Tibial Shaft Fractures In Children Research Articles

Risk factors of adverse long-term consequences of tibial shaft fractures in children

To analyze leg length discrepancy and overgrowth after tibial shaft fractures in children. We analyzed medical records of 103 patients younger 14 years old with tibial shaft fractures between January 2003 and November 2018. Treatment included plastering and insertion of titanium elastic nail. To identify the risk factors of leg length discrepancy ≥1 cm and overgrowth ≥1 cm, we performed logistic regression analysis. Statistical analysis was carried out using the SPSS software for Windows. Gender (p=0.014) and treatment methods (p=0.011) are the most significant predictors of leg length discrepancy and overgrowth. In boys, the risk of leg length discrepancy ≥1 cm was 7.4 times higher than in girls. The risk of leg length discrepancy ≥1 cm was 4.3 times higher after insertion of titanium elastic nail compared to plastering. The risk of overgrowth ≥1 cm was 5.4 times higher in boys than in girls. The risk of overgrowth ≥1 cm was 4.7 times higher after insertion of titanium elastic nail compared to plastering. One should consider the risk of leg length discrepancy and overgrowth in children with tibial shaft fractures. This is especially true for boys undergoing insertion of titanium elastic nail.

Tibial shaft fractures in children: flexible intramedullary nailing in growing children especially weighing 50 kg (110 lbs) or more.

Currently the gold standard in surgical treatment of displaced tibial shaft fractures in children with open growth cartilage is elastic stable intramedullary nailing (ESIN). The purpose of this study is the analysis of indications, complications, and duration of treatment using intramedullary flexible nails in children who are still growing but especially weighing 50 kg or more. Hospital records from 2017 to 2020 were retrospectively reviewed to identify the children from 4 to 17 years of age with displaced tibial shaft fractures admitted to the hospital. Only children with open growth cartilage, with a minimum of 6 months of follow-up and complete clinical data, were included. Studies of 91 children xwere analyzed. The average patient age at the time of the injury was 10.88 ± 2.82 years. In the entire group, 31.9% children weighed 50 kg or more, and 68.1% of the children were below this weight. All children were treated using ESIN. The mean time to nail removal was 8.4 ± 4.09 months in the whole group of children stabilized with ESIN. There were no differences in the two groups depending on the weight ( P = 0.637). Only two adverse events were observed. This study demonstrates that the use of ESIN in displaced tibial shaft fractures in growing children weighing 50 kg or more is acceptable and safe. The discussion to be made is whether it is still an acceptable method of treatment for this type of fracture due to the progressive obesity epidemic in children and adolescents.

External fixation versus elastic stable intramedullary nailing in the treatment of open tibial shaft fractures in children

IntroductionExternal fixator (EF) is a popular choice for open tibial fractures, but pin tract infection (PTI) and refracture are common complications. Elastic stable intramedullary nail (ESIN) has been reported in the treatment for open tibial fractures. This study aims to compare the clinical outcomes of EF vs. ESIN in the treatment for open tibial shaft fracture in children retrospectively.MethodsPatients aged 5–11 years with Gustilo-Anderson II and IIIA tibial shaft fracture treated at our institute from January 2008 to January 2018 were reviewed retrospectively and categorized into EF and ESIN groups. Patients with pathological fracture, neuromuscular disorder, metabolic disease, previous tibial fracture or instrumentation, and polytrauma were excluded. Patients with follow-up < 24 months or incomplete medical records were also excluded.ResultsIn all, 55 patients (33 males, 22 females) were included in the EF group, whereas 37 patients (21 males, 16 females) were included in the ESIN group. There was no statistically significant difference between the two groups concerning sex, age, body weight, duration from injury to surgery, Gustilo-Anderson (GA) classification, and concomitant injuries. There was no case of nonunion and malunion in either group. The angulation at the latest follow-up was higher in the EF group than the ESIN group (P < 0.01). The radiological union was faster in the ESIN group (7.0 ± 0.9 weeks) than those in the EF group (9.0 ± 2.2 weeks) (P < 0.01). Limb length discrepancy (LLD) was more in the EF group (12.1 ± 4.4, mm) than in the ESIN group (7.3 ± 4.3, mm) (P < 0.01).ConclusionESIN is a viable option in selected patients of GA grade II and IIIA open tibial fractures with comparable clinical outcomes as external fixator. Pin tract infection is the most troublesome complication in the EF group while implant prominence is a nuisance in the ESIN group.

