Tibial Fractures Pediatric

Tibial Growth Plate Anatomy

Proximal tibial physis: Contributes 57% of tibial length. Located 1-2 cm distal to joint line. Protected by tibial tubercle apophysis.

Distal tibial physis: Contributes 43% of tibial length. Asymmetric closure (central, then medial, then lateral).

Tibial tubercle apophysis: Secondary ossification center. Vulnerable during adolescence (Osgood-Schlatter).

Blood Supply

Nutrient artery: Enters posterior cortex at junction of proximal and middle thirds. Supplies inner 2/3 of cortex.

Periosteal vessels: Supply outer 1/3 of cortex. More robust in children = better healing.

Proximal tibia: Vulnerable area at popliteal trifurcation. Watch for vascular injury with displaced proximal fractures.

Soft Tissue Considerations

Anteromedial tibia: Subcutaneous, minimal soft tissue coverage. Risk of open fractures and wound complications.

Compartments: Four leg compartments. Children can develop compartment syndrome. Floating knee has highest risk.

Periosteum: Thick in children. Helps maintain reduction. Contributes to rapid healing.

Toddler's Fracture (CAST)

Childhood Accidental Spiral Tibial fracture

Characteristics: Age 9 months to 3 years (walking age). Non-displaced spiral or oblique fracture. Distal tibial shaft most common. Often not visible on initial X-ray. Low energy mechanism (twist, fall).

Tibial Spine Fractures

Key point: Intermeniscal ligament may block reduction in Type II and III.

Tibial Shaft Classification

By pattern: Spiral, oblique, transverse, comminuted

By location: Proximal, middle, distal third

By stability: Stable (isolated tibia, intact fibula) vs unstable (both bones, significant displacement)

Associated fibula: Intact fibula may cause valgus malunion. Both bone fractures are unstable.

X-ray Protocol

Views: AP and lateral tibia/fibula. Include knee and ankle joints.

Toddler's fracture: May be negative initially. Look for subtle periosteal reaction at 10-14 days. Bone scan or MRI if clinical suspicion high.

Tibial spine: AP and lateral knee. CT if surgical planning needed.

MRI and CT

MRI indications: Occult toddler's fracture, tibial spine assessment, associated soft tissue injury.

CT indications: Tibial spine fracture surgical planning, complex intra-articular fractures.

Bone scan: Rarely needed. Can confirm occult toddler's fracture if clinical suspicion.

Toddler's Fracture Management

Treatment: Long leg cast or walking boot for 3-4 weeks.

Key points:

• Treat clinically even if X-ray negative
• No reduction needed (non-displaced)
• Rapid healing in this age group
• Follow-up X-ray at 2 weeks shows callus

Prognosis: Excellent. Heals rapidly with no long-term sequelae.

Cozen's Fracture Management

Acute treatment: Long leg cast for 4-6 weeks. Anatomic reduction attempted but not essential.

Cozen's phenomenon: Progressive valgus develops 6-18 months post-injury.

Natural history: Spontaneous correction by skeletal maturity in most cases.

Avoid: Overcorrecting into varus acutely. Performing early osteotomy for valgus. Promising parents deformity will not occur.

Tibial Spine Management

Type I: Extension cast for 4-6 weeks. Non-weight bearing initially.

Type II: Attempt closed reduction with extension. If reducible, cast. If blocked by intermeniscal ligament, surgery.

Type III and IV: Surgical fixation (open or arthroscopic). Options include suture fixation, screw fixation.

Rehabilitation: ROM after healing. ACL rehab protocol.

Tibial Shaft Management

Under 6 years: Long leg cast. Accept up to 10 degrees angulation, 1cm shortening.

6-10 years: Cast if stable and acceptable alignment. Consider flexible nails if unstable.

Over 10 years: Flexible IM nails preferred for displaced fractures. Rigid nails avoided (proximal tibial physis risk).

Both bone fractures: More unstable. Lower threshold for operative fixation.

Flexible IM Nailing (TENS/ESIN)

Indications: Age over 6-10 years, unstable shaft fractures, polytrauma.

Entry points: Medial and lateral distal metaphysis (avoid physis).

Nail size: 40% of medullary canal at isthmus.

Key points: Pre-contour nails for apex anterior angulation. Avoid proximal entry (tibial tubercle physis damage).

Tibial Spine Fixation

Approach: Arthroscopic preferred, open if needed.

Fixation options:

• Suture fixation through bone tunnels
• Screw fixation (avoid physes)
• Suture anchors

Key step: Clear intermeniscal ligament if blocking reduction.

Post-op: Extension brace or cast 4-6 weeks.

Floating Knee (Pediatric)

Definition: Ipsilateral femur and tibia fractures.

Mechanism: High energy trauma (MVA, fall from height).

Associated injuries: Knee ligament injuries (40-80%), vascular injuries, other trauma.

Management: Usually requires surgical stabilization of both levels. Femur typically flexible nails. Tibia cast or nails depending on pattern.

Complications: Highest risk of compartment syndrome. LLD possible.

Pathological Fractures

Causes: Simple bone cyst, fibrous dysplasia, osteogenesis imperfecta.

Presentation: Fracture with minimal trauma. May have prior symptoms.

Management: Treat fracture first. Address underlying pathology. Curettage and bone graft for cysts if needed.