TIBIA AND FIBULA SHAFT FRACTURE IN PEDIATRIC CASE

A. INTRODUCTION

Diaphyseal fractures of the tibia and fibula are common in children, being third in
frequency, after fractures of the femur and both-bone forearm fractures. They represent
15% of pediatric fractures. Of these fractures, 30% are associated with ipsilateral fibular
fractures. They occur most commonly in boys younger than 10 years. Ratio of incidence in
boys and girls is 2:1. The mechanism depends on the age of the child, with more benign
fractures occurring in the younger age group. The tibia is the second most commonly
fractured bone in abused children; 26% of abused children with fractures have a tibia
fracture. The typical tibial fracture is usually treated by external immobilization, with or
without reduction, and outcomes are generally good. Open fracture, which is relatively
rare, requires meticulous evaluation and treatment, with generally satisfactory results.1,2

Differential between bone in child and adult:3

1. Fracture more common in child
2. Stronger and more active periosteum
3. More rapid fracture healing
4. Special problems of diagnosis
5. Spontaneous correction of certain residual deformities
6. Differences in complications
7. Different emphasis on methods of treatment
8. Torn ligaments and dislocations less common
9. Less tolerance of major blood loss
10. Still has epiphysial plate

B. MECHANISM OF INJURY

Tibial fractures in children can be due to indirect or direct trauma, and fractures
vary with the age of the child. In an infant and child younger than 4 years, an indirect
injury caused by a fall from a height or from a standing position or a bicycle spoke injury
results in a spiral or oblique fracture. In a child older than 4 years, the most common
injury is the result of a pedestrian accident in which the child is struck by a car and

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 sustains a complete, often comminuted fracture. Shannak reported 63% of tibial fractures
to be due to road traffic accidents, with 18% resulting from falls. Sporting activities also
account for a large proportion of tibial fractures in the older age group, with Yang and
Letts reporting 41% of their cases to be due to skiing or skating accidents, 40% to be due
to falls, and only 16% to be due to motor vehicle accidents. Child abuse accounts for less
than 5% of tibial fractures in children. Open injuries in children occur in up to 8% of all
tibial fractures and are predominantly incurred in motor vehicle accidents, which account
for between 75% and 85% of these injuries.1
C. ANATOMY OF TIBIA AND FIBULA4

The anteromedial aspect of the tibia is subcutaneous, with no overlying musculature

for protection.2
Three consistent ossification centers form the tibia:2
a. Diaphyseal: Ossifies at 7 weeks of gestation.
b. Proximal epiphysis: The ossification center appears just after birth, with closure at
age 16 years.
c. Distal epiphysis: The ossification center appears in second year, with closure at age
15 years.
The medial malleolus and tibial tubercle may present as separate ossification centers
and should not be confused with fracture.2
Fibular ossification centers:2

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 a. Diaphyseal: Ossifies at 8 weeks of gestation.
b. Distal epiphysis: The ossification center appears at age 2 years, with closure at age
16 years.
c. Proximal epiphysis: The ossification center appears at age 4 years, with closure at
age 16 to 18 years.

Fascial Compartments
The lower leg has four fascial compartments. The anterior compartment contains
the extensor digitorum longus, the extensor hallucis longus, and the tibialis anterior
muscles; the anterior tibial artery and deep peroneal nerve run in this compartment. The
lateral compartment contains the peroneus longus and brevis muscles. The superficial
peroneal nerve runs through this compartment. The superficial posterior compartment
contains the soleus and gastrocnemius muscles. The deep posterior compartment contains
the flexor digitorum longus, the flexor hallucis longus, and the tibialis posterior muscles.
The posterior tibial artery, peroneal artery, and tibial nerve run in this compartment.5

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 Pictures of muscle compartment 4

Pictures of muscle compartment 1

D. CLASSIFICATION

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The behaviour of these injuries and therefore the choice of treatment depends on the
following factors: 6
1. The state of the soft tissues
The risk of complications and the progress to fracture healing are directly related to
the amount and type of soft-tissue damage. Closed fractures are best described
using Tschernes (Oestern and Tscherne, 1984) method; for open injuries, Gustilos
grading is more useful (Gustilo et al., 1984). The incidence of tissue breakdown
and/or infection ranges from 1 per cent for Gustilo type I to 30 per cent for type
IIIC.

