CHILDREN’S FRACTURES - TIBIA
By: Robert H. Sheinberg, D.P.M., D.A.B.P.S., F.A.C.F.A.S.
Tibial fractures are common injuries in toddlers, children and adolescents. They can occur from minor falls or twisting injuries, in which the knee is locked or fixed in flexion and the foot externally rotates relative to the leg. They can also occur in sports from direct or indirect trauma. Direct trauma would include a hit on the side of the leg by a helmet in football or possibly from being kicked by another player during a sporting event. They are also common in motor vehicle accidents.
Fractures of the tibia can occur in the upper one-third, middle one-third or lower one-third of the bone. They are often associated with fractures of the outer bone called the fibula. Fractures can also be open, in which the fracture fragments are exposed to the outside via puncture wound or major skin opening in the leg. These would be considered surgical emergencies.
The injury can present itself in a young child who avoids walking on his leg. There may not be any overt signs of injury. Tenderness to touch the fractured area is always seen. Deformity in which the bone looks distorted may be uncommon but is also a sign that urgent care needs to be administered. With more major direct trauma to the region, swelling can be immediate and diffuse along the leg. Numbness and tingling down the extremity may follow with an inability to flex and extend the toes are move the ankle up and down without severe pain. This would also be an emergency as concerns would be present for compartment syndrome.
Other areas of injury must be sought out. This can include injuries to the knee, femur or spine.
Immediate evaluation is necessary to evaluate the injury. Assessing the circulation and neurologic status to the extremity are critical. Expanding hematoma in the leg can cause severe pain, necessitating an immediate surgical procedure to decompress compartments in the leg.
X-rays: X-rays are necessary and would also include the knee and ankle. The fracture configuration is assessed and treatment begun.
Treatment: If there is not an open fracture or injury to the arteries and nerves, then a gentle closed reduction with cast immobilization may be all that is necessary to allow the injury to heal. Proper attention is made towards evaluating the alignment of the lower leg to the upper leg. Angular deformities in which the bone looks bowed in or out must also be addressed to prevent any long-term stress on the knee or ankle joints after the fracture is healed.
Closed reduction and cast immobilization may be necessary under a general anesthetic if the fracture is malaligned. This will allow the child to be comfortable while the fracture is manipulated without the patient having pain, or splinting to prevent proper reduction.
Following closed reduction the cast would be necessary above the knee for 4-6 weeks at a minimum. Once the fracture begins to heal, which would be evident on x-ray, the cast can be changed to a below-the-knee cast initially nonweightbearing but would progress to weightbearing.
If at any time the fracture appears to be slightly malaligned, the cast can be wedged to help realign the extremity.
In severe fractures in which the bone is in multiple pieces and unstable, placing an external fixation device may be necessary. These devices are also used in open fractures to allow treatment to the skin during the healing process. In a small number of cases unstable fractures may be treated by placing small pins through the skin into the fracture site to give the fracture some stability. Rarely are plates and screws necessary because of the enhanced healing potential of children.
Complications: Complications following tibia fractures are relatively uncommon in low energy injuries. Low energy fractures would include those that occur from a minor or major twisting injury to the foot or leg or can be seen in a sporting event. More major traumatic injuries can predispose the child to compartment Syndrome. This occurs when the pressure in the leg compartments elevate, causing injury to the nerves, arteries, muscle and skin. A high index of suspicion is necessary for the physician so that these can be treated immediately with a procedure to release the pressure.
Delayed union or nonunion of fractures of the tibia are relatively uncommon in children, especially ones with low energy without any bone loss. They are also more common in open tibia fractures that occur in the central portion of the bone. Angulation of the bone may be present if it occurred during the healing process. The fracture may appear to be stable at first but over time a progressive deformity may develop. It is important that x-rays are taken frequently to evaluate the position of the fracture during the healing process. Necessary wedging the cast helps to minimize the deformity.
If there is malunion that is causing a current problem or the potential for a future problem to the joints above and below the injury, it should be treated surgically to help realign the extremity. If the bone is externally or internally rotated more than the opposite limb, surgery may also be necessary to help align the extremities symmetrically.
Growth disturbances are rare when the fracture occurs away from the growth plate areas of the bone. Although they may occur, they are minor. Fractures that occur in the growth plate regions of the bone are more complicated and growth plate disturbances including a premature growth plate closure may occur.