Letter to the Editor With Respect to: Comparison of Short-leg and Long-leg Casts for the Treatment of Distal Third Tibial Shaft Fractures in Children, Barnett, Scott A. MD; Fontenot, Bailli BS; Leonardi, Claudia PhD; Gonzales, Joseph A. MD; Gargiulo, Dominic DO; Heffernan, Michael J. MD. March 2021 - Volume 41 - Issue 3 - pp. e259-e265.

Tribe, Howard C. BSc (Hons), PgCert (T&O), MEd, PhD, MBBS, MRCS; Lindisfarne, Edward FRCS (T&O)Author Information

To study the functional outcome of femoral and tibial shaft fractures in children treated by tens nail

Objectives: The main objective of the study was to evaluate the functional outcome of fracture of shaft of femur and tibia in children treated by TEN/ESIN system. Methodology: The present study was an observational clinical study which included cases with the diagnosis of femoral and tibial fractures admitted to the Orthopaedics Department of Kempegowda Institute of Medical Sciences and Research Center, Bangalore. Study included a total of 30 subjects with the age between 5–16 years. Detailed history, clinical examination was done, and associated injuries were noted. Results: The present study involved a total of 30 patients with femoral and tibial shaft fractures in children treated by TENs nail. Maximum numbers of the patients were seen in the age group of 6–10 years and the mean age of the study was 9.16 ±3.62 years. On a whole, males were predominated when compared to females and showed the greater incidence of tibial fractures which accounts for 66.7%. The main cause for the fractures among children was Road Traffic Accident (RTA), which accounts for greater percentage of 67.7% followed by self-fall which accounts for 22.6%. Among the side affected, greater numbers of children were affected with left tibia. More number of patients was operated with nail size 3.5 mm with 50%, followed by nail size of 3 mm with 30%. The total hospital stay in days in the study was 8.26±2.38 and the total time for union in weeks in the study was 8.52±1.03. Excellent outcomes were seen with tibial fracture (80%) and femur fracture (90%) and study subjects showed least (19.3%) complications. Conclusion: TENs nail is an existing successful treatment option for the fractures of shaft of femur and tibia in children. TENS nailing is an uncomplicated, consistent and rapid method which is associated with positive safety and efficacy outcomes.

Management of Open Tibial Shaft Fractures in Children with Intramedullary Elastic Nail

Management of Open Tibial Shaft Fractures in Children with Intramedullary Elastic Nail

Comparison of Long vs. Short Leg Casts for Distal Third Tibial Shaft Fractures in Children

Comparison of Long vs. Short Leg Casts for Distal Third Tibial Shaft Fractures in Children

Risk Factors for Failure of Cast Treatment in Displaced Pediatric Tibial Shaft Fractures.

As there is a current increasing tendency to treat displaced tibial shaft fractures in adolescents surgically, it has become more important to predict failure of cast treatment for these patients. In the past, redisplacement of pediatric tibial shaft fractures has been reported at rates of 20% to 40%. Although the efficacy of the three-point index (TPI), gap index, and cast index has been demonstrated for upper extremity fractures in children, to date no index has been shown to accurately predict redisplacement for pediatric tibial shaft fractures. The aim of this study was to determine the predictive factors for redisplacement in pediatric tibial shaft fractures. In all, 157 displaced pediatric tibial shaft fractures were evaluated retrospectively. Patient age, initial and postreduction fracture angulation, shortening and translation, quality of reduction, obliquity of fracture, associated fibular fractures, and 3 indices (TPI, cast index, and gap index) were analyzed. Receiver operating characteristic analysis was performed to determine the cutoff points and logistic regression was used to show the risk factors of redisplacement. There were 53 female and 104 male patients with a mean age of 9.1 (5 to 15 y) and 45 patients developed redisplacement during the follow-up. Mean TPI and gap index and initial and postreduction fracture translation were higher in patients with redisplacement, while TPI>0.855 and postreduction translation >18% were the only independent risk factors for fracture redisplacement. No differences were observed regarding associated fibular fracture, quality of reduction, initial/postreduction angulation, and shortening. The TPI>0.855 and postreduction translation >18% are independent risk factors for redisplacement of tibial shaft fractures in children. Although the gap index can be useful, the cast index is not an appropriate tool for these fractures.

