Epidemiology
Etiology
Toddler's fracture
Definition
Minimally displaced oblique fracture of tibia
Management
Heal rapidly - can be treated in short leg weight bearing cast for 4 weeks
Management options
Closed reduction and casting
ORIF - plate, flexible nails
Nonoperative management
| Acceptable reduction | Poor remodelling potential | Duration of casting |
|---|---|---|
|
Varus / valgus < 5o Anterior / posterior < 5o Rotation 5o Shortening <10 mm |
Valgus Apex posterior angulation / recurvatum Rotational alignment Shortening - in 2-10 year old average overgrowth is only 5mm |
Neonates 2-3 weeks Juveniles 4-6 weeks Adolescents 8-12 weeks |
Long leg cast
General anesthesia and fluoroscopy
- leg hanging over edge of bed
- gravity assists reduction
- apply short leg cast
- check reduction
- apply long leg cast in 45° knee flexion
- helps control unstable fractures
- prevents early weight bearing
- plantar flexion ankle - mild plantar flexion for first 2-3 weeks to prevent posterior angulation
- 20° plantar flexion for middle & distal third
- 10° plantar flexion for proximal third
Cast wedging
Technique article cast wedging PDF
Operative management
Indications
Open fractures
Irreducible fractures
Failure nonoperative management
Compartment syndrome
Multi-trauma
Options
Plate
Flexible nails
External fixation
Plate fixation
Flexible nails
Advantages
Reduced time in cast / ROM of knee and ankle
Reduced risk wound issues
Risks
Delayed / nonunion
Residual angular deformity
Technique
JBJS Essential surgical technique flexible nails tibial fractures PDF
Results
Pennock et al J Pediatr Orthop 2020
- 172 tibial shaft fractures treated with flexible nails
- 3% nonunion
- 10% delayed union (>6 months to heal)
- 57% residual deformity > 5 degrees
- 14% residual deformity > 10 degrees
Fanelli et al
Open Fractures
Treated along the same principles as adult compound fractures
Buckley et al (1994)
- 42 cases
- average time to union 5 months (range 2-21)
- 4 patients had > 1 cm overgrowth
- 3 infections (7%) all resolved
Antibiotics
- first generation cephalosporin for Grade I & II
- add Gentamicin for Grade III injuries
- add Penicillin for farm yard & lawn mower injuries
Compartment Syndrome
- as for adults
- measure compartment pressures in ventilated or severely head injured children
Fixation
- Grade I - reduced +/- percutaneous pinning, long leg cast once wound closed
- Grade II & III - external fixation
Amputation
- indications for primary amputations not clear in children
- accepted indication for primary amputation is open tibia
- + avascular leg with posterior tibial nerve injury and insensate foot
- MESS Score useful predictor of amputation