interobserver and intraobserver reliability of the Meyers and McKeever classification, as well as a cohort of measurements of tibial spine fractures and treatment recommendations. Forty patients were included based on previous reliability studies. Interobserver and intraobserver data were analyzed using kappa and intraclass correlation coefficient reliability measures for categorical and continuous variables, respectively. Good interobserver reliability was seen with superior displacement measurements of the anterior portion of the tibial spine fracture (0.73, 0.78) and excellent intraobserver reliability with an intraclass correlation coefficient of 0.81. Several measurements demonstrated moderate interobserver and intraobserver reliability including posterior-proximal displacement, and length and height of the tibial spine fracture. Moderate intraobserver reliability was seen with a majority of measurements and classification schemata (0.42 to 0.60) except for a poor agreement in posterior-sagittal displacement (0.27). Classifying tibial spine fractures according to the original Meyers and McKeever classification demonstrated fair agreement [κ=0.35, 0.33 (inter); 0.47 (intra)]. When combining Type III and IV, agreement increased for both reviews [κ=0.42, 0.44 (inter); 0.52 (intra)]. A total of 24 (60%) fractures were classified as 3 different types. There was fair agreement in both reviews regarding open reduction (either open or arthroscopic) versus closed reduction for initial treatment [κ=0.33, 0.38 (inter); 0.51 (intra)]. Measurement of superior displacement of the anterior portion of tibial spine fractures on the lateral images is the only radiographic assessment with good interobserver and intraobserver reliability. Reliability of radiographic measurements and a modified classification for tibial spine fractures remains fair, and perhaps unacceptable, even among a group of pediatric sports medicine specialty-trained surgeons. Level III-diagnostic reliability study of nonconsecutive patients.

Pediatric tibial shaft and distal metaphyseal fractures.

Objectives This study aims to investigate the effects of associated factors like age, fracture level, accompanying fibular fractures and wound condition on healing by determining and comparing union scores of pediatric tibial fractures (PTFs).Patients and methods Forty-five patients with 46 PTFs (32 males, 13 females; mean age 9.5 years; range 2 to 16 years) who were treated by closed reduction and casting or operated between January 2016 and January 2019 were retrospectively evaluated. The union scores were evaluated at the end of fourth, sixth and eighth weeks and compared to each other. Effects of the age, associated fibular fractures, wound condition, fracture level and treatment type to union score were analyzed.Results Twenty-eight (60.9%) out of 46 PTFs had associated fibular fractures and 18 (39.1%) did not. Motor vehicle accident was the most frequent etiologic factor (47.8%). Thirty-four out of 46 fractures were closed tibial fractures (73.9%) and 12 had open wound (26.1%). There was a negative correlation between age and the union scores (p<0.001 for each week). No significant difference was observed between the union score of diaphyseal and metaphyseal fractures at the fourth, sixth, and eighth weeks. The union scores of each week were higher in the conservative group compared to operative group (p<0.001 for each week). Associated fibular fracture group had lower union scores compared to isolated tibial fracture group at fourth, sixth and eighth weeks. Likewise, the union scores of the open fracture group were lower than the closed fracture group (p<0.05 for each week).ConclusionAssociated fibular fractures, open fractures and aging negatively affect union scores of PTFs. Attention should be paid, particularly in these conditions, during the selection of the operation type and the follow-up period of PTFs.

The Vacuum-Assisted Closure Device Increases Value in the Treatment of Gustilo Grade IIIb Open Tibia Fractures in Children.

BackgroundWound management associated with Gustilo grade IIIb open tibia fractures in children often requires muscle flaps, skin grafts, and amputations. The purpose of this study is to report the outcomes and complications of vacuum-assisted closure (VAC) treatment, as well as discuss its role in optimizing value when treating these injuries.MethodsA retrospective review of medical records and imaging studies was performed from 2008-2015. Six pediatric patients with Gustilo grade IIIb fractures managed with the VAC were identified. The time to treatment, frequency of VAC changes, VAC size, and closure attempts, including muscle flaps and skin grafts, were documented. Fracture fixation methods, the incidence of delayed union or nonunion, as well as the occurrence of deep tissue infection and compartment syndrome were detailed.ResultsFive patients were male and one was female with an average age of 12 years (range 8-15 years). All patients sustained a Gustilo IIIb open tibia fracture and were treated with irrigation, debridement, intravenous (IV) antibiotics, fixation, and a VAC as a wound care adjunct. Three patients required both a muscle flap and a skin graft. One patient required a skin graft. There was one case of deep tissue infection. Three patients were treated successfully with the VAC alone and did not require any flap procedures.ConclusionsWound care for Gustilo grade IIIb open tibia fractures in children traditionally involved potentially painful twice-daily dressing changes with solutions such as dilute bleach or iodine. The implementation of VAC markedly reduced the frequency of dressing changes every three days. In the current study, the open wound gradually closed with only a VAC in 50% of Gustilo grade IIIb open pediatric tibia fractures. In summary, the VAC is an adjunct that increases value in the care of pediatric patients with Gustilo grade IIIb open tibia fractures (Value = Outcomes/Cost).Level of evidenceTherapeutic level IV

Minimally Invasive Medial Plate Osteosynthesis of High-Energy Pediatric Tibia Fractures.