Study of enders nailing in tibia shaft fracture in paediatric patient

Background and Aim: The exposed anatomical location of the tibia makes it vulnerable to the direct blow and high energy trauma as a result of motor vehicle accidents, thus resulting in comminuted fractures which are frequently open with significant loss of skin and soft tissues. The purpose of our study was to present results of fixation of unstable tibial shaft fractures in children with Ender’s nailing.Material and Methods: This is a study of 30 patients of unstable tibial shaft fractures in children treated with Ender’s nailing. 24 were closed fractures & 6 were open grade one fractures with only punctured wounds. Twenty patients had concomitant fibula fractures. In 26 patients tibia fracture was an isolated injury, one had associated same side clavicle fracture and one had associated same side lower end radius fracture.Results: Average time for fracture union was 9 weeks (range 6 to 15 weeks). All fractures united without 2nd operative intervention. Slight nail back out occurred in many patients, but only in 2 patients significant proximal migration of nails occurred causing some knee irritation, but not requiring any operative intervention before fracture union. In all patients implant removed 6 to 7 months after surgery. There was some restriction of knee movements in 4 patients in which nails were significantly backed out, but after implant removal full knee movements achieved in all patients there was full ankle movements in all patients at final follow-up. Conclusion: Based on our results, Ender’s nailing is an effective method of treatment in these cases, which allows rapid healing of tibial shaft fractures with an acceptable rate of complications.

Increasing rates of surgical treatment for paediatric tibial shaft fractures: a national database study from between 2000 and 2012.

PurposeTibia fractures are the third most common long bone fracture in children. Because of the remodelling potential of the tibial diaphysis, nonoperative treatment has historically been advocated for most tibial shaft fractures in children. The purpose of this study was to estimate the rate of surgical treatment of tibial shaft fractures over time and identify demographic factors associated with surgical treatment, utilizing a large, publicly available, national database.MethodsThe Healthcare Cost and Utilization Project Kids’ Inpatient Database was evaluated for the years between 2000 and 2012. Tibial shaft fractures and surgically treated patients were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes. Univariable and multivariable logistic regression were used to determine variables associated with a greater proportion of surgical treatment. Statistical analyses were performed utilizing SAS statistical software v.9.4. Statistical significance was set at p < 0.05.ResultsIn all, 24 166 tibial shaft fracture admissions were identified, with 15 621 (64.7%) treated surgically. The percentage of patients receiving surgery to treat tibial shaft fractures increased from 57.3% in 2000 to 74.3% in 2012 (p < 0.001). Multivariable regression showed that increasing age was associated with increased rate of surgical treatment (p < 0.001). The greatest increase in surgical treatment was seen in children aged five to nine years, increasing from 23.0% in 2000 to 46.2% in 2012.ConclusionThe rate of operative treatment of paediatric tibial shaft fractures increased over time. The largest increase was seen in children aged five to nine years. Increased proportion of surgical treatment was associated with older age, concurrent femur fracture and non-Medicaid insurance status.Level of EvidenceLevel III - Retrospective comparative study

A prospective RCT comparing the outcome of above-knee and below-knee pop cast application for isolated tibial shaft fractures in children

Purpose: Above-Knee Cast has been standard treatment for treating tibial fractures in children. We conducted this study to evaluate the time of union, complication and cost of treatment between above- Knee and Below-Knee Cast groups in children with isolated tibial shaft fractures. Study Design: Sixty children of age 6 months-15 years were randomized into Above-Knee and Below-Knee Cast group, who were followed and compared; till 6 months from January 2012 to March 2013. 10 children (6 torus, 2 undisplaced, 2 displaced fractures) lost to follow up at 6 months and were analyzed with missing value data analysis at 6 months. Results: All fracture united (8.30±2.69 weeks in Above-Knee Cast, 7.70±2.54 weeks in Below-Knee Cast). The pre-reduction parameters were varus (2-8o), valgus (4-8o), anterior angulation (4-9o), Posterior angulation (2-10o), Internal Rotation (3-6o), External rotation (3-6o), shortening (6.46 mm). At 6 months, above parameters were 2.83o±0.85, 3.20o±0.44, 2.83o±1.32, 2.67o±0.84, 3.40o±0.54, 2.83o±0.75, 2.67±1.15mm respectively in Above-Knee group and 2.60o±0.84, 2.50o±0.52, 3.00o±1.00, 2.93o±1.32, 3.00o±1.41, 2.33o±0.57, 2.00±0.00mm respectively in Below-Knee group. Reinforcement requirement of plaster was higher in Below-Knee cast (p=0.014). There were no refractures, residual complications. Conclusions and clinical relevance: Below-Knee cast is as effective as Above-Knee Cast for treatment of Isolated tibial shaft fractures in child with superior ROM at knee and low cost (p