2. The severity of the bone injury

High-energy fractures are more damaging and take longer to heal than low-energy
fractures; this is regardless of whether the fracture is open or closed. Lowenergy
breaks are typically closed or Gustilo I or II, and spiral. High-energy fractures are
usually caused by direct trauma and tend to be open (Gustilo III AC), transverse or
comminuted.

3. Stability of the fracture

Consider whether it will displace if weightbearing is allowed. Long oblique
fractures tend to shorten; those with a butterfly fragment tend to angulate towards
the butterfly. Severely comminuted fractures are the least stable of all, and the most
likely to need mechanical fixation.
4. Degree of contamination
In open fractures this is an important additional variable.

Clinical types: 4

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 open fracture / close fracture
Etiology : 4
traumatic fracture/ stress fracture/ pathologic fracture
Configuration classification: 4

E. CLINICAL FEATURES 1

A good history should be obtained from the patient, parents, or other witnesses. It
is important to determine whether the mechanism of injury was a direct or indirect force.
Direct trauma to the leg, such as being run over by a motor vehicle, may have grave
complications because the soft tissue injury is much greater than may be apparent on the
initial examination. Often the mechanism of injury in a young child is uncertain, with the
only information being pain over the tibia and an inability to walk.
Physical examination begins with inspection of the leg for soft tissue injury,
including evidence of an open injury. Frequently there is no obvious deformity of the leg
because the majority of tibial fractures are undisplaced or minimally displaced. In a young
child who is unable to ambulate, palpation of the thigh and leg is necessary to help define
the location of the injury. In an older child who is able to point to the location of the pain,
it is not necessary to deeply palpate the leg in an attempt to identify the fracture. However,
it is of paramount importance to assess the condition of the soft tissue envelope
surrounding the leg at the time of initial evaluation, especially in a child who has sustained
direct trauma to the leg in a pedestrianmotor vehicle accident or a severe twisting injury

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 to the leg. Although compartment syndromes are relatively rare in a child with a tibial
fracture, a full assessment should include evaluation of the pain elicited on passive
dorsiflexion and plantar flexion of the toes; a complete neurologic examination, including
a motor and sensory examination; palpation of the distal pulses; and assessment of
capillary refill time. At completion of the physical examination the injured leg should be
splinted if transport of the patient is necessary.

F. RADIOLOGIC FINDING

Anteroposterior (AP) and lateral views of the tibia and knee should be obtained. AP,
lateral, and mortise views of the ankle should be obtained to rule out concomitant ankle
injury. Comparison radiographs of the uninjured contralateral extremity are rarely
necessary. Technetium bone scan or MRI may be obtained to rule out occult fracture in the
appropriate clinical setting. 2

The entire length of the tibia and fibula, as well as the knee and ankle joints, must
be seen. The type of fracture, its level and the degree of angulations and displacement are
recorded. Rotational deformity can be gauged by comparing the width of the tibia-fibular
interspaces above and below the fracture. Spiral fractures without comminuting are low
energy injuries. Transverse, short oblique and comminuted fractures, especially if
displaced or associated with a fibular fracture at a similar level, are high energy injuries. 6

G. TREATMENT
The main objectives are: 6
a. to limit soft-tissue damage and preserve (or restore, in the case of open fractures) skin
cover
b. to prevent or at least recognize a compartment syndrome
c. to obtain and hold fracture alignment

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d. to start early weightbearing (loading promotes healing)
e. to start joint movements as soon as possible.

