Initial Treatment of Tibia Fractures in Children
The initial treatment for most pediatric tibia fractures is closed reduction and casting, which remains the mainstay of management for the majority of these injuries. 1, 2, 3
Primary Treatment Approach
Closed reduction and casting should be the first-line treatment for most pediatric tibial shaft fractures. This approach is effective for the majority of patients and achieves union in approximately 10 weeks with nonunion rates less than 2%. 3 The cast must be well-molded to control length, alignment, and rotation of the fracture. 2
Acceptable Alignment Parameters
When treating with casting, the following alignment parameters are acceptable: 2
- Less than 10° of coronal and sagittal angulation
- 50% translation
- 10 mm of shortening
Critical Monitoring Point
Fractures of the tibial shaft without an associated fibular shaft fracture require close follow-up during the first 3 weeks after injury, as they may fall into varus malalignment despite initial adequate reduction. 2 This represents a common pitfall where seemingly stable fractures deteriorate in the cast.
Indications for Surgical Treatment
Surgical intervention should be considered as the initial treatment in the following scenarios: 1, 2, 4
Absolute Indications
- Open fractures (particularly Grade II and above) 1, 4
- Fractures associated with compartment syndrome 1, 4
- Multiply injured patients 1
- Ipsilateral femoral fractures (floating knee) 4
- Irreducible fractures 1, 2
Relative Indications
- Adolescent patients (particularly those older than 10 years, where 74% undergo surgical fixation) 5, 2
- Comminuted fractures 2, 4
- Displaced fractures with intact fibula 4
- Fractures that cannot be adequately reduced and stabilized with a cast 2
Surgical Treatment Options
When surgery is indicated, flexible intramedullary nailing is gaining wide adoption and is the predominant mode of surgical stabilization for pediatric tibial shaft fractures. 1, 2 Other options include: 1, 2, 3
- External fixation (particularly useful for open fractures and multiply injured patients)
- Minimally invasive plate osteosynthesis
- Rigid intramedullary nailing (in older adolescents with closed physes)
Special Consideration for Open Fractures
Grade I open tibial shaft fractures may be safely treated with irrigation and debridement in the emergency department, followed by closed reduction and casting. 1 However, this remains an area where definitive high-level evidence is lacking.
Age-Based Treatment Algorithm
Treatment decisions are heavily influenced by patient age: 5, 2
- Children under 10 years: Closed reduction and casting is typically successful
- Children over 10 years: Surgical fixation becomes increasingly appropriate, with 74% of patients in this age group undergoing operative treatment 5
- Adolescents: Should be strongly considered for surgical stabilization 2
Critical Complication to Monitor
Compartment syndrome remains the most significant early complication regardless of treatment method (closed or surgical). 3, 4 It should be suspected in the face of pain out of proportion to the injury or increasing narcotic requirements. 4 Diagnosis may be particularly difficult in young children or those with altered mental status. 3
Treatment Outcomes
Most pediatric tibial shaft fractures achieve excellent outcomes with appropriate treatment. Union occurs in approximately 10 weeks with closed treatment, and most patients return to full activities with uneventful healing. 1, 3 The average hospital stay for operative cases is approximately 3 days. 5