Quadruple ESIN (Elastic Stable Intramedullary Nailing): Modified Treatment in Pediatric Distal Tibial Fractures.

Nailing of the tibial shaft with 2 Prevot nails is the gold standard for tibial shaft fractures in children. This technical report aims to show a simple way to stabilize pediatric distal tibial fractures without changing of the operation method. A retrospective chart review of all distal tibial fractures treated with the modified elastic stable intramedullary nailing (ESIN) method during a 6-year period was conducted. The modified ESIN technique hardly differs from the classic method, other than the addition of 2 other Prevot nails inserted using the same entry point. Eight children were treated with the modified ESIN. The mean operation duration was 57 minutes (range, 33 to 88 min). In all cases 2 to 4 mm titanium nails were used. None of our patients required a postoperative cast.Within an average of 14.5 days all of the patients could fully bear their weight (2 to 30 d) and full range of motion was reached. The modified ESIN technique achieves good results regarding stability and early weight-bearing. Therefore, this technique could be applied in unstable distal tibial fractures. Nevertheless, a prospective and biomechanical study is needed to verify our experience. Level IV-therapeutic studies.

Fracture union in percutaneous Kirschner wire fixation in paediatric tibial shaft fractures

PurposeTo evaluate the efficacy of intramedullary Kirschner wires for the treatment of unstable tibial shaft fractures in children. MethodsThis prospective study was conducted at the Department of Orthopaedic Surgery in Maharishi Markandeshwar Medical College from June 2005 to June 2010. Sixty-six children having closed fracture of the tibial shaft with a mean age of 7.7 years (range, 2–14 years) were recruited from emergency and outpatient department. They were treated with percutaneous intramedullary Kirschner wires. The clinical results of our study were rated on the basis of the criteria of union, nonunion, delayed union or malunion. All children were followed for one year. ResultsChildren achieved union in a mean time of 8 weeks (range, 6–10 weeks). Postoperatively, three children (4.55%) had delayed union, one (1.52%) valgus deformity of lower leg, three (4.55%) postoperative knee pain and twelve (18.18%) skin irritation at pin site. Wires were removed after 8–22 weeks without any complications. No patient was lost to follow-up. The results were excellent in 95.45% and good in 4.55% children. ConclusionThis technique is cost-effective, simple, quick to perform, safe and reliable and avoids prolonged hospitalization with good results.

Complex Tibial Shaft Fractures in Children Involving the Distal Physis Managed with the Ilizarov Method.

ABSTRACTIntroductionSegmental fractures in the juvenile distal tibia with physeal involvement present specific challenges. Injury to the growth plate may be overlooked, potentially resulting in late sequelae. Fracture stabilization can be complex. Previous reports of management of such an injury are by open reduction and internal fixation. This study reviews the management and outcome of a group of such patients treated with Ilizarov external fixators.Materials and methodsPatients aged 16 or younger treated in our unit between March 2013 and November 2014 by Ilizarov circular fine wire fixation for tibial fractures with ipsilateral physeal injuries were identified. Retrospective collection of patient demographics, fracture classification, treatment pathways, fixation methods, postoperative follow-up, outcomes, and complications was undertaken.ResultsEight patients were identified; two had Gustilo and Anderson grade IIIA open injuries. All were managed definitively using an Ilizarov external fixator in combination with percutaneous screw fixation of the physeal component as required. All patients were ambulant during treatment and were allowed unrestricted weight-bearing immediately postoperative. All but one attended school. All fractures united. In follow-up, one patient had a distal tibial physeal growth arrest, but there were no other complications.ConclusionPediatric patients with complex distal tibial fractures should be scrutinized for concomitant physeal injury. Where identified treatment, using a combination of internal fixation and an Ilizarov fixator can be considered.How to cite this articleRogers GP, Tan HB, Foster P, et al. Complex Tibial Shaft Fractures in Children Involving the Distal Physis Managed with the Ilizarov Method. Strategies Trauma Limb Reconstr 2019;14(1):20–24.