Nonoperative
Most pediatric fractures of the tibia and fibula are uncomplicated and may be
treated by simple manipulation and casting, especially when they are nondisplaced or
minimally displaced. However, isolated tibial diaphyseal fractures tend to fall into varus,
whereas fractures of the tibia and fibula tend to fall into valgus with shortening and
recurvatum. 2

The muscles in the anterior and the lateral compartments of the lower leg produce a valgus
deformity in complete ipsilateral tibia and fibula fractures. 2

Displaced fractures may be initially treated with closed reduction and casting with
the patient under general anesthesia. 2
In children, acceptable reduction includes : 2
50% apposition of the fracture ends, <1 cm of shortening, and
<5- to 10-degree angulation in the sagittal and coronal planes.
A long leg cast is applied with the ankle slightly plantar flexed (20 degrees for distal and
middle third fractures, 10 degrees for proximal third fractures) to prevent posterior
angulation of the fracture in the initial 2 to 3 weeks. The knee is flexed to 45 degrees to
provide rotational control and to prevent weight bearing. 2

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 Fracture alignment must be carefully monitored, particularly during the initial 3
weeks when atrophy and diminished swelling may result in loss of reduction. Some
patients require repeat manipulation and cast application under general anesthesia 2 to 3
weeks after initial casting. The cast may require wedging (opening or closing wedge) to
provide correction of angulatory deformity. 2

Operative
Operative management of tibial fractures in children are typically required in <5%
of cases. 2
Indications for operative management include: 2
Open fracture.
Fractures in which a stable reduction is unable to be achieved or maintained.
Associated vascular injury.
Fractures associated with compartment syndrome.
Severely comminuted fractures.
Associated femoral fracture (floating knee).
Fractures in patients with spasticity syndromes (cerebral palsy, head injury).
Patients with bleeding diatheses (hemophilia).
Patients with multisystem injuries.

Open fractures or grossly contaminated fractures with associated vascular

compromise may be treated with debridement of compromised tissues and external
fixation, particularly in older children. Severe degloving injuries may require the use of
flexible, intramedullary nails for fracture stabilization. Regional or free flaps or skin
grafting may be required for skin closure. 2
Other methods of operative fixation include: 2
percutaneous pins,
plates and screws,
flexible intramedullary nails or rigid intramedullary nails (in adolescents after
closure of the proximal tibia physis).

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 Postoperatively, a long leg cast is usually placed (depending on the method of
fixation), with the knee in 45 degrees of flexion to allow for rotational control. The cast is
maintained for 4 to 16 weeks depending on the status of healing, as evidenced by serial
radiographs, as well as the healing of associated injuries. 2

H. COMPLICATION

a. Compartment syndrome: In pediatric tibia fractures, compartment syndrome is most

common after severe injury in which the interosseous membrane surrounding the
anterior compartment is disrupted. Patients with elevated compartment pressures >30
mm Hg or within 30 mm Hg of diastolic blood pressure should receive emergency
fasciotomies of all four compartments of the leg to avoid neurologic and ischemic
sequelae. 2
b. Angular deformity: Correction of deformity varies by age and gender. 2
Girls <8 years old and boys <10 years old often experience significant
remodeling.
Girls 9 to 12 years old and boys 11 to 12 years old can correct up to 50% of
angulation.
In children >13 years, <25% angular correction is expected.
Posterior and valgus angulation tends to correct the least with remodeling.
c. Malrotation: Rotational deformity of the tibia does not correct with remodeling and
is poorly tolerated, often resulting in malpositioning of the foot with the
development of associated ankle and foot problems. Supramalleolar osteotomy may
be required for rotational correction. 2
d. Premature proximal tibial physeal closure: This may occur with unrecognized crush
injury (Salter Type V) to the proximal tibial physis, resulting in growth arrest. This
most commonly affects the anterior physis and leads to a recurvatum deformity of
the affected knee. 2

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 e. Delayed union and nonunion: Uncommon in children, but it may occur as a result of
infection, the use of external fixation, or inadequate immobilization. Fibulectomy,
bone grafting, reamed intramedullary nailing (adolescents), and plate fixation with
bone grafting have all been described as methods to treat tibial nonunions in the
pediatric population. 2

I. PROGNOSIS
a. For diaphyseal fractures, union can be expected in over 95 per cent of cases.
b. Time to healing varies according to patient age:
Neonates: 2 to 3 weeks
Children: 4 to 6 weeks
Adolescents: 8 to 12 weeks

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 CASE REPORT

PATIENTS IDENTITY
NAME : R (boy)
AGE : 7 years old
REGISTRATION : 527616
ADMISSION DATE : January 3th, 2012

HISTORY TAKING
Chief Complaint:
Pain at the left leg
Suffered since 3 hours before admitted to the Wahidin Sudirohusodo general hospital due
to traffic accident.
Mechanism of Trauma :
The patient was playing beside the street and got hit by motorcycle from his left side.
History of unconsciousness (-), vomiting (-), nausea (-).
History of prior treatment at Faisal Hospital.