We report on the largest series to date of minimally invasive medial plate osteosynthesis of high-energy tibia fractures in skeletally immature patients. Retrospective. Level 1 trauma center. Skeletally immature patients with high-energy tibia fractures treated with minimally invasive medial plate osteosynthesis between 2006 and 2017. We identified 28 fractures in 26 patients. We reviewed the record for patient, injury, and treatment factors as well as for complications and reoperation. We assessed the relationships between age, implant selection, and implant removal using χ and t test analyses. Mean age was 12 years (4-15) with OTA/AO classifications including 42A (18), 42B (6), and 42C (4). There were 10 open fractures (1 type I, 2 type II, and 7 type III). Mean follow-up was 37.6 months (minimum 7). Mean time to full weight-bearing and union was 2 and 3 months, respectively. Plate stock (2.7, 3.5, and 4.5 mm) and length (6-20 holes) varied independent of age, P = 0.19. There were 2 superficial infections, one 15 mm leg length discrepancy, and one case of fasciotomy at the time of plate fixation for trauma-related compartment syndrome. Implant removal was more likely in younger patients (10.9 vs. 13.2 years, P = 0.04) and not associated with plate stock, P = 0.97. There were no neurovascular injuries, losses of reduction, or rotational deformities. Angulation was universally <5 degrees in the coronal plane and <10 degrees in the sagittal plane. Minimally invasive medial plate osteosynthesis of high-energy pediatric tibia fractures may be performed with a low rate of complications and should be considered in this select patient population with multiple injuries, high-energy mechanisms, and significant soft-tissue trauma. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatments of Pediatric Tibia Fractures: An Epidemiological Study of the Trends in the United States

Purpose: Pediatric forearm fractures have traditionally been successfully treated with closed reduction and casting, however internationally, there has been an observed increase in incidence and rate of operative treatment. It is not clear if the same trends can be established in the United States. The purpose of this study was to describe how pediatric forearm fractures and their management has changed in the United States. Methods: The Nationwide Emergency Department Sample (NEDS) was queried using ICD-9-CM codes to identify a …

Treatments of Pediatric Tibia Fractures: An Epidemiological Study of the Trends in the United States

Treatments of Pediatric Tibia Fractures: An Epidemiological Study of the Trends in the United States

Arthroscopic tri-pulley Technology reduction and internal fixation of pediatric Tibial Eminence fracture: a retrospective analysis

BackgroundFixing a tibial eminence fracture with a tri-pulley is a new technique. The purpose of this study was to present the early clinical outcome of arthroscopic tri-pulley suture fixation for tibial eminence fractures in children.MethodsTwenty-one pediatric patients with type II or type III anterior tibial eminence fractures were included in this retrospective study. All Patients underwent surgical fixation by tri-pulley technology and were followed up for at least 24 months. They were evaluated preoperatively and postoperatively by physical, X-ray, and computed tomography (CT) examination and subjectively with the International Knee Documentation Committee (IKDC), and Lysholm questionnaires.ResultsThe patients included 12 males and 9 females; mean age, 12.5 years (range, 8 ~ 16 years). They were followed-up for a median of 27 months (range, 24 ~ 39 months). We did not find post-operative instability in any of the patients by physical examination. The KT-2000 difference of both knees decreased from 9.3 ± 1.2 mm preoperatively to 2.6 ± 0.8 mm 24 months postoperatively (P < 0.001); the IKDC subjective knee evaluation score improved from 43.1 ± 13.2 preoperatively to 83.8 ± 6.3 postoperatively (P < 0.001); and Lysholm improved from 48.3 ± 6.21 to 87.1 ± 9.8 (P < 0.001). No unhealed fractures or epiphyseal damage were reported in the postoperative X-ray and CT.ConclusionsArthroscopic tri-pulley fixation technology may provide a suitable technique for repair of tibial eminence fractures in skeletally immature patients.Level of evidenceCase series; Level of evidence IV.