A Comparison of Two Approaches for the Closed Treatment of Low-Energy Tibial Fractures in Children

Many orthopaedic surgeons treat tibial shaft fractures in children with a period of non-weight-bearing after application of a long leg cast, presumably to prevent fracture angulation and shortening. We hypothesized that allowing children to immediately bear weight as tolerated in a cast with the knee in 10° of flexion would lessen disability, without increasing the risk of unacceptable shortening or angulation. We divided eighty-one children, between the ages of four and fourteen years, with a low-energy, closed tibial shaft fracture into two groups. One group (forty children) received a long leg cast with the knee flexed 60° and were asked not to bear weight. The second group (forty-one children) received a long leg cast with the knee flexed 10° and were encouraged to bear weight as tolerated. All patients were switched to short leg walking casts at four weeks. We compared time to healing, overall alignment, shortening, and physical disability as determined by the Activities Scale for Kids-Performance (ASK-P) questionnaire. The mean time to fracture union was 10.8 weeks in both groups (p = 0.47). At the time of healing, mean coronal alignment was within 1.3° in both groups, mean sagittal alignment was within 1°, and mean shortening was <0.5 mm, with no significant differences. The ASK-P scores showed that both groups had overall improvement in physical functioning over time. However, at six weeks, the children who were allowed to bear weight as tolerated had better overall scores (p = 0.03) and better standing skills (p = 0.01) than those who were initially instructed to be non-weight-bearing. Children with low-energy tibial shaft fractures can be successfully managed by immobilizing the knee in 10° of flexion and encouraging early weight-bearing, without affecting the time to union or increasing the risk of angulation and shortening at the fracture site.

Tibia Fractures

The purpose of this study is to provide a summary of the absolute and the relative surgical indications for both closed and operative treatment of tibial shaft fractures. A literature review of the pertinent literature was undertaken, and a limited number of the most significant papers are cited. Recommendations are provided for fractures that are most likely to need surgical intervention and relative indications for fractures that may benefit from surgical stabilization. Successful closed treatment can be achieved either by casting and conventional 3-point molding or by utilizing the Sarmiento technique of casting. Either technique depends on soft tissues to maintain bony alignment. The reported results are significantly improved after surgical stabilization after open tibial shaft fractures and tibial shaft fractures associated with ipsilateral femoral fractures. Relative indications for surgical stabilization include comminuted fractures, displaced fractures with an intact fibula, and displaced fractures in adolescents. Compartment syndrome remains the most significant early complication encountered when treating tibial shaft fractures in children and adolescents by either closed or surgical methods and should be considered in the face of pain out of proportion to the injury or increasing narcotic requirements. Tibial fractures are one of the more common injuries treated by orthopedic surgeons. Although most can be treated by closed techniques, certain fractures benefit significantly from surgical stabilization.

Elastic stable intramedullary nailing of tibial shaft fractures in children

Tibial fractures in the skeletally immature patient are usually treated without surgery. Elastic stable intramedullary nailing (ESIN) is commonly used for other diaphyseal fracture locations. Its advantages are minimally invasive surgery with a short hospitalisation duration, primary bone union and early weight bearing. The purpose of this study was to assess the use of ESIN in displaced tibial fractures in children over 6years old and in cases of polytrauma. This study was carried out over a 6-year period. The protocol consisted in ESIN of shaft tibial fractures in children over 6. Frontal and sagittal angulation, shortening and lengthening were measured on days 0, 2, 15, 30 and 45. At 6months, 1 and 2years, the femoro-tibial axis and eventual shortening or lengthening were assessed. The study involved 86 children (average age 11.8years). As early as day 30, all patients had normal knee mobility and symmetrical foot progress angle. At 2-year follow-up, frontal angulation and leg length discrepancy had decreased and affected 2% of patients. Four patients (5%) suffered from superficial infections. There were no cases of osteomyelitis or refracture. The fixation of paediatric diaphyseal tibial fractures with ESIN is a rapid, well-codified and effective method for treating long-bone closed fractures in children. Advantages over other fixation techniques include a lower infection rate, a lower refracture rate, ease of management, and an aesthetically pleasing scar.