GENERAL STATE
Mild sickness / well nourish / aware
Blood pressure : 110/70 mmHg
Radial pulse : 82 x / minute
Respiratory rate : 20 x / minute
Temperature : 36,5 c (axilla)

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LOCALISATION STATE
a. Regio : Left Leg
Inspection : Deformity (+), swelling (+), hematoma (+), wound (-).
Palpation : Tenderness (+)
Range of Movement (ROM) : Active and passive movement of knee and ankle joints
are limited due to pain.
Neurovascular Distal (NVD) : Sensibility is good, pulse of dorsalis pedis artery is
palpable, capillary refill < 2.

Front Aspect

b. Regio : Left foot

Inspection : Abrasion lesion (vulnus excoriation) at medial aspect size 3 x 2 cm,
deformity (-), swelling (-), hematoma (-).
Palpation : Tenderness (+)
Range of Movement (ROM) : active and passive movement of ankle joint is limited
due to pain.
Neurovascular Distal (NVD) : Sensibility is good, pulse of dorsalis pedis artery is
palpable, capillary refill < 2.

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 Medial Aspect

Leg Length Discrepancy

Leg Length Discrepancy is acceptable.

LABORATORY FINDINGS
WBC 16,82 x 103 /uL PLT 354 x 103 /uL
RBC 4,61 x 106 /uL CT 900
HGB 13,6 g/dL BT 300
HCT 38,9 % HbSAg (-)

RADIOLOGIC FINDINGS

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Oblique
view

Radiologic Findings : Within in normal limit.

15


Lateral AP
view view

Radiologic Findings :
The right cruris x-ray photo shows within in normal limit.
There is a fracture disruption in alignment of the left cruris x-ray on the AP view
The density of bone is radiopack and there is a fracture line in distal of tibia and
fibula in left cruris. The type of fracture is oblique type.
The soft tissue of left cruris is swollen in minimal stage.

DIAGNOSIS
Closed fracture of the Left distal tibia
Closed fracture distal third of the Left fibula
Vulnus excoriation of the Left foot

MANAGEMENT
IVFD Apply long leg back slab
Antibiotic ORIF
Analgesic

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Applied Long Leg Back Slab

Front Aspect

Left Leg X-Ray

Applied Long Leg Back Slab


Lateral
view

RESUME
A boy, 7 years old, came to Wahidin Sudirohusodo Hospital with chief complaint is
pain at the left leg. It suffered since 3 hours before admitted to the hospital due to traffic
accident.
On the left leg region: Deformity (+), swelling (+), hematoma (+), Tenderness (+),
active and passive movement of knee and ankle joints are limited due to pain.
Radiography showed fracture line in distal of tibia and fibula.
On the left foot region: Abrasion lesion (vulnus excoriation) at medial aspect size 3 x 2
cm, tenderness (+), active and passive movement of ankle joint is limited due to pain.
Radiologic findings is within normal limit.

REFERENCES

1. Herring John Anthony. Lower Extremities Injuries. Tachdjians Pediatric Orthopardics. 4 th
edition. Texas:2008. Chapter 43.14.
2. Koval, K., Zuckerman, J. Tibia Fibula Shaft in Handbook of Fractures Third Edition.
p.610-20.
3. Salter Robert B. Specific Fractures and Joint Injuries in Children. Textbook of Disorders
and Injuries of the Musculoskeletal System 3rd edition. UK: 1999. p.499-504
4. Thompson JC. Classification Neer of Proximal Humerus Fractures. Netters Concise
Orthopaedic Anatomy. 2nd Edition.p. 288
5. Heinrich SD. Injuries of the shaft of tibia and fibula. Rockwood and Wilkins' Fractures in
Children, 6th . UK: 2006. p. 1033-74
6. Solomon L, Warwick D, Nayagam S. Fracture of Proximal Humerus.In: Apleys System
of Orthopaedics and Fractures. 9th edition. UK: 2010. p.896-904