Flexible intramedullary nail fixation for paediatric tibial diaphysis fractures

Background and objectives:Paediatric tibial diaphysis fractures were usually treated by conservative treatment with- out surgery. Nowadays, flexible intramedullary nails are frequently used in these fractures. The aim of this study was to assess the outcome of this technique and to evaluate the results regarding the union rate and postoperative com- plications. Methods:This study included 48 patients aged between 5 and 15 years. Forty-six cases had unilateral tibial diaphysis fractures and 2 cases had bilateral fractures. All the patients were treated with closed flexible intramedullary nailing. The study was done prospectively over a period of 2.5 years in West Erbil Emergency Hospital with a minimum follow up of 6 months. Results: In our study, the mean age was 8.8 years. The participants consisted of 36 patients (72%) males and 14 (28%) females. Fractures of the distal third of the tibial diaphysis were the most common and accounted for 31 cases (62%), those with middle third fracture were 19 cases (38%) and the upper third were 4 cases (8%). All patients got union with an average of 11 weeks. Nail protrusion and skin irritation were the most common complications, found in 10 patients (20%), and reoperation was done in three of them by cutting tip of the nail. Conclusion:Flexible intramedullary nails are effective and minimally invasive method for treatment of paediatric tibial diaphysis fractures; they control the length, angulations and rotation, as they provide stability through three points of fixations for each nail.

Risk Factors for Adverse Radiographic Outcomes After Elastic Stable Intramedullary Nailing of Unstable Diaphyseal Tibia Fractures in Children.

Elastic stable intramedullary nails (ESIN) are commonly utilized to treat unstable pediatric tibia fractures but have been associated with complications. The purpose of this study was to identify risk factors for adverse radiographic outcomes after ESIN of pediatric tibia fractures. A retrospective review of all patients who underwent diaphyseal tibia fracture stabilization with ESIN between 2010 and 2018 at 3 pediatric level 1 trauma centers was performed. Inclusion criteria were open growth plates, no intra-articular or physeal fracture involvement, and radiographic follow-up until union. Patient demographics, injury mechanism, fracture characteristics, and implant fill relative to the medullary canal were recorded. Radiographic outcome measures included achievement of and time to union, residual angular deformity, and additional procedures. One hundred seventy-two patients met inclusion criteria and were followed for a mean of 1.2 years. Nonunions were observed in 3% of the patient cohort. Another 10% required >6 months to heal, but did not require further surgical intervention. Angular deformities were common with 57% having a residual deformity ≥5 degrees and 14% having a residual deformity ≥10 degrees. Of the patients with a residual deformity between 5 and 10 degrees, 3% were symptomatic, where as 26% of the patients with a residual deformity ≥10 degrees were symptomatic. Greater angular deformities were associated with open fractures, compartment syndrome, and longer time to union. Patient age, weight, tibial comminution, and canal fill were not associated with nonunions or malunions. ESIN of pediatric tibia fractures results in reliable healing for a majority of patients, but poses risks for residual angular deformities and delayed healing. Open fractures and compartment syndrome were associated with adverse radiographic outcomes.

CLOSED REDUCTION IN THE TREATMENT OF DISPLACED TIBIAL SPINE FRACTURES: REVISITING A LOST ART

Background:There is renewed interest in optimal treatment, and development of algorithmic care for pediatric tibial spine fractures. While recent publications have most often investigated operative treatment, closed reduction of selected tibial spine fractures may result in good outcomes without invasive surgical procedures.Purpose:To evaluate an institutional series of displaced tibial spine factures treated with closed reduction for factors associated with treatment success.Methods:An IRB-approved, retrospective review of consecutive pediatric patients treated by a tertiary pediatric orthopedic group for displaced tibial spine fractures with closed reduction (2000 - 2017) was performed (Figure 1). Those with inadequate imaging or follow up were excluded. Demographics, injury data, exam findings, and reduction variables were recorded. Radiographic measures of fracture displacement pre and post-reduction, and at union were noted. Statistical comparison of variables associated with definitive closed reduction vs conversion to operative treatment was performed.Results:Of the 35 patients (mean age= 10.9 years [6-16 years]; 24 males) who underwent closed reduction of a tibial spine fracture, 19 (54.2%) had Type II Meyers and McKeever fractures, with the remainder Type III. Mean time to treatment was 6 days (2 hrs-46 days). Hemarthrosis aspiration with anesthetic injection was performed in 20 (57.1%) patients and 9 (25.7%) had general anesthesia or procedural sedation. Short-duration immobilization (typically 3 weeks) of long-leg casting (32, 91.4%) or bracing was utilized. The average reduction (Δ) in superior displacement of the tibial spine fragment was 4.6mm (0-16.4 mm) with 12 fractures improving > 5 mm following reduction maneuver.Eight patients (22.8%) failed closed reduction and were converted to operative fixation to treat residual displacement. Although no differences where noted in demographics, injury mechanism, classification (II vs III), or type of reduction; failures of closed reduction were noted to have more superior displacement (12.93 vs. 8.17 mm; p=0.023).Conclusion:Closed reduction of both Type II and Type III tibial spine fractures can result in acceptable reduction in in pediatric patients. Further prospective study of closed reduction of tibial spine fractures in selected patients presenting early, without critical meniscal pathology is warranted.Figure 1.Imaging showing improvement of displacement of tibial spine fracture fragment in an 11 year-old male patient A. Pre-reduction x-ray B. Post-reduction fluoroscopic imaging in OR C. Seventeen days post-reduction x-ray D. Final x-ray 640 days post-reduction