Clinical evaluation of end caps in elastic stable intramedullary nailing of femoral and tibial shaft fractures in children.

Elastic stable intramedullary nailing (ESIN) may be complicated by the loss of reduction following push out of the nails at the entry site in unstable femoral and tibial fractures, especially in older and heavier children and following technical failures. An end cap system addressing this complication was evaluated clinically. In a retrospective case series, 49 femoral and five tibial fractures in 54 pediatric patients treated by ESIN and end caps were documented in two European tertiary centers. End caps were used to interlock standard ESIN nails. The results were evaluated regarding difficulties in the placement and removal of the end cap system, fracture stability and healing, and return to normal activities by analyzing patient charts and X-rays. Fifty-three of 54 fractures were stabilized sufficiently with ESIN and end caps. Loss of reduction was observed in one patient, requiring additional surgery. Six complications were observed, five of which were not related to end caps. There were no significant leg length differences or varus/valgus deformities. A rotational difference of >10°-20° was found in one patient. Removal of the end caps and nails was rated as simple and uncomplicated in 35/37 cases. End caps avoided postoperative instability in the majority of pediatric patients with lower limb shaft fractures, even in heavier, older patients and those with instable fracture types. End caps, however, will not compensate for operative technical insufficiency concerning reduction or nail placement. To maximize the stability of ESIN-instrumented unstable fractures, end caps require properly placed nails.

Early weight bearing after complete tibial shaft fractures in children

This study determined the prevalence of complications related to early weight bearing and the factors associated with time to healing in children after a complete tibial shaft fracture. Radiographs and medical records were reviewed from patients with unilateral, closed, complete tibial shaft fractures who were treated nonoperatively with a long leg cast. There were 55 males (68.8%) and 25 females (31.2%) with a mean ± SD age of 6.0 ± 4.0 years (range 1-16). There were few complications (2.5%) and patients healed faster if they bore weight earlier (0.3 days faster for each day earlier to weight bearing, P = 0.02), were younger (2.3 days faster per year younger, P < 0.001), were female (2.7 days faster than males, P = 0.02), or did not have a closed reduction (3.8 days faster, P = 0.002) (R = 0.63). Time to weight bearing after complete tibial shaft fracture was not associated with an increased risk of complications. Earlier weight bearing was associated with a shorter time to healing. This study provides support for treatment with early weight bearing in children with closed, complete tibial shaft fractures.

The ortho-plastic management of Gustilo grade IIIB fractures of the tibia in children: A systematic review of the literature

Background The challenges of managing Gustilo IIIB tibial fractures in children are unique. A multi-disciplinary, evidence based approach is needed. We aimed to evaluate the evidence for the ortho-plastic management of Gustilo grade IIIB open tibial shaft fractures in children based on a review of all published data in order to rationalise the orthopaedic and plastic surgical approach to these complex injuries. Method A systematic review of the literature was performed. Gustilo grade IIIB tibial shaft fractures in pre-adolescent and adolescent children were identified and evaluated with regard to both the skeletal and soft tissue management, and the outcome. Results Of 54 children with grade IIIB tibial fractures, a mean union time of 31 weeks included 33 weeks for 42 adolescents and 23 weeks for 12 pre-adolescents. Faster union time in pre-adolescents tended towards significance. Delayed union occurred in 22%, nonunion in 13%, mostly in adolescents. Two of 45 covered by vascularised flaps and 3 of 9 treated without flaps developed deep infection ( p = 0.028). There was no correlation between method of skeletal fixation and union time. Conclusion Gustilo IIIB tibial shaft fractures in pre-adolescents tended towards faster healing with fewer complications, irrespective of the method of skeletal fixation. In adolescents, healing times were similar to adults. Soft tissue closure without flaps was associated with deep infection in one-third of patients, requiring debridement and flap cover. Adequate debridement and flap cover is suggested in all cases, irrespective of age.