Open Reduction of Closed Pediatric Tibial Shaft Fractures Treated With Intramedullary Stabilization Does Not Increase Risk of Postoperative Complications.

To compare union and complication rates in pediatric patients presenting with tibial shaft fractures treated with closed or open reduction before intramedullary stabilization. Retrospective review. Multiple pediatric trauma centers. Pediatric patients presenting with tibial shaft fractures treated with intramedullary stabilization. Intramedullary stabilization after closed or open reduction (percutaneous and open approach). Union rates, infection rate (superficial and deep), and unplanned return to the operating room (OR). One hundred sixty-six patients were included in this study. One hundred thirty-six patients presented with closed fractures, and 30 patients presented with open tibial shaft fractures. Thirty-seven of the 136 patients (27%) with closed fractures had their fracture specifically opened during surgical fixation. There was no statistical difference in radiographic union at 6 months between fractures electively opened and those treated with closed reduction alone 97% versus 98% (P = 0.9). No patient who underwent an open reduction developed infections or wound-healing concerns, whereas 2 of the 99 (2%) patients treated closed had superficial surgical site infections requiring additional treatment (P = 0.999). There was no difference in unplanned return to OR between those who underwent open reduction at the time of intramedullary stabilization (P = 0.568). Performing an open reduction in a closed pediatric tibial shaft fracture before intramedullary fixation does not increase the risk of surgical site infections or wound issues, delayed union, or unplanned return to the OR. An open reduction of a closed tibial shaft fracture for purposes of improving a reduction before intramedullary stabilization may be a safe and effective clinical practice. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparative Study between Nancy Nail and Conservative Treatment in Diaphyseal Fracture Tibia in Children

Abstract Background nonphyseal fractures of the tibia and fibula are among the most common injuries involving the lower extremities in children and adolescents; represent approximately 15% of all pediatric fractures. They occur more frequently in boys than girls. Aim of the Work assessing of efficacy and safety of treatment of diaphyseal fracture tibia in children by nancy nail versus conservative treatment. Patients and Methods this review was done using standard methodology outlined in the Cochrane Handbook and reported the findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines. Results ESIN is an ideal device for treating pediatric tibial fractures allowing mobilization and maintenance of alignment until bridging callus forms. The device would exploit the rapid healing and ability to remodel without risking the physis or blood supply to the tibia. Conclusion the present study supports the treatment of tibial shaft fractures in children aged 8-13 years with ESIN, as it hastens fracture union, and allows earlier, weight bearing, rehabilitation and return to normal activity.

Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures

IntroductionThe first-line treatment of paediatric tibial fractures is non-operative but the number of operatively treated patients is rising. Elastic intramedullary nailing and external fixation are widely used in children while solid intramedullary nailing, the standard procedure in adults, is usually not recommended due to the open physes. Materials and MethodsBetween January 2007 and October 2017, unreamed locked solid intramedullary nailing was used in 16 cases of adolescent (mean age 13.7 ± 1.25 years) tibial diaphyseal fractures with open physes. An atypical, physeal-sparing method was used in all cases. Fourteen patients were managed by the standard implant used routinely in adult trauma care. Two patients were treated by a special nail, modified specifically for paediatric care. ResultsGood functional healing was found in all cases treated by the atypical method. Partial weight bearing began immediately after surgery in 38% of the cases. Full weight bearing was allowed 7.3 ± 2.4 weeks postoperatively. The average time to fracture union was 11.5 ± 2.9 weeks. Superficial infection and wound healing complication occurred in 3 cases. Deep infection, compartment syndrome or other bone related complications did not arise. DiscussionThe treatment of tibial fractures in adolescents is challenging due to larger body size and significant growth potential. The atypical intramedullary nailing method presented in this study can provide optimal functional healing, early mobilization and weight bearing while completely sparing the physis. This method can serve as an alternative in the operative treatment of adolescent tibial diaphyseal